JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 69, NO. 13, 2017
ª 2017 PUBLISHED BY ELSEVIER ON BEHALF OF THE
ISSN 0735-1097/$36.00
AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
http://dx.doi.org/10.1016/j.jacc.2017.02.039
LEADERSHIP PAGE
Leadership in Cardiology
Development of Cardiologists as
Leaders to Improve Our Health
Care System
A. Allen Seals, MD, FACC, Immediate-Past Chair,
ACC’s Board of Governors
Mark Hertling, Lieutenant General, U.S. Army (Ret)
E
ffective medical leadership is vital in deliv-
“to effectively attack this chaos, we need a new kind of
ering high-quality health care and building
leadership at every level of the health care system” (1).
interprofessional health care teams. Currently,
For cardiologists, this will require not only a commit-
there is a critical need to involve physicians in signifi-
ment to constantly improving medical skills, but also a
cant roles in our increasingly complex health care
foundation of strong personal and professional values
environment. Cardiovascular specialists are uniquely
and a broad understanding of the complex inter-
positioned to fill these leadership roles—in private
related medical systems of care, while simulta-
clinics, in local hospitals, and in medical centers, as
neously complementing those competencies with an
well as in nonpatient care positions in insurance, reg-
increased range of nontechnical leadership skills that
ulatory, and governmental institutions.
will help them lead across professional boundaries.
THE PHYSICIAN LEADERSHIP IMPERATIVE
medical leadership, the training of good medical
While quality medical care clearly requires good
leaders has not previously been a traditional role of
The reality of our health care system is that quality
graduate medical education programs or the post-
cardiovascular care demands the utilization of com-
graduate practice environment. In the past, if
plex medical care, often involving novel pharmaco-
addressed at all, the typical training curricula would
logical
treatments,
complex
interventional
suggest
coursework
in
“communication
skills,”
procedures, and prolonged outpatient treatment
“negotiation techniques,” “business acumen,” or
plans. The demands on the health care system
“time management.” After leaving training, the
become increasingly more complex when patients
young physician is too often limited to continue
must interact with multiple medical specialists and
medical education focused on clinical sciences and
navigate through a maze of diagnostic facilities,
training, while formal leadership training is reserved
outpatient clinics, and inpatient hospitalizations.
for health care administrators. Practicing cardiolo-
Most of this medical care takes place under the
gists in the conventional clinic and hospital settings
external influence of insurance-based authorization
often find that leadership skills are unfulfilling
review, regulatory oversight of the utilization of re-
because they are all too often viewed as process ori-
sources, and government quality-based payment
ented, or only “nice to have” competencies.
programs as most recently mandated under the
Medicare Access and CHIP Reauthorization Act.
However, in 2015, with the broadly supported
COCATS 4 (Core Cardiovascular Training Statement 4)
The Harvard Business Review has addressed this
and the parallel development of the Accreditation
complexity of our health care systems, and the need
Council for Graduate Medical Education statement on
for innovative and consistently evolving physician
the Next Accreditation System, training of leadership
leadership development. In a paper titled “Turning
skills was formally accepted and implemented. Both
Doctors into Leaders,” Thomas H. Lee, MD, writes that
COCATS 4 and Next Accreditation System embrace
Seals and Hertling
JACC VOL. 69, NO. 13, 2017
APRIL 4, 2017:1744–7
the
philosophy
Leadership Page
that
modern-day
cardiologists
values remains the most fundamental prerequisite for
“participate in a team-based system, use information
the individual character that defines an effective
technology, practice cost-effective medicine, and
leader. Most leaders come to the table with the best of
importantly, help them function as a health care
intentions, but unfortunately these individuals typi-
leader” (2).
cally lead with only 1 lens—their own. It is not until
TRANSLATING THE MILITARY LEADERSHIP
standing, sense the culture and the dynamics of
MODEL TO THE HEALTH CARE LANDSCAPE
the surroundings, and gather feedback—that their self-
leaders take a look around—gain situational under-
perception is either validated or disproved. SelfA few years ago, a hospital system in Florida began
awareness, a key component embedded in individual
using a military training model to contribute to
attributes and emotional intelligence, is a key factor of
improving the leader attributes and competencies
leading effectively. The higher the level of leadership,
possessed by their physicians. Adapting a definition of
the more crucial personal character becomes, and in
leadership used by soldiers, this program further
fact, individual attributes and emotional intelligence
refined an encompassing definition of leadership that
often trump scholarly intelligence in contributing to
could guide physicians in improving health care teams
leadership effectiveness. Thus, in the health care
and patient engagement (3). That definition, bor-
management setting requiring effective leadership,
rowed from a military training manual, but adapted to
there is an increasing need to focus on competencies
the demands of health care, reads that “leadership is
related to how we work together, communicate with
the art of understanding motivations, influencing
each other, and manage positive change (3).
