See Article, p 231
Other physicians often ask physician executives, “How did you get where you are?” In anesthesiology, we often hear this question from young practitioners thinking about their career options or older physicians who want to contribute in a different way. Recently, there has been increasing reflection on physician career paths to the C-suite. A Harvard Business Review article by Stoller et al1 discusses how to train physician leaders, stating that it takes a combination of intentional, internal, and external leadership experiences.
Dr Paul Taheri, chief executive officer (CEO) of the Group Practice at Yale Medicine, offers a 2-tiered approach. The first part introduces physicians who oversee a service line, section, or unit, to the fundamental business principles of health care delivery. This includes personal leadership development through a year-long, one-day-a-month program. Emerging leaders who complete the first program enroll in an advanced program that includes finance, operational concepts with a health care focus, and leadership principles and competencies, such as strategic thinking, influence, and negotiation. The Cleveland Clinic offers an internal 10-day off-site training course in leadership competencies, covering topics that fall outside the domain of traditional medical training. Core to the curriculum is emotional intelligence (including an individual 360° evaluation with feedback and executive coaching), team building, conflict resolution, and situational leadership. In 10 years of follow-up after the initial course, 43% of the physician participants had been promoted to leadership positions at the Cleveland Clinic. In 2019, Dr Amol Gupta, then a clinical researcher, furthered the debate over physician versus nonphysician leadership. He opined that current evidence suggested that hospitals with physician executives outperform those without, thus recognizing the positive impact that physician CEOs have on the quality of hospital care. There is a need to build a foundation of CEO characteristics that are essential to guiding positive change at hospitals and refocusing health care back to its original intention: patient care.2
Certainly, an understanding of any business is critical to running it. Being clear on what makes money—to further support the mission and to care for more patients—and what loses money is what makes a successful physician, business leader, administrator, or CEO. You cannot fix something you do not understand. The process of how health care works and what does not work is foundational to any level of leadership in today’s health care systems. A more specific question is why might anesthesiologists in particular make great leaders? As 3 anesthesiologists who lead health systems (Figures 1–3), we are pleased in this commentary article to reflect on the essential characteristics that we think helped in our transition to CEO and what makes us successful in these roles.
WHY DO WE THINK ANESTHESIOLOGISTS MAKE THE MOST EFFECTIVE HEALTH SYSTEM CEOs?
As anesthesiologists, patients are always at the center of what we do. By design, our specialty requires us to collaborate with our colleagues to ensure that the patient has the greatest likelihood for a positive outcome. Our training—including being highly observant to changing circumstances, data-analytical from multiple sources, and precise in decision-making—is not only unique to the role of anesthesiologists in patient care but also the best foundation for a system CEO.
Our practice of medicine requires us to be collaborators, communicators, and consensus builders. Health system leaders have to think broadly, across the needs of the entire system; and as an anesthesiologist, one cannot be successful in the perioperative world without understanding this system-level thinking. “Management of a ‘system’ requires knowledge of the interrelationships between all of the components within that system and of everybody that works in it.” Dr Neal K. Shah cited these famous words from Dr W. Edwards Deming to introduce the topic of lean six sigma and building a quality improvement culture in his 2021 commentary article in Anesthesia & Analgesia.3
Systems theory, and the accompanying greater understanding of systems, is one of the major breakthroughs in understanding the complex world of organizations. This field studies systems from the perspective of the whole system, its various subsystems, and the recurring patterns in the relationships between subsystems. Systems theory has greatly influenced how we understand and change organizations. Basically, it is a way of helping one to view systems from a broad perspective that includes seeing overall structures, patterns, and cycles, rather than seeing only specific events in the system.4 Essentially, CEOs quickly learn they must ask the right questions to clearly identify the problem before launching into fixing mode. This is a skill that is inherently true for any physician, but especially so, and usually under very short timelines, for anesthesiologists.
