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Straight Talk: Today’s Cancer Centers

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

Thursday, February 18, 2021

By Brian J. Bolwell, MD, FACP​

Dr. Joe Simone left us unexpectedly. He was known to be the Yoda of cancer center directors. He had been the CEO of St. Jude's Children's Research Hospital, Physician-in-Chief at Memorial Sloan Kettering Cancer Center, and Clinical Director of the Huntsman Cancer Institute at the University of Utah. He was the person you called if you wanted insight about academic cancer centers. He had seen it all and had an enormous fund of knowledge about academic medicine.

Joe may be best known for his masterful paper published in 1999, “Understanding Academic Medical Centers: Simone's Maxims." This must-read begins by stating the truism “Institutions Don't Love you Back" and escalates from there. Read it today, regardless of whether or not you have read it before. You'll always learn something new.

Joe was a huge influence on me, for a variety of reasons. I met him several times, and served on a consultative committee with him. He was a man of good cheer, obviously extremely talented, but filled with humility. He knew how to run a meeting. He kept all stakeholders engaged and participatory, and adroitly avoided tedium by completing discussions efficiently and, if necessary, firmly. I learned a lot just by watching him—how he treated others, how he engaged others, and most importantly, how he led.

And that is how he influenced me most. He wrote about leadership. Whenever I write a column or essay about leadership, I always think about Joe.

My interest in leadership principles began when I received my personal 360 evaluation about my leadership skills about 20 years ago. I thought I was a wonderful leader and that I knew it all. Well, I received a 25-page evaluation about my leadership skills, and 24.5 pages of it were highly critical. I thought I was a good leader, but in reality I was nowhere close to being the leader I wanted to be. I knew very little about the entire concept. But it was a wonderful opportunity for me to learn and get better.

So I started reading leadership books voraciously. I realized that if I wanted to improve, I needed to change my behaviors and actions. Simply gaining insight was not enough—I needed to change. But I also learned that all the leadership books that were available were about corporate America. There was essentially no literature on leadership in health care.

That is when I started to read Dr. Simone's essays on leadership. First, I discovered Simone's Maxims. I must have read it 10 times back then. An entire section is about leadership. He wrote “Leadership does matter….the ill effects of poor leadership, at any level from the CEO to department head to housekeeping, insidiously permeate an entire institution…what makes great leaders is not a secret—they have courage and character, they remain focused on the important aspects of an issue in the midst of chaos, and they articulate a consistent, simple public vision." Wow. That is a playbook for leadership in a few sentences. I think the concept of remaining focused on the key aspect of an issue in the midst of chaos is especially true today.

The complexity of health care keeps growing. In the past 12 months, the pandemic has made such complexity more acute, but challenges with insurance pre-authorizations, financial toxicities for patients, disparities in care delivery, a new age of genomics and immunologic therapies, and more means that a leader can be easily drawn in an infinite number of directions. More than ever, staying focused on the core of an issue and not the stuff on the periphery is absolutely essential for effective health care leadership.

Dr. Simone wrote many leadership columns in Oncology Times. One of his best is “The Best Advice I Ever Received." He said that, when he first became CEO of St. Jude's, a mentor advised him to “take time to think; make it part of your schedule." He did so, and said that it was invaluable to him. This is something I have also tried to do. Not just to give me time to think, but also to have time to deal with the unexpected.

If you are a leader, such as chair of a big cancer center, unexpected challenges are ubiquitous and occur almost daily. They can create chaos if you are not careful. It's better to expect the unexpected and have time to think about how to manage the issue, and then address it in a well-thought-out manner.

Later in this essay Dr. Simone writes about his father, who told him “you should never hate anyone; you should hate what they do….I will never forget that advice, the best of them all." No need for me to add to that.

My favorite essay from Dr. Simone is one of his last, published in 2017, entitled, “What Makes a Great leader?" In this essay, he references Peter Drucker, W. Edwards Deming, and Abraham Lincoln. He ends this essay with a brilliant summary of the core principles of great leadership: “First, though he remains confident in his final decision, he must have humility in sufficient measure to mitigate arrogance and promote active listening to those holding other views.

