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Straight Talk: Today’s Cancer Centers

Brian J. Bolwell, MD, FACP, shares insight on the issues that impact cancer leaders.

Tuesday, February 4, 2020

​By Brian J. Bolwell, MD, FA CP


People who have careers in health care generally say they entered the field because they wanted to help people.
Implicit in such a statement is that they possess high levels of empathy. Empathy is a character trait that many aspire to obtain and is frequently lauded as a quintessential characteristic of emotional intelligence. For those of us in oncology, the ability to be empathetic to those with cancer is an essential part of the job.

I recently came across an article in Wired magazine by Robin Wright entitled “Empathy Is Tearing Us Apart” that caused me to reevaluate my one-dimensional view of empathy. Previously, I thought you either possessed it or you did not. The backdrop of the article is that current animosity between political parties across the country is
a real issue, and the author examined potential drivers that intensify it. Wright quotes a recent study that found “empathetic concern does not reduce partisan animosity in the electorate and in some respects even exacerbates it.”

The study found that Americans who scored high on an empathy scale were more likely to score higher not only on the favorability rating of their political party of choice, but also in the degree of negativity rating towards the opposing party. So, a high level of empathy was polarizing, as highly empathetic people also had high negative feelings towards the opposing group.

Clearly, people do not deploy empathy indiscriminately. People are selective in how they utilize empathy. Wright describes evidence that empathy is deployed tactically. But more importantly, the study showed that highly empathetic people view the out-group more unfavorably (relative to their own group) than low empathy people.
Therefore, their feelings of empathy vanished when they viewed those with opposing political views.

When you ask people about empathy, they naturally reflect on times when they do indeed feel empathy, and not on the political partisanship of the world. The fact that highly empathetic people have heightened negative emotions toward the out-group then strengthens the opposite feelings that the out-group has towards them. It becomes
a vicious cycle. This essay certainly can explain some of the current polarization of American politics today.

This is an obvious contrast to being an empathetic physician. In health care, we are supposed to care for everyone, regardless of background, socioeconomic status, or beliefs. We have to deploy empathy towards everyone we treat. But we cannot choose who receives our empathy. As learned, kind, and caring individuals, it’s our duty to apply
our knowledge and compassion to everyone. And yet, all of us, to some degree, deploy our reservoir of empathy quite discriminately to those we like and agree with, and withhold it from those we oppose. It’s important to be aware of the psychological tendency to treat with heightened negativity those you disagree with.

Nobody’s perfect. But being aware of our tendencies and unconscious bias is an opportunity to self-reflect. 

As a leader, it’s important to evaluate and self-reflect to ensure you are able to learn and grow. I talk about empathy all the time yet previously had not given thought to how I tactically deploy it. Rather than having it or not, I now look at the scope and direction of my empathy. 

Leadership is about supporting others. Generally, they are part of your team or organization. A limited leader defines their organization narrowly. This could mean the individuals they interact with every day or only the people who agree with them. It’s much harder to use your influence and support those who do not immediately
touch your team. It’s even more difficult to support those who you do not agree with or who don’t agree with you. But that is what a true leader must do.

Ask yourself what type of leader you aspire to be. A leader who is limited, or one who can take on the challenges and lead those who are difficult, and even more importantly, a leader who can inspire and elevate others from afar.

The path forward may be self-reflection. Living your values or speaking empty words? If you believe in the value of empathy, check yourself. Are you empathetic towards those who share your views and those who oppose them? Are you exhibiting empathy to all? Can you practice servant leadership to those outside your immediate chain of command? Can you affect those on the fringe of your organization?

Give this some thought, as you witness behavior of our leaders nationally, and as you yourself grow as a leader. Tolerance for those who you oppose may be something to consider. As a leader, using your authority to support not just the favored group but also others may be an opportunity to display wisdom as well as real empathy. Most
importantly, constantly self-reflect. Examine not just what you think but what you do—every single day. What you do is who you are. We all think we are empathetic. But reflect on how you behave. That will define how much empathy you truly possess. 

Tuesday, January 7, 2020

By Brian J. Bolwell, MD, FACP

A common challenge for leaders is in-person communication; some are skilled, but many struggle. The ability to effectively communicate is undoubtedly an essential skill for leadership and it tends to be a central theme in books, research, and seminars. Although it's critical for success, communication skills are rarely taught beyond the basics unless you seek outside counsel from an executive coach or media training.