people and teams, and communicating purpose and
Effective leaders cannot remain effective if they
direction to accomplish stated goals while improving
lose their sense of humility and self. Whether one is
the organization” (4). In the U.S. military—like in
serving as an Army commander or as a physician
medicine—life or death scenarios are often presented.
medical director in a hospital, self-reflection is an
Similarly, in the military as it is in medicine, it is a
important part of the leadership journey. Harvard
requirement of leaders to bring a group of differen-
Business Review author Anthony K. Tjan states this
tially
high-
same self-awareness “.allows the best business-
performing team to succeed in a mission. Although
builders to walk the tightrope of leadership: projec-
at first the military is seemingly an unlikely source for
ting
leadership skills in health care, the U.S. Army employs
humble enough to be open to new ideas and opposing
a number of applicable and simple techniques and
opinions” (5).
skilled
individuals
together
as
a
models to build leadership skills. One of the most
conviction
Cardiovascular
while
simultaneously
professionals
remaining
operate
within
translatable of these is the “Be, Know, Do” leadership
constantly shifting local environments and a rapidly
model. The “Be” is all about character. It reflects who
changing national health care landscape. It is no
a leader is and how he or she is perceived. The “Know”
surprise that leaders in health care often only focus
is a leader’s knowledge and understanding of skills
on the task at hand. In contrast, an effective physi-
required to do his or her job and perform. Finally,
cian leader considers how to lead from a 360 “Do” is where action takes hold—how does the leader
perspective, and proven and accomplished leaders
generate trust? How does the leader develop others to
demonstrate the ability to incorporate new ideas and
contribute to the organization to accomplish goals and
concepts each day and over time. Stakeholders matter
meet the mission? Although the “Be” and “Know”
and their perception of how physician leaders
tenets of this leadership model are incredibly impor-
execute their role matters even more. Leaders must
tant, it is in the action-oriented “Do” portion where
take the time to seek feedback from these involved
leaders can struggle. Failure in leadership occurs
stakeholders, actively engage peer colleagues, as well
when an idea or decision makes it to the point of ac-
as seek advice from other team members. And, while
tion, and there is no one there to drive it to finality.
doing so, the leader must actively listen and be pre-
The core of leadership is that effective leaders take
pared for honest critiques. As the Greek philosopher
action and get things done.
WHAT MAKES AN EFFECTIVE LEADER?
Epictetus wrote, “We have two ears and one mouth so
that we can listen twice as much as we speak” (6).
ORGANIZATIONAL COMPETENCIES
Two concepts help define an effective leader: individual attributes and emotional intelligence. The
Beyond the fundamentals of personal character (in-
development of strong personal and professional
tellectual attributes and emotional intelligence),
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Seals and Hertling
JACC VOL. 69, NO. 13, 2017
APRIL 4, 2017:1744–7
Leadership Page
organizational-based leadership skills or compe-
Effective versus ineffective leadership can make or
tencies are also critical to effective leadership. Most
break an institution or practice. Unfortunately, when
organizations maintain a set of core leadership skills
there is a failure to meet a mission or health care
that are critical to conducting business each day.
system goal, it can often be tied to a leader’s failure to
These leadership skills, or competencies, are reflec-
adhere to these characteristics of team building.
tive of one’s culture and leadership expectation. The
“Toxic leaders”—those individuals who are defined as
military uses a “leadership requirements model” that,
being more concerned with self-aggrandizement,
based on years of research, centers on who the leader
personal gain, or professional recognition rather
is and what the leader knows—or the leader’s attri-
than care for the patient or contributions to health
butes—and what the leaders does—or his or her com-
care—consistently ignore these tenets of team build-
petencies (3).
ing, and consequently they often cause harm to their
The American College of Cardiology (ACC), as part
organization or to the profession. Stanford University
of its new governance transformation, is leading the
professor Robert Sutton, PhD, has studied “toxic
way in physician professionalism and leader devel-
leaders” and writes that the negative effect that
opment by defining key leadership competencies and
destructive leaders have on their organizations “is
incorporating them into the organizational structure
seen in the costs of increased turnover, absenteeism,
of the College. Beginning with the Board of Trustees,
decreased commitment to work, and the distraction
these principles of leadership competency are now
and impaired individual performance documented in
being implemented through the entire ACC leader-
studies
ship structure—including selection of chairs and
mobbing” (9). Toxic leaders can significantly damage
members in all committees, sections, and councils.
