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Change

Bolwell, Brian J., MD, FACP

doi: 10.1097/01.COT.0000535066.27513.fc
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“Everyone thinks of changing the world, but no one thinks of changing himself.”—Leo Tolstoy

I flew to New York in mid-April and, as I've come to expect, there were delays. And while no one wishes for delays in their travel, it presents extra, unplanned time. Rather than walk, peruse shops, or head to the bar, I read.

I consume leadership books while others consume greasy food. I've read many, and the vast majority have common themes, lauding the importance of integrity and honesty as paramount for every leader. For example, in Seven Pillars of Servant Leadership by James Sipe and Don Frick, pillar one states that a leader must be a person of character, acting with integrity and demonstrating humility.

Similarly, James Hunter, in his book The World's Most Powerful Leadership Principle: How to Become a Servant Leader, states that “leadership development and character development are one.” Most also discuss the importance of relationships in the workplace, putting the team first, the need to communicate endlessly, and the ability to deliver results.

All of this is important, but if you want to develop as a leader, you need to put these goals, and more, into action. And that means you need to get better. You need to improve. You need to change.

Early in his book, Hunter asks the following: “Are you truly committed to personal continuous improvement? Can your ego handle receiving feedback, even emotionally painful feedback, from others, including subordinates, to better understand where you are now as a leader and where you need to be as a leader? Are you willing to do the necessary work, take the necessary risks, and suffer the necessary pain in order to close the gaps between where you currently are as a leader and where you need to be as a leader?”

And here's the rub. Not too many people really want to change. Few of us want to hear negative feedback, let alone invite negative feedback. Tolstoy knew it. Hunter knows it. Most of us understand it, but few are willing to accept and live it. A leopard does not change its spots.

This is certainly indicative of leadership in medicine. Medicine, especially academic medicine, tends to attract intellectually brilliant people who want to be experts in their field and be recognized in their work. This recognition is addictive. Such academic experts are frequently promoted to leadership positions. Unfortunately, the skills required for leading people are quite different than those required to be an academic expert.

Putting others first is foreign territory. Being humble is not part of the playbook for academic success. Admitting when you are wrong, asking for advice, developing work relationships, giving accolades to the team and not yourself, developing emotional intelligence and character—these are skills that are required of leading people, but not necessarily of being an academic leader in medicine. As a result, most academic medical leaders never evolve and never change.

The good news is most authors of leadership books believe anyone can be a better leader if they put their mind to it. The challenge is that change is hard. Change takes work. Change can be painful. But I feel it's an endeavor worth pursuing in the academic medicine space.

This leads to two questions. Why change in the first place? And, if one wants to change, how do you do it?

Generally people change because they want to get better. More importantly, they are motivated because the current state is generating some distress or anxiety that they would like to quell. The harder issue: how you do it? How do you change?

There is an excellent book by Allen Wheelis entitled How People Change. It's only 117 pages and I read it while waiting for my New York flight. It is outstanding and worth the read. It was written in 1973 and, although parts are dated, it is filled with insight. Here are my take-aways from the book:

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Insight does not produce change.

Insight is instrumental to change, but it does not directly achieve it. This is a key point. 360 evaluations, which occur when people who work with you, or work for you, are asked in a safe environment about your strengths and weaknesses as a leader, are great. These reviews generate tremendous insight into how others perceive your leadership. My 360 evaluation was painful, uncomfortable to read, and caused me distress. Although that sounds bad, it was the catalyst for my need to change. But the information does not directly lead to anything in and of itself. It's new information to you, but it is just that, information. Change requires action.

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Personality change follows behavior change.

If we want to change what we are, we must change what we do. Entrenched forces will protest and resist because the norm is easy, our norm is safe. The new mode will be unpleasant, unnatural, and anxiety provoking. Change requires new actions over a prolonged period of time. Stick with it. Work through the distress and anxiety. Feeling uncomfortable sometimes means you're on the right path.

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Freedom is required for change.

Freedom is the range of experiences seen as elective, in other words, freedom is in our choices. Freedom is opposed by necessity—life's daily obligations that, for some, become a regimented existence that is inflexible and filled with duty that cannot be altered. Contrary to what many believe, we do have freedom. Every day in our lives we have more freedom than we realize. Each moment provides freedom, thousands of individual choices. Every moment is an opportunity to make a choice. If you believe you are shackled by necessity or obligation or the drudgery of daily life, change will never be in your grasp. You need the mindset to have the free will to change.

Wheelis writes, “for some people, necessity expands cancerously, every possibility of invention and variation being transformed into inflexible routine until all freedom is eaten away...the more we are strong and daring, the more we will diminish necessity in favor of expanding freedom.”

The sequence for successful evolution is suffering (or significant anxiety), insight, will, action, change.

The good news is that if one can achieve these steps and change; if one's destiny is shaped from within, then one has become more of a creator...and gained freedom.

I think about this stuff a lot because I am extremely motivated to get better. I agree with these points and I have changed.

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Step 1

Step 1 is to want to get better. Not everyone does. Many are prisoners of necessity and feel that external forces prevent the idea of change, while others are basically satisfied with who they are and see no reason for character development. Sadly, I think this is true of most people, and these are the people who Tolstoy referred to when he said everyone wants to change the world but nobody wants to change themselves.

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Step 2

Step 2 is insight into your current behavior and leadership skills (or lack thereof). This is where honest feedback, including 360 evaluations, is essential.

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Step 3

Step 3 is to generate the energy, and the will, to deal with the discomfort of change. Wheelis suggests anger is a useful tool for this step. I am not sure about that, but I do agree that the will to change is required.

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Step 4

Step 4 is the most important point of the entire book in my opinion. If you want to change, you must change what you do. You must change behavior. And you must do this over and over again. This has been my biggest evolution. I have drastically changed many of my behaviors. I am more even. I am calmer, especially in public. I try to use conflict as an educational opportunity. I still slip, but I am different today than I was 15 years ago.

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Step 5

The revelation of the book for me was step 5. Change generates freedom. This is a profound point. If one's destiny is shaped from within, then freedom is achieved.

Leadership development and character development are one and the same. If you want to be a better leader you need to change. Start with generating insight about your current actions. Then follow the steps described above. They make sense, and they work. What you may not realize is that if you change from within, the result is freedom. It's a long journey and a daily challenge, but if successful, ridding yourself from some of the chains of necessity and gaining more freedom is pretty darn cool.

BRIAN J. BOLWELL, MD, FACP, is Chairman of the Taussig Cancer Institute and Professor of Medicine at the Cleveland Clinic Lerner School of Medicine. Cleveland Clinic is a top 10 cancer hospital according to U.S. News & World Report.

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