In my ongoing study of leadership, I recently completed formal training to become an executive coach. They even gave me a certificate! It turns out, just as with leadership, there is a vast array of literature on coaching. The Center for Creative Leadership has an excellent textbook entitled Compass: Your Guide for Leadership Development and Coaching. This book devotes a chapter to communication, outlining specific barriers to effective communication and what steps we can take to get better at this essential skill.

Attentive Listening

The first barrier to effective communication is that you have not developed attentive listening skills. Wow, give that some thought. Most leaders believe communication to be all about delivering their personal vision or priorities. But before you can be a good communicator, you need to understand your team—their questions, confusion, struggles, barriers, doubts, and fears. The only way to know this is to listen to your team. Ask them questions and truly take the time and energy to listen. You can't know your team unless you engage with them… and listen to what they say. One of the principles of executive coaching is to always be an active listener and resist the temptation to prematurely offer solutions. Hear what your team has to say before you craft a response.

Pay Attention to Emotions

It's important to consider your team's emotional response to the message you're sharing. If you continue on without regard to their emotions, there is a good chance that significant parts of your message will be lost. You will appear to be tone deaf if your communication ignores the downstream consequences of your words.

When delivering a message, directive or initiative, build the time and space for feedback. Be able to articulate not only what you are going to do (and asking your team to do) but how you expect your team to accomplish tasks. If you care about the emotional impact of your message, you can proactively address and mitigate your team's concerns and fears. So learn to speak to the hearts of people. This one is very difficult for physicians who are so data-driven and consumed with numbers. You must acknowledge the emotions of your audience and address their issues directly.

Share the Big Picture…Constantly

Another pitfall is if you fail to convey the big picture to your employees. I think this is common in health care, especially physician leaders. Physicians are very good at presentations that focus on the specific details of a given medical topic. But communication to people who are part of your workforce must be thematic and constantly refer back to the big picture. As a leader, it's your job to ensure your teams understand the rationale for big decisions. Do not overwhelm people with details they do not need to know, but do share how they fit into the organization. You must tie how their work relates to your topic or presentation, cascading back up to the mission, values, and big picture.

Be All About the "We"

Many physicians have a communication style that comes across as too slick or manipulative. I think we have all witnessed this as physicians love to use big words and appear clever. Being confident is great, but not at the risk of alienating others. In order to more effectively communicate, you need to get the perspective of others first, and focus on "we" not "me."

Stop the Spin

Find out what is on the mind of your audience, and address it directly. Discuss the fact that we are all in this together. Next, be straight. Tell the truth. Stop spinning. Give your team credit that they know spin when they hear it. We see this all the time. A leader is asked a difficult question and that leader never addresses the issue. Better to be authentic and say "I don't know" if you don't, or even better, lay out the facts honestly and directly.

Learn From the Best

We all have seen leaders who are excellent communicators. Watch them. Ask them questions about what tools they like to use. Steal their ideas! For me, I like telling stories. It's an easy way to connect with people. Effective communicators are always masters at storytelling. They resonate with others by making it personal.

The fundamental points are these: listen to your team and understand how they feel. Then, be simple and straight. If you are, then you likely are a skilled communicator. No matter what, work on connection and authenticity, skills we can all stretch that will help us communicate.

Wednesday, November 6, 2019

By Brian J. Bolwell, MD, FACP

I recently read a wonderful and profound article about values by Mark Manson. He has a highly irreverent writing style, and his bestselling book features a word beginning with the letter "F" that no one should use in a formal setting.

Manson says there are innumerable books about self-help and how to grow as a person and how to achieve success. The limitation of these texts is that they focus on the end goal, like growing, without focusing on values. There are many examples of tyrannical dictators throughout history who may have accomplished success on some level, but their actions led to horrific and catastrophic consequences. Success cannot just be about a superficial definition of personal achievement. Life is not just about growing as a person to become better; it must be about defining what a better person is. It's about defining your values, and possibly realigning them in a more positive direction.