an organization’s culture and function, and as Sutton
The 5 competencies representing leadership skills
implies, should be dealt with appropriately.
of
psychological
abuse,
bullying
and
that the College considers fundamental for an ACC
One of the most important ways physician leaders
leader include: exhibits influential leadership, dem-
can connect with and build a strong team is by un-
onstrates
demon-
derstanding the motivations of team members. Great
strates strategic leadership, anticipates and leads
leaders will find out what triggers others and tailor
business-focused
proficiency,
change, and maintains organizational awareness and
their leadership techniques and communication style
stewardship. These competencies are presented with
to best reach each team member, or their patients.
the fundamental premise that the ACC leader will
Great leaders listen and then determine the method
respect others, remain selfless, and always remain
of influence they will use before acting accordingly.
focused on delivering results (7). In addition, the
This simple approach can be applied to large or small
ACC has added leadership and administrative com-
groups, or on an individual level. A good leader un-
petencies to its ACC’s Lifelong Learning Compe-
derstands each member of the team because that
tencies Educational Portfolio alongside the 18 areas
leader has determined the team member’s motiva-
of clinical expertise. This is yet another acknowl-
tion. When team members are understood and heard,
edgment from the College that cardiovascular spe-
they
cialists must be effective leaders in efforts to ensure
contribute much more to the organization’s goal.
high-quality care and promote individual and population health (8).
HOW TO BUILD AN EMPOWERED,
HIGHLY-EFFECTIVE HEALTH CARE TEAM
Effective leaders must first understand themselves
and understand those around them. Then, an effective leader must master the art of being both a strong
team builder and a strong team player. The military
uses 7 characteristics to define effective teams: trust,
standards, accountability, confidence, teamwork,
challenge, and rewards. In a similar manner, a
physician leader must understand how these charac-
are
empowered
and
invested,
and
they
When physicians grow as effective leaders, they
grow both personally and professionally, and they
learn skills to propel them as agents of change for
better health care. It is imperative that physicians and
cardiovascular team (CVT) members take expanded
roles in health care institutions—both at the strategic
and direction-setting level, and the day-to-day
tactical operations. To land that coveted “seat at the
table,” physicians must learn “table manners,” such
as how to effectively lead and build productive,
motivated teams (3).
THE ACC’S ROLE IN DEVELOPING THE
NEXT GENERATION OF LEADERS
teristics contribute to high-performing teams, and
then embrace the responsibilities inherent in each of
On a national perspective, with the Triple Aim as a
these areas (3).
marker for success of the future of health care, the
Seals and Hertling
JACC VOL. 69, NO. 13, 2017
APRIL 4, 2017:1744–7
Leadership Page
ACC is convinced that physician and CVT member
personality, physicality, and morality. Dr. Walsh
leadership
described these attributes as characteristics that
is
critical
to
meeting
the
goals
of
improving health through better health, better out-
define individuals with the capacity to influence and
comes, and lower costs. Empowering and arming both
act as true leaders.
physicians and CVT members with leadership skills
The College is steadfastly committed to leadership
can help remove the divide that exists between health
development across the spectrum of ACC member-
care providers and health care administrators. In an
ship. In addition to the Leadership Forum, there are
environment where the percent of U.S. gross domes-
formal leadership programs within the College,
tic product spent on health care far outweighs de-
including ACC’s Emerging Faculty Program, Interna-
fense spending, it is critical that America’s health care
tional Leadership Training Program, Board of Gover-
providers have the skills and tools to lead in impor-
nors Mentoring Program, and ACC’s Leadership
tant policy decisions.
Academy. All of these ACC leadership training initia-
The ACC has devoted considerable efforts and re-
tives present College members with excellent oppor-
sources to addressing the critical need for College
tunities to learn and grow as leaders within the
members
recently
structure of the College. As the ACC continues its
concluded 2017 ACC Leadership Forum adopted the
charge to transform cardiovascular care and improve
theme: “Growing Leaders and Empowering Pro-
heart health, a strong foundation of leaders is critical
fessionals to Improve Health Care.” A broad spectrum
to help the College accomplish its mission and to
of
provide value to its members as they grow and
ACC
to
develop
members
as
heard
leaders.
from
The
ACC
leadership,
including ACC President Mary Norine Walsh, MD,
become more effective, empowered leaders.
FACC, who discussed her personal leadership journey
and what it means to lead “without title.” From her
ADDRESS FOR CORRESPONDENCE: Dr. A. Allen Seals,
perspective, she highlighted 6 personal attributes—
American College of Cardiology, 2400 N Street NW,
intellectuality,
Washington, DC 20037. E-mail: [email protected].
sociability,
emotional
stability,
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