We understand that our organizations operate from different perspectives. As Levi5 of the Massachusetts Institute of Technology pointed out in his presentation at the 2013 Innovation in Health Care Conference, Accelerating System Thinking in Health Systems via Collaboration With Academia, our organizations are mechanical systems, crafted to achieve a defined goal. Parts must fit well together to match the demands of the environment, and action comes through planning. Our organizations also encompass diverse, and sometimes contradictory, interests and goals. In this case, competition for resources is expected, and action comes through power … and we have all seen this at play in academic organizations! Finally, our organizations are also institutions filled with meanings, artifacts, values, and routines. Informal norms and traditions exert an incredibly strong influence on behavior; action comes through habit.5 In the presentation, Levi5 discusses 2 very successful projects: 1 at Massachusetts General Hospital and 1 at Beth Israel Deaconess Medical Center, where he helped smooth inpatient bed census and reorganize operating room (OR) block times. As a systems thinker, he approached each of the tasks looking at the broader environment in which the problem was nested.
To give a specific current challenge we all face: as health systems begin to think beyond coronavirus disease 2019 (COVID-19), many of us are facing staffing issues in the OR and inpatient units. Some of this has to do with the nursing crisis that has been looming for years, but there are other variables too, including pandemic exhaustion, childcare challenges, and new working situations. Simply filling the gaps in inpatient or perioperative nursing does not solve our problem. When we look across our system of care, the vacancies in care management, transportation, and postacute staffing have as much to do with our ability to get patients the right level of care as our bedside staffing. And the solution to our staffing challenges is more than recruitment; it will involve hiring packages that address work-life balance and child care. It will certainly involve new staffing models and new ways of interacting with external partners. Success will require attending to ingrained habits, new and more complex resource allocation, and change for long-embedded processes in our organizations.
A core value of anesthesiologists is problem-solving. When we see an issue that will impact patient care, we are programmed to move into assessment, collaboration, and innovation to manage the problem successfully for both the short term (get the case done safely in the patient’s best interest), and the long term (eliminate the problem that required a workaround). Each will require different interventions. Anesthesiologists are fortunately natural multitaskers. When confronted with multiple problems at the same time, we are able to prioritize clearly and always put the patient first to ensure a positive outcome.6 As anesthesiologists, we care for the patient, our colleagues, our system, and our communities at the same time. Keeping our balance is the key. We are compromisers in the best sense of the word, working to find new, even novel, solutions that deliver positive outcomes for everyone. These attributes translate well to the skills needed by a CEO to be successful.
WHAT WE HAVE ADDED TO OUR SKILLSET: ACTIVE LISTENING
As anesthesiologists who are now health system leaders, we have had to hone our ability to actively listen. This is a critical skill. Active listening allows us to build consensus even at the most challenging and difficult times, to find solutions, to implement those solutions, and to ensure positive results. Active listening is not always easy. Daily pressures and demands often overtake our work. It also requires the listener to pause and to resist the impulse to immediately problem-solve or react to what is being said. It involves being 100% present. The aim is to continue to listen to thoroughly absorb, understand, respond, and retain what is being said. While engaging in active listening, the listener needs to pay close attention to the speaker’s behavior and body language to gain a better understanding of their message. Active listeners also signal that they are following along with visual cues, such as nodding, eye contact, and avoiding interruptions.
By practicing active listening, all 3 of us have learned to pay attention to insight and perspective and to withhold judgment and not to react emotionally even when we disagree with the speaker. In addition, we avoid assumptions by asking clarifying questions and summarizing what we have heard so our teams can be aligned.7 We then review the available options, formulate a plan of action, and move to put the plan into place.