 Importantly, our behavior defines our true values. We might say we are a leader that embraces psychological safety, but if we bristle whenever we are questioned, then clearly we are not living our stated value. Actions don't lie. Many of us state values we wish we had instead of values we actually possess. We lie to ourselves. I can't stress it enough—how we behave (and not what we say) reflects our real values.

A corollary to this is self-love. Self-love is important on many levels, including developing resilience. But if our primary value is self-love, all you will do (because actions define our values) is chase one high after another. We therefore need to value something above ourselves. It can be a cause, or a moral code, or being an empathetic cancer physician. The point is to choose something positive and good because positive values add meaning and purpose to life.

Defining good versus bad values is not a linear exercise, but in general, good values are evidence-based and controllable. Bad values are emotion-based and uncontrollable. Manson says that most people, most of the time, make decisions via feelings and not based on knowledge. Given that our feelings are generally self-centered, this leads to decisions based on short-term goals, and decisions that can be warped. People that lead their lives based on goals fueled by emotion are on a never-ending quest for more. The way out is to stop living via one's emotions and find a purpose that is bigger than ourselves. It must be a real purpose that is rational and, ideally, inspiring. Honesty, vulnerability, and humility are good values. Wanting to feel good all the time is not.

Manson closes his article by discussing steps necessary to change and evolve one's values. Step one requires that the old value fails followed by self-awareness about this failure. From failure and awareness, you form new values and hopefully live them.

I have re-read this essay many times. Basically, this is an introduction to servant leadership. Most of the literature about servant leadership is about values. Honesty, courage, transparency. It's all good. Why then do relatively few leaders live good values consistently? Why are there so few servant leaders? Why are so many people, especially in academic medicine, consumed with values that are emotion-based? As I've previously written, I think it is because they are rewarded for individual-focused, emotion-based values. From podium presentations to grants or notoriety and fame, the individual academic medicine goal is about an individual. The reward system for academic superstars fuels values that are emotion-based. And, as stated above, the superstars chase one high after another. It explains, at least in part, why so many stars have such a hard time focusing on the team instead of themselves.

If you want to get better, if you want to change, you must change what you do (see Change, Oncology Times 40(11):16-17). Well, Manson's essay says the same thing about values. We all live our values. What we do is what we really are. It's not what we say we are. Therefore, if you want to adopt more positive values, you must change what you do. Your actions must change. The problem is that it is very hard for people to change their actions, so, as a result, even with insight, relatively few people take the step to change. But it can be done.

If you feel like you are on a Sisyphean climb chasing after your own personal goals, consider a pause for self-reflection. Think about values that really matter. Contemplate if you are really living those vales. If not, try to have the courage and vulnerability to change your behavior. If you can truly change and live positive values, it not only feels good, it can be liberating. Living more positive values may not lead to more personal success. It may not be noticed by many. But at the end of the day, it will feel good. And I think that one positive step that represents change towards more positive values will only lead to more steps. You will not need the validation of others for your identity or sense of purpose. The liberation is that how you act is totally up to you, and if you are willing, you can act in wonderful ways that go far beyond you.


Friday, October 18, 2019

By Brian J. Bolwell, MD, FACP

I receive constant and varied feedback on my columns. While most people seem to appreciate the content, some think that leadership is not only easy but also intuitive. Everyone is certainly entitled to their opinion; however, I would venture a guess that those who claim it's easy are not, in fact, in organizational leadership positions.

The reality is, leadership presents many challenges. Some leaders believe that being a leader is analogous to being a reservoir for problems, and a dumping ground for everyone's complaints, woes, and issues. One of the most common challenges is conflict resolution, or taking the complaints and problems and providing counsel and guidance. The conflict may be between others in your organization, or it may involve you personally. Sometimes it is the result of hard conversations that are necessary to hold a person accountable. I am far from an expert at conflict resolution, but I have improved over the years, primarily because I picked up some useful tools.

Talk to People

I have previously discussed the importance of face-to-face interaction (see Talk to People, Oncology Times 2017;39(20):17), but I cannot emphasize enough that having a conversation (not an email) is crucial when conflict arises. It is inevitable that the accurate tone and message through email will get distorted by the reader… especially if they are in a conflict.