“Second, he knows that at some time he will be asked to compromise basic principles. If his values cannot be sustained because of the environment, the great leader may choose to lose favor, be fired, or quit over a key principle. If the position or stature or pay means so much that the leader will not put his job on the line for a core value, he is no longer free and has taken a step down a slippery slope. Great leaders have the mindset upon taking a position of holding core values and principles dear, no matter what the cost."

This is why I believe that courage, and living your values, are the key ingredients that separate great leaders from others. Joe knew this, and lived it.

So you can always learn from Dr. Simone. But for me it goes further. He showed me that you could talk, and write, about leadership in health care, and specifically, in oncology. He was the only person that I knew who was doing this, and doing it so well. Writing about leadership, and teaching it, became my new North Star. I find the subject endlessly fascinating, and I keep discovering new opportunities to improve my personal leadership. But Joe was the pioneer.

When I wrote my first essay on leadership for Oncology Times, I sent it to Joe for his comments. He was gracious and positive. That validation gave me the confidence to start writing my leadership column on a regular basis.

So I will keep at it and continue to write about what I learn about leadership. But I will always be following in the great man's footsteps. As will so many others.

Friday, November 13, 2020

By Brian J. Bolwell, MD, FACP

I used to be a busy clinician. I was, in fact, a very busy clinician for 25 years. Being in the clinical trenches was great. My clinical skills were well-honed in my area of expertise (bone marrow transplantation). I had significant clinical credibility throughout the organization, and I was known as a go-to doc. Covering the inpatient service for many weeks throughout the year was wearing, but, in general, it was highly rewarding.

I remember during that time that I had a significant disdain for what I called “meeting doctors," those in leadership who were rarely in the clinical trenches and who spent most of their time in various leadership meetings throughout the day. I thought these meeting doctors were people who did not “get it" and whose time could be better used elsewhere, like seeing some patients.

So now I am a “meeting doctor." I still see some patients, but far fewer than I used to. Leading a cancer center is different. Instead of in the trenches, I now find myself in a lot of meetings. All leaders have lots of meetings. I highly value most of them, especially one-on-one meetings with various members of the cancer center, both physician and non-physician. I always learn stuff about the cancer center, or their careers, or about science, during those meetings.

Meetings are important for building consensus and making decisions. But there is not an abundance of literature about how to lead or use meetings effectively. In my experience, one of the keys is to provide a safe haven for open dialogue. The issue of psychological safety is extremely important. The best decisions are made when all participate, and when many opinions are offered. The only way to achieve psychological safety is to seek it out, and make it abundantly clear to all that you want to hear differing opinions, and there will never be retribution for those who provide a contrary perspective.

I recently read a short, excellent essay in the Harvard Business Review entitled “7 Strategies for Better Group Decision-Making" by Torben Emmerling and Duncan Rooders. The first point they make is to keep the meeting group small when you need to make an important decision. Larger groups tend to have a higher desire to preserve harmony and to prevent dissent. Additionally, larger groups tend to evaluate information that is consistent with pre-existing beliefs. When I read this, I immediately wanted to read the entire essay because these points resonated with me.

I have been in many meetings with a large group. Dissenting opinions are rare in these settings, and most of the conversation is dialogue from people agreeing with the leader's point. The larger the group, the more difficult it is to provide a different opinion. When you're the only person providing a different opinion, it usually doesn't feel very good. I know this from personal experience. You risk being viewed as not part of the group, or not being a team player, or being emotionally unintelligent, or worse. Smaller groups make it easier for all to share their opinions.

The next points made by the authors build on tactics to elicit differing opinions. They suggest choosing a heterogeneous group over a homogenous one, and appointing a strategic dissenter. The dissenter is tasked with acting as a counterforce to the group's consensus. They believe that having a contrarian will lead to better decision-making, and better outcomes. This also makes sense and is aligned with the importance of psychological safety.