LEADING WITH A DOCTOR’S HEART: WHY HEALTH SYSTEM PHYSICIAN LEADERSHIP IS MORE EFFECTIVE THAN NONPHYSICIAN LEADERSHIP
In our experience and our practice, we believe that physicians are better suited to lead health systems than nonphysicians. Why is this? The answer is delegation skills, communication skills, and the ability to put ourselves in someone else’s shoes.1,2 It is also the credibility that comes through first-hand experience in the core functions of the purpose of the health system: keeping patients healthy. Statistics bear this out. According to the 2016 USNews & World Report (USNWR) ranking, the Mayo Clinic is America’s best hospital, and the Cleveland Clinic is the second best. The CEOs of both—Gianrico Farrugia and Tomislav Mihaljevic, respectively—are highly skilled physicians. In fact, both institutions have been physician-led since their inception around a century ago. A study published in 2011 examined CEOs in the top-100 best hospitals in USNWR in 3 key medical specialties: cancer, digestive disorders, and cardiovascular care. A simple question was asked: are hospitals ranked more highly when they are led by medically trained doctors or nonphysician professional managers? The analysis showed that hospital quality scores are approximately 25% higher in physician-run hospitals than in manager-run hospitals. These findings of course do not prove that doctors make better leaders, though the results are surely consistent with that assertion. Other studies also observed this correlation. For example, while research by Bloom, Sadun, and Van Reenen revealed how important good management practices are to hospital performance, they also found that the proportion of managers with clinical degrees had the strongest positive effect. In other words, the separation of clinical and managerial knowledge inside hospitals was associated with worse management.1
In an analysis of the 2019 USNWR “Best Hospitals” list, higher ranked hospitals were more frequently managed by physician executives. Furthermore, of the 21 hospitals on the 2019 USNWR “Honor Roll,” 13 were physician-managed, and the top 6—Mayo Clinic, Massachusetts General Hospital, Johns Hopkins Hospital, Cleveland Clinic, New York-Presbyterian Hospital-Columbia and Cornell, and UCLA Medical Center3—were physician-run.
We recognize, however, that not every physician has the makings of a successful CEO. As with any professional role, a physician CEO requires the capacity to manage successfully while balancing multiple needs at the same time and often innovating along the way. These skills are not always part of a physician’s role. Indeed, many physicians’ practices are highly successful because of their ability to precisely follow outlined steps, repeatedly. The work of a CEO is far from this, in that it is predictably unpredictable. In addition to the clinical knowledge a physician brings to the role, a physician CEO requires the capacity to manage successfully, with strong interpersonal skills, emotional intelligence, motivational skills, financial skills, and the ability to develop, communicate, and refine a strategic vision.2 It is also important for a CEO to actively solicit dissenting opinions, to explore nontraditional alternatives, and to hire people with skillsets differing from their own. In most department leadership roles, hiring is for skillsets similar to the leader’s own, so there are more people with these skills to serve more patients within the specialty area.
The best health system CEOs are able to listen, delegate, and celebrate the successes of those we have mentored. But that is not all. As anesthesiologists and health system leaders, we have learned the important lesson that it is not about “winning.” Rather, it is about finding the “win-win” so that everyone’s interests are satisfied and the issue is resolved with a more innovative result than if no stakeholder collaboration had occurred. Again, these are skills that are part and parcel of the anesthesiologist’s regular experience. It is also about alignment. As physicians, we create alignment that builds on the strengths of those around us. We understand the value of data and empirical evidence to strengthen our collaborative knowledge base and build consensus. Collaboration is the very foundation of a physician’s training—especially an anesthesiologist’s training.
We all value the role of mentorship. As physicians, we are natural mentors, and we are all here because of someone who mentored us. Saint and Chopra,8 in an excellent Harvard Business Review article, discuss how as a mentor, “we serve as a coach, sponsor, and connector.” The “coach” teaches how to improve in a particular skill, and the “sponsor” helps boost mentees by promoting them for specific awards or positions. It is important for people to remember that sponsors risk their own reputations when vouching for mentees. The “connector” serves as a master networker who pairs mentees with other people who can help them.8 All of us had an excellent mentor who pushed us in advancing our research, taking career risks, and recommending us for roles and responsibilities that would advance our careers and positions inside and outside of our organizations. Often, our anesthesiology departmental chairs served this critical role. Now, as CEOs, we are all paying it forward by promoting mentoring programs in our own institutions.
BEING COMMITTED TO SOMETHING BIGGER THAN YOURSELF
Perhaps one of the strongest arguments for anesthesiologists as health system CEOs is our fundamental appreciation of being part of a larger health care team. In our practice of medicine, we naturally collaborate across specialties to safely enable complex and invasive procedural interventions. This ability to be a team player is a key factor in effective leadership. Counterintuitive in some ways, strong leadership frequently avoids the use of “command and control,” which is an externalized and often rigid, coercive, and noncollaborative leadership style.9 Rather, we see ourselves as servant leaders, those who deemphasize self and prioritize the needs of others. In addition, we have learned to embrace creative and innovative thinking. All the great ideas do not need to be ours! We focus on nourishing these abilities in our teams while holding them accountable for outcomes.