Always have a conversation and observe how it is perceived. And, when having that conversation, remember to follow two fundamental leadership principles: listen and be honest. You must hear the other person (or persons) out, and grasp both the surface message and, more importantly, the non-verbal cues. The only way to do that is to listen. And while honesty is often hard, it's always the proper path.

Be the Teacher

Our work environment frequently generates interpersonal conflict. Sometimes this conflict can get heated. When that occurs, nothing positive results and usually somebody gets hurt. When in conflict, consider that the other person does not know as much about the topic in question as you do or they are missing key facts. If that is indeed the case, the conflict is an educational opportunity. Take a breath, and review the topic. Educate the other person. Learn from them as well. I have used this approach many times and, at the very least, it can reduce the tension in the room.

Right the Wrongs

When in conflict with somebody you respect, do three things. First, apologize if the conflict results in any harm. Do not mess around with this. Really apologize. Second, you need to forgive (see Let It Go, Oncology Times 2018;40(24):29). Holding grudges hurts the team, the other person, and especially you. True forgiveness requires courage and inner strength, but more than that, it is always the right thing to do. Finally, if the person in conflict with you is a colleague that you admire or, more importantly, a friend, then make sure they know they matter. Tell them they are doing well. And tell them that they have many wonderful qualities, specifically stating what those qualities are. This is important stuff.

As a leader, with both your words and actions, you influence those around you. It's up to you, with each interaction—saying hello in a momentary passing or in large meetings—to have a positive impact. It's your job to be the bigger person, as your words and title carry weight. Make sure people know their value. Let people know during conflict that they are heard, appreciated, and valued. Right wrongs when you can.

Perception, Not Intention

Not uncommonly, one person feels hurt after an encounter, which surprises the other. How can this be? Hurt feelings can arise in any situation, but especially in conflict. How something is stated, or the intent behind the words, is not always how they are perceived or interpreted. That is key. It doesn't matter what you say, it matters what the other person hears. It's not just the message, it's also how the message is delivered that matters. My opportunity, to this day, is to remember the difference between my intent and my impact. Of course my intentions are always noble (at least they are to me). But if my impact is off-putting, then my message is lost.

It's All About You

A person's core values are critically important when trying to understand their behaviors. This can get to the root of what causes conflict in the first place. Looking inward, understanding your values, and what makes you, YOU, is imperative to understanding your response. Why does the behavior of some people drive others nuts? Or, to make it more personal, when you get angry about the behaviors or actions of somebody else, why are you so angry? What causes conflict?

Most of the time, it's personal. One reason is that the behavior of the other person is in conflict with your core values. If you are aware of this basic fact, then maybe you will be able to better manage the interaction. For example, honesty is a big deal to me. It is a core value. But the fact is, honesty may not be a core value to everyone. If you are clear about your core values, then hopefully you will be more aware of your triggers that lead to anger, or conflict, or your responses. That knowledge and awareness should empower you to manage any encounter in a more productive way. Knowing is half the battle.

Leadership is about working with other people. While the goals of servant leadership are real and the principles work, unfortunately, leadership also involves conflict management. Basic tools can help. For me, exploring my core values is a useful way to identify why I might be stressed about something. Plus, examining the core values of others is frequently a useful strategy to identify the origins of a conflict. With all of these tools, it is beneficial to pause. And remember, nobody ever said this leadership stuff would be easy.

Thursday, September 5, 2019

I recently led a retreat of our institute leaders. The goal was to discuss challenges and opportunities in our current health care environment and to discuss leadership approaches to some of the issues we face every day. Reimbursement for most of what we do in clinical medicine is declining annually. This leads to budget shortfalls that need to be addressed. Physician burnout is real, and many physicians feel less autonomy. For those of us in academic medicine, the pressures to fulfill both our clinical obligations and our academic mission can be difficult to achieve simultaneously. All these issues (and more) make clinical medical leadership particularly complex. So we convened clinical leaders to discuss these topics, and I was to lead the session.

I planned an agenda and crafted an introduction to frame the morning. The group was from all over the organization, but the challenges were fairly consistent. I devoted time for people to openly, and in a safe environment, articulate why their concerns seemed daunting and difficult to manage. The first hour was a calm, honest, and highly participatory dialogue of these items. In fact, I did not devote enough time to this part and extended the session discussing our collective challenges.