Indeed, in Patrick Lencioni's excellent book, The Five Dysfunctions of a Team, his first two dysfunctions are a lack of trust and a fear of conflict. He strongly believes that a willingness to disagree, and to have healthy conflict, is essential for a well-functioning team. Therefore, having a team member be assigned the role of dissenter will insure conflict that will likely lead to a deeper discussion.

The essay by Emmerling and Rooders provides three suggestions of how to deliver a dissenting opinion. Focus feedback on the strategy, not on the individual; express comments as a suggestion, not a mandate; and express feedback in a way that shows that you appreciate the individuals working towards your collective goal. These suggestions highlight the importance of aligning impact with intent. When providing differing opinions, one's intent is generally noble—you are trying to elevate the dialogue and come to a better decision.

But if you are too blunt, or too personal, with your feedback then your impact will be quite different. You will be viewed in a negative light and lose any potential positive impact. This has been an issue that I have historically struggled with. I wish I could take back some of my dissenting feedback because I know that sometimes my impact totally negated my intent. This has been a hard won lesson for me, and it's a very important lesson to learn.

Another excellent point raised by the authors is to avoid an over-reliance on experts in meetings. While experts may be able to add useful information, the essay states that “blind trust in expert opinions can make the group susceptible to biases and distort the outcome." I agree. Far too often have I seen groups cave to the opinion of a so-called expert when more data from frontline employees about the issue in question would be more useful. In general, the knowledge of the people most familiar with the topic at hand is more important.

So, for those of you who are leaders and lead meetings, remember some simple points. If you need to make an important decision, keep the meeting size small. Whether you are leading or attending a meeting, remember that healthy conflict is essential for the best decisions. Reward, rather than punish, those who offer differing opinions. When offering another opinion, be respectful to all and focus on ideas and not on individuals. Finally, have confidence that your team will arrive at a good decision using their knowledge and skills, and avoid an overreliance on experts.

And it's a good idea, no matter what your leadership role is, to continue to see patients in clinic. It is rewarding, enjoyable, and helps when replying to those people who accuse you of not “getting it."

Wednesday, September 23, 2020

By Brian J. Bolwell, MD, FACP 

The more I read about leadership, the easier it is to identify fundamental principles that are repeatedly discussed– like trust. Stephen Covey's book, The Speed of Trust, is a personal favorite. One highlight is Covey's concept of Relationship Trust and the core behaviors needed to generate trust. Talk straight. Tell the truth. Do not spin facts. That all sounds simple, but many leaders struggle to do the things that generate trust.

In July's Harvard Business Review, there's an article focused on trust by Frances Frei and Anne Morriss entitled, Begin with Trust. The authors state that trust is the basis for almost everything we do as civilized people, and while trust is essential for effective leadership, many leaders fall short when trying to generate trust. They state, "the traditional leadership narrative is all about you: your vision, your talents, and your charisma. But leadership really isn't about you. It's about empowering other people as a result of your presence, and about making sure that the impact of your leadership continues in your absence. Your job as a leader is to create the conditions for your people to fully realize their own capacity and power."

I have emphasized this point before. As stated above, it's mostly about supporting your people. It's about recruiting talented people to join your team, getting your team whatever they need to excel, and when they do, giving them credit for their success. In short, doing whatever it takes to give your team whatever they need to succeed.

So how do you build trust? Frei and Morriss state that there are three core drivers of trust: authenticity, logic, and empathy. They write: "People tend to trust you when they believe they are interacting with the real you (authenticity), when they have faith in your judgment and competence (logic), and when they feel that you care about them (empathy)."

Empathy: People don't care what you know until they know that you care—a common but useful phrase used in leadership texts. I would argue that people can't know that you care unless you interact with them. So consider communicating with your team in a variety of ways. More importantly, you need to demonstrate that you have their collective backs. You cannot just say that you care about them. You have to prove it. Do what you need to do for your team.