WORKING WITH WHAT YOU’VE GOT: WHAT THE BEST PHYSICIAN LEADERS DO FOR INSPIRATION
Over the years, we have found that the best ideas come when we get out of our day-to-day routines. We routinely take nuggets of insight from our passions outside of work and incorporate them into our leadership tool kits. For example, M. F. Newman’s military training provided him with a safe environment to make mistakes as an early leader, to learn from those mistakes, and to appreciate mentorship. D. Lubarsky’s triathlon training and club leadership gave him both tremendous personal resilience and the experience of mentoring younger athletes. J. M. Conroy set up a not-for-profit, “Women of Impact,” to elevate women’s leadership in all aspects of medicine while fixing what is broken in health care. She has found the connections she has made with women who she would not have otherwise met to be energizing.
All 3 of us read voraciously. We find inspiration in for-pleasure books that seemingly have no connection to our work inside the health care bubble. Often, these new perspectives allow us to think of things in a way we may never have envisioned. Our recent reading list includes such titles as Premonition, by Michael Lewis, a fascinating read about the visionaries who saw COVID-19 coming 15 years ago; Madam Speaker, by Susan Page, which teaches the difference between the “inside” and the “outside” game; You’re in Charge … Now What? by Thomas Neff and James Citrin, a CEO leadership how-to; Make Your Bed, by William H. McRaven, which is about developing positive habits; Five Dysfunctions of a Team, by Patrick Lencioni, a practical guide on building great teams; American Nations, by Colin Woodward, a great insight into the cultural origins of the “tribes” in the United States that persist today; Born a Crime, by Trevor Noah, which highlights institutionalized racism in a foreign culture and, although less obvious to some, the way this is mirrored in the United States; In Vino Duplicitas, by Peter Hellman, which exposes the powerful self-delusions that attend the need to be with the “in” crowd, even among the already accomplished; and 2 classics by Ryan Holiday: Ego is the Enemy, which teaches you exactly what it says, and The Obstacle is the Way, which elucidates how to find solutions within life’s problems.
Also vital to creative thinking is removing ourselves from the daily drumbeat. This mental freedom is often the catalyst for that “ah-ha” moment when we realize the innovation we need to overcome a roadblock or to build on a success. In short, we lead by establishing the goals we want to achieve, but also by allowing creativity outside our normal routine to drive the direction we take to get there. The best ideas often come when mowing the lawn, riding through the countryside, or in the shower. These are moments when we are apart from the work but not so far removed that creative ideas cannot be sparked for later use in the workplace.
GIVING BACK: LEADING BY EXAMPLE FROM THE HEART AND POCKETBOOK
Being a truly effective leader of a health system also requires philanthropic investment. Indeed, it is the single most important example a CEO can set. In its best form, philanthropy allows people to invest in their passion, fulfill a dream, and effect change. When physician leaders invest in the organization’s capacity, they start a virtuous cycle. They enable the health system to give back to the community, which builds trust. Philanthropy allows populations on the fringes to be a part of an integrated health system, which creates better outcomes for them and the community at large. When additional stakeholders (government, patients, families, and community members) buy into that concept and benefits are realized (confirmed by the data), the benefit of collective investment is recognized and resonates with all the groups. The key is to embrace philanthropy that inures benefits to our communities that will ultimately benefit the health system.
Our collective thesis is that physicians make outstanding health system CEOs, and that anesthesiologists make the best CEOs. This is because of the training in our specialty, which orients anesthesiologists as part of a health care team rather than a solo practitioner. As anesthesiologists, we are skilled collaborators, problem solvers, and multitaskers. On our journeys to becoming CEOs, we have found it vital to become active listeners and to find perspective and inspiration in areas far afield from health care. Finally, we stress the importance of CEOs giving back to their hospital systems through personal philanthropic investment.
Name: Joanne M. Conroy, MD.
Contribution: This author helped write the manuscript and approve the final manuscript.
Name: David Lubarsky, MD, MBA.
Contribution: This author helped write and revise the manuscript and approve the final manuscript.
Name: Mark F. Newman, MD.
Contribution: This author helped write and revise the manuscript and approve the final manuscript.
This manuscript was handled by: Thomas R. Vetter, MD, MPH.