Importantly, the next step was to focus on what we could do as leaders in a positive and problem-solving way. There were two reasons for this. First, as I recently wrote, the environment is what it is, but all of us as leaders can respond as we wish. It makes sense to me to respond to difficulties, whatever they may be, by being the best leader I can be. Secondly, there was an abundance of knowledge and talent in the room and I knew our time together was an ideal way to harness this collective wisdom and strategize practical solutions to some of our problems. To set the stage for both of these goals, we decided to ask the question—what were you like when you were at your best?

It's a good question. When I posed this question to the group, one basic theme emerged. Some viewed themselves as leaders, and some as managers. Those that were self-described managers tended to take organizational edicts verbatim. Those who felt they were leaders tended to carry out such organizational imperatives in a more nuanced, individualistic way, not necessarily applying the requests broadly to all. The discussion led me to ask the question of myself.

To clarify, I am not referring to when I was at my best athletically when I was younger. That is admittedly a low bar. I am not referring to when I was at my best as a parent. In reality, it's the times that I messed up as a parent, and not any successes, that are still quite fresh in my brain. I am not referring to my personal academic career. This is a leadership question. As a leader, when were you at your best?

It turns out that when I feel that I am doing well in my leadership role, it's really not about me, but rather the team. The team is doing well. The "team" can be the cancer center as a whole or a program—the compartmentalization is not important. When I feel good about myself as a leader, it's usually because the team is thriving.

So how does that happen? The individuals on your team matter. It starts with recruiting and continues with retention. I spend a lot of time on recruiting. I look for people who are smart, who care, who can work in a team environment, who have resilience. Not just those individuals with a killer resume. While important, their resumes or CVs are a fairly small part of the equation. The more you recruit, the better you get at it. Unfortunately, I see too many leaders who treat recruiting as an afterthought or who delegate it to others. This is a mistake. Leaders must be active in recruiting.

Once you have them, how do you keep the good people? You create an environment that they are proud of that has many good people to work with and where people are held accountable. Some leaders do not "get" accountability, perhaps because they shy away from hard or uncomfortable conversations. Perhaps they delegate accountability. Maybe they fear that accountability will set a negative tone. In fact, accountability lifts the team. If you have high-performing people and you ignore the underperformer, you will only deflate your good people. Trust will erode. Culture will diminish. Whereas if you address personnel challenges in an empathetic but honest way, all will appreciate it, trust will rise, and culture will elevate.

When things are going well, clarity exists. Responsibility is fully defined and socialized. Data is shared frequently. Transparency is the rule. The group discusses and agrees on who is responsible for what. Tasks and issues are communicated in simple and clear ways. Clear communications is not trivial and should not be relegated to an afterthought. For some reason, academics thrive on ostentatious vocabulary and have an uncanny ability to make simple things complicated. Please avoid this temptation! Talk in simple and direct terms. Be clear and to the point.

Additionally, actively cultivate a safe environment for feedback. Invite your team to disagree with you, and/or to tell you when you are wrong. Address challenges and problems openly and honestly—no sacred cows. If there are obstacles, then the role of the leader is to remove them. Frequently these are political obstacles. So be it. My job is to deal with those barriers. Then, when success is achieved, credit is dispersed freely. My role as a leader is to credit others. Credit the team that is in the trenches and actually doing the work. When part of your organization is going well, others want to emulate it. They want to see how success was achieved and mimic it. The more good people you have, the more good people want to join you and be part of the organization. Everyone wants to be part of a successful, nurturing, and enjoyable culture. Good teams attract good talent.

Thusly, I am at my best as a leader when my team is at its best. I provide transparency and honesty. I talk in simple terms and I address what needs to be addressed. I hire good people and have their back. I admit when I make mistakes. I ask for advice and listen. I provide a safe environment for open dialogue.

How about you? When were you at your best as a leader? If your answer is all about your personal success, then I suggest reading any of the leadership books I have previously referenced in this column. Work is about people and relationships. Step one as a leader is to go beyond ordering people to do things because you are the boss, and instead form connections with people in your organization. If you believe that your personal success as a leader is all about you, please stop, put your title on the shelf, and go talk to your people and get to know them. You will be pleasantly surprised at what happens next.