Authenticity: Authenticity is a challenge as too often leaders appear to be playing a role. They seem to be reading from a script. They seem stiff, or they spin the truth, or they just talk about good stuff (and not the hard issues), or they avoid eye contact, or they say things that are obviously not true, or they demonstrate through actions that they are not being straight and true. When this occurs, it's easily perceived by their audience and peers. People are hard-wired to spot authenticity, or the lack thereof.

I suggest that you let your guard down and just be who you are. Some would argue you have to show invincibility as a leader, as if you have every answer and are not afraid. In trying times, I prefer to showcase humanity and share my uncertainty. In doing so I always reaffirm that we are in it together. I would argue being honest about uncertainty is relatable and far more engaging for your teams. We are human, we make mistakes, and collectively, we learn.


Logic: Ultimately, you need to show that you know what you are doing and you can achieve results. You need to get things done, and get them done at a high level. Many books on Servant Leadership focus solely on character development, the importance of evolving your behaviors in a positive way and of continued self-reflection, insight, and learning. All of these things are important, but if you want to be an effective leader, you need to deliver results. You need to be able to think clearly and logically. As a leader, you must hit your business objectives and also translate them in digestible terms for your teams. Your role is to perform well and achieve goals but also to ensure everyone on your team understands how their work impacts the organization so the team is aligned with a higher purpose.

COVID-19 has been a test of leadership. It is fair to ask if your leaders have performed well, and, if so, how? Likely it's because they have performed well in one or more of these three areas—authenticity, logic, or empathy. In the COVID-19 era, ask yourself how can you be a better leader?

Step one is to show that your leadership team can deliver. Your leadership team must show that they can make clear decisions, adapt in this constantly evolving situation, and offer clear organizational recommendations. And you need at all levels to be able to effectively communicate.

Next, it is imperative that your team knows that their safety and welfare are your top priority. Without your team, you cannot do anything. You certainly cannot deliver clinical care. You cannot do clinical research. This is a time to truly act as a servant leader and put your team above everything else. Explore all workplace options, including work from home and social distancing. It's not enough to say that you care about your team, you must prove it.

Finally, be you. Let your team know that you can't stand this pandemic either. Let them know if you are scared. Let them see you unfiltered. If you are an accomplished leader, you probably already have plenty of gravitas. Now is the time, more than ever, for them to see that you are human.

I send out regular emails to everyone in the cancer center, not just to my direct reports. In addition to contextualizing important data about our response to COVID-19, these emails include stories about me and my experiences during these strange times. My hope in sharing facts as well as vulnerabilities is to bring about moments of connection and levity. I want to help my team cope with the reality of our situation. I've received feedback stating the importance of these emails to my team's resiliency. My correspondence is not perfect, it's flawed—like me—and that brings about an unprecedented level of connection within the cancer center.

As you deal with the challenges of this pandemic, remember the importance of delivering and developing trust, with logic, empathy and authenticity.

Especially authenticity.



Friday, July 10, 2020

By Brian J. Bolwell, MD, FACP

I recently read a Harvard Business Review article entitled, "The Elements of Good Judgment" by Sir Andrew Likierman. The graphics accompanying the article are pictures of an owl from various angles, presumably because owls are believed to be wise. I can't validate the wisdom of owls, but the tenants outlined on decision-making and how to exercise good judgment are exemplary qualities for aspiring or seasoned leaders alike.

The author defines judgment as "the ability to combine personal qualities with relevant knowledge and experience to form opinions and make decisions." He describes various components of good judgment beginning with learning which includes filtering out your own biases—conscious and unconscious. Second, is the skill of listening, emphasizing the importance of being skeptical when presented information in order to identify gaps in data. He further suggests that one should try to discern any biases from the source of information that is the basis for a decision. Finally, he highly recommends getting input from people on more than one side of an argument—especially from people with whom you disagree or can offer a dissenting opinion to the topic at hand.

His breakdown of good judgment has a direct correlation to leadership. I especially like the advice that one should be skeptical of information that does not make sense. I frequently encounter information that seems dubious. For instance, I'm given a data set, and the presenter wants me to agree with the conclusion of the presentation straight away. But as I look at the data, the desired comment does not make sense, or flow from the provided information. While it may be tempting or easier to just "go with it," a prudent leader should pause and ask pointed questions. Obviously, one would need to do so with tact and respect.

Another component of good judgment, as described in the article, is to seek diversity, not validation. The author says that "unfortunately, many CEOs and entrepreneurs bring people on board who simply echo and validate them." The manner in which Abraham Lincoln composed his cabinet is frequently cited as a best practice. Lincoln purposely formed a cabinet largely composed of individuals who disagreed with him. Seeking diverse opinions is always useful, whether in a formal way (assembly of a cabinet), or more informally (asking someone outside of your inner circle). Studies have shown that optimally performing groups have an environment that encourages diversity of thought. Obtaining different perspectives is a key part of good judgment. As you progress up the career ladder, you will already have the people who tell you yes, but it's up to you to seek and appoint those that will offer a different point of view.

Likierman emphasizes the importance of detachment when making decisions. Key is the ability to understand one's own biases, intellectually and emotionally. Biases can cloud judgment and take a decision-making process off track. Likierman suggests having processes in place that keep people aware of biases. I think this is a very important point. It is only achievable if you have insight into your own biases. One way to do so is to go through formal training on unconscious bias. I have done so, and it is a worthwhile experience.

The final point in Likierman's essay is that one should evaluate the feasibility of execution. "When reviewing projects, smart leaders think carefully about the risks of implementation. A leader with good judgment anticipates risks after a course has been determined and knows by whom those risks are best managed."

This is a critical point as change is constant. All organizations try to anticipate the future and set goals to serve them well moving forward. Often, several new goals are launched simultaneously. There is extreme focus on the "what." What we need to improve. What we need to change. What we need to prioritize.

A focus on the what is extremely important, it is the core of strategic development. But equally important is the "how." How are we going to execute these new goals? How do we designate who owns what parts of the new project? How do we determine if we have the resources in place to be able to execute?

Knowing how to execute is central to good leadership. This is especially true when leading physicians. Physicians require data to make decisions. So, a big part of how to execute is having reliable and transparent data. Execution also generally requires teamwork. Therefore, part of operationalizing new goals is forming highly functional teams. In addition, not all people have equal skills. Therefore, seek out those who excel at operations and who also get things done. With an assembled team, ask them about the feasibility of implementing a new decision. If challenges exist, have an honest conversation and, if necessary, modify the new goal.

Good judgment is a lot like good leadership. Listen to many stakeholders. Encourage diversity of thought. Keep learning. Never believe that you have all the answers. Talk to the front line about how to implement a new goal. Stay humble.

As far as owls go, I googled the question, "Are owls wise?" It turns out that, although they are great hunters, they do not seem to be wiser than other birds. They certainly look wise in pictures. As for me, I do not believe that I appear particularly wise in my pictures. Therefore, utilizing good judgment, I asked Oncology Times to post a picture of an owl to accompany this essay.

Thursday, April 16, 2020

By Brian J. Bolwell, MD, FACP

The current coronavirus pandemic will likely change the delivery of health care forever, even if only because virtual visits now become widely accepted and utilized.

It will not, however, change the importance of leadership. Indeed, this crisis illuminates how important leadership is. Some states, such as Ohio and California, have governors who were, and continue to be, proactive, thoughtful, and honest in their approach, with favorable results.

A crisis tends to illuminate leadership skills.

Most cancer centers, including ours, have seen a decline in the number of new cancer referrals. This appears to be due to many things, including patient reluctance to seek care because they are afraid to go out and risk contracting COVID-19, and because some patients simply cannot receive the care that they seek. That said, we still have plenty of patients who need our care. The central issues facing most major cancer centers is how to prepare for a potential surge in COVID-19 cases at their institution, and how to maintain their center's ability to continue to deliver cancer care.

This essay will focus on the second point—how to maintain your ability to care for cancer patients.

By far, the most important issue is to care for your workforce. Your employees. Your people. Your docs, your nurses, your administrative support staff—everybody. Nothing happens without your people. Everything you do throughout this pandemic needs to start with asking yourself how this decision will affect the people who work for the cancer center. And that means that everything you do has to focus on managing fear. They are scared. Everyone is scared of this virus. The news is filled with daily stories of otherwise healthy caregivers who developed this virus and died. Many doctors and nurses, really for the first time in our lifetime, are afraid to physically be with patients. It's not just the workforce that is scared. Patients are scared. I am scared.

So how do you manage this?

I certainly do not have all the answers, but I will tell you what I am doing and what seems to be helping me.

First, you need to get the basics right. Have a straightforward process for screening everyone who enters the building with basic questions about shortness of breath, temperature taking, and supplying masks if a person does not already have a mask. Have a process for who to test for COVID-19, and, ideally, have a testing station available in your cancer center. Have the process well-oiled. The sense of calm and professionalism will in itself reduce anxiety for those who enter the building. Report out the facts about caregivers who have acquired COVID-19 at your institution, and whether there is any indication that they acquired the disease at work. Next, have your IT leaders make sure that your virtual visit system is functional, and that everyone is trained to do virtual visits. Most clinic visits these days are virtual, so you need to make sure that your system works. Much routine cancer care for the indefinite future will be via virtual visits, and you need to have your system fully operational.

More importantly, be a leader. Those who read this column know that I believe leadership development and character development are one and the same. So be a person of character. Tell the truth. Be transparent. Address challenges. Do not spin the facts—give the facts as they are. Be informed. Educate yourself every day.

For me, this means I do several things every day. First, I show up. If your nurses are coming every day and delivering infusions to your patients, it's pretty important that you show up as well. That means you need to be visible. Walk around and say hello to folks. It goes a long way.

Next, we have organized our cancer center for the current situation. We have representatives on all major organizational COVID-19 task forces. Note that you do not have to personally attend all of these meetings yourself. Delegate when appropriate. It is better for you and it empowers others. We have a daily (now three times/week) brief cancer center leadership huddle to align and report out any new developments.

Probably the single most important thing I do is to craft a daily email to the entire cancer center. I report out organizational data (how many COVID-19 patients are in our health care system, what our current modeling shows, etc.), as well as national and international data. I supply graphs and tables of national COVID-19 data. This means that every day I need to educate myself about what is occurring with the pandemic. I also disseminate information about the medicine of COVID-19 disease, about testing, and about outcomes. Anything I know I send out to everyone, with my personal commentary.

But the daily email is not just about data. I also discuss what I am feeling and what we all are feeling. I speak frankly and simply. I am totally authentic. Sometimes I try to inject humor. At one point, I said my hands were getting destroyed from all the hand washing. Later that day, I received at least 25 replies from various members of the cancer center, suggesting the best hand moisturizer for me to use. Some dropped off samples to my office. So the next day, I thanked them in the daily email. Then a bunch of people wanted to know the data about the best hand moisturizer, so the next day I sent out everyone's suggestions!

Most importantly, at least once a week I tell the cancer center workforce that they are the reason that I come to work, and how proud I am of them, and how important they are (among other things).

All this communication takes a lot of work and is time-consuming. But it is time well spent.

The daily communication seems to be useful. I have never received as much positive feedback as I have about these daily updates. Many have requested that I continue to do it after the pandemic is over.

So my advice about how to lead through these new and choppy waters is to go back to the basics. Be honest, transparent, and straight. Do not spin the facts. Ideally, educate and inform on many levels. And let people see who you are. Authenticity goes a long way.