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Leading and Managing in Unmanageable Times

2005; Lippincott Williams & Wilkins; Volume: 59; Issue: 4 Linguagem: Inglês

10.1097/01.ta.0000187809.46099.83

1529-8809

Philip S. Barie,

Trauma and Emergency Care Studies

Trauma surgery is in crisis. The reasons are known as well to you as they are to me: no operations; no reimbursement; no fellows; no partners; more elderly patients; relations with surgical specialists; babysitting for surgical specialists; night call; malpractice and lifestyle. Reimbursement is low, but liability risk is high. Our work is nocturnal and unpredictable, and much of it is non-operative unless emergency general surgery is part of our practice. We can find neither enough trained surgeons to hire, nor fellows to train, nor residents and students to follow in our footsteps. Many of our organizations, Eastern Association for the Surgery of Trauma (EAST) included, are working hard to make change, but incremental progress at a time when change is needed urgently frustrates many of us. At times, the outlook can seem rather bleak. Surgeons are action-oriented, and often externally-oriented. We believe we must be, to be effective in our work, but surgical skills do not always equate with leadership skills. I shall share with you some principles of management and leadership to provide a set of tools to navigate this crisis personally, as well as to help you lead your teams. Team, a central theme of this presentation, is a familiar concept to trauma surgeons. We lead a team every day in the trauma bay, in committee meetings and so on, but there are many ways to lead more effectively. Several hundred books are published each year on the subjects of leadership and management. It is impossible to be familiar with all that is written and espoused. Some of the material is Bravo Sierra (BS), quite frankly. There are more than 9,000 theories extant about how to lead and manage; I couldn’t possibly distill it all, but there are some timeless principles. It is some of those principles that I would like to talk to you about today. Being a manager and being a leader involves numerous competencies. Twenty of them are listed in Table 1.1 The ones denoted by an asterisk are believed to be really important: Communication skills; having a compelling vision of the future that your team believes in and is willing to follow you toward; delegation of authority; the ability to manage conflict; the ability to manage time; the ability to manage one’s personal stressors; and, of course, setting goals, but crucial is building and nurturing the team.Table 1: Competencies of an Effective LeaderFigure 1 shows some of the important leadership attributes in a competing values framework.2,3 On each end of the lines are opposing values, internal on the left, external on the right, maintaining the status quo on the left, productivity on the right, defining four domains. Some skills are necessary to maintain ourselves and our organizations, whereas there are other skills that point externally or toward the future.Fig 1.: Leadership skills are depicted in a competing values framework. Each line represents a continuum between opposing values, here between internal and external influences, flexibility and control, and change and the status quo. The leadership attributes are thus divided into four domains. In the upper right, the qualities of creativity, innovation, and vision promote flexibility, change, and external productivity. Adapted from Reference 1.For a leader, thinking about the future is very important.4,5 Some tasks are best left to people who plan action (managers). Other tasks are best left to people who have the skills to look forward (leaders). I encourage all of you, in your personal practices and personal lives, to become futurists and to think strategically; think about what you want to accomplish and set your strategic goals. How you accomplish your goals follows naturally from deciding what the goals are. Consider the range of possibilities. Use your imagination. Your vision will create meaning for everyone in your organization.6 The future becomes the present, creating a common identity and shared goals. Vision provides a worthwhile challenge, and provides a catalyst for change. If your vision is compelling, your team will follow you enthusiastically. Important insight into becoming an effective leader comes from the scion of the leadership literature, someone who is particularly expert in the management of nonprofit organizations. Peter Drucker remains active well into his nineties.7 His books are on bookstands everywhere, even in airports; you might look for one on the way home from this meeting. Drucker is Professor of Social Policy and Management at Claremont Graduate University in California. To Drucker, the first secret of effectiveness as a leader is to understand the people you work with so that you can make use of their strengths.8 Remember that, making use of strengths. It is an important concept, but perhaps counterintuitive to how we work as clinicians and educators. Consider one example as to how great managers think and work.1 Answer the question for yourselves as I pose it. You must choose between two managers, one of whom is effective and the other, mediocre. You have two positions to fill, one in a high-performance unit and one in a unit that is struggling. Neither unit has reached its maximum potential. Where would you put the excellent manager? Great leaders put the excellent manager with the high-performing unit. Use your best to get better. You can use change, as we will talk about, to bring in someone new, a turn-around specialist for example, to work with your struggling unit. Great teachers use their best resources to bring all of their pupils to their maximum potential. Great leaders use their best resources to develop their best strategies. Skilled leaders know when to act and know when to hold back. Skilled leaders assuage doubt by improving information, but know that the data collection process can actually delay decision-making. I have had several colleagues and residents over the years who were brilliant strategists, but who would hesitate when action was called for, paralysis by analysis. Great leaders achieve a balance of thinking, looking forward, collecting data, but knowing when to act, accepting that there will be uncertainty. The great battlefield commanders throughout history have understood this. We as trauma surgeons deal with uncertainty every day, so this is something we can understand. Great leaders not only accept uncertainty but also use it to their advantage, because they know that their opponent is going to have the same uncertainties. However, battlefield commanders often dispense with the formalities of contingency planning, which we cannot do because we know that we have a product (health care) to produce, customers to serve, and expectations of quality to meet through best processes and the reduction of error. Becoming an Effective Leader How does an individual become an effective leader and manager? Start with yourself. Opportunities for leadership abound. We lead every day in the trauma bay even as the junior-most member of the attending staff. You may be asked to lead in a committee meeting, even on short notice. You can lead even by changing a manner of practice in your own institution. It is important to be your own chief executive officer (CEO) and to manage your own career. Our Association is about mentoring our junior members. Certainly it is appropriate to bring other people along, but until surgeons become very senior in their own careers, it is unlikely that their sole focus will be on you as the beneficiary. You must manage yourself.9 Develop a deep, honest, objective understanding of your strengths and weaknesses, how you learn, how you perform, and consider your own contingency plans. Understand that as objective and dispassionate we are expected to be, we are passionate about our lives and careers. Our emotions affect our actions, and understanding our emotions can help us lead4,10,11 (Table 2).Table 2: Emotional Intelligence Domains and Associated CompetenciesIt is human nature that we manage to our strengths. Performance is not built from weakness. It is easier to transform competence into greatness than to transform incompetence to mediocrity, but you must always keep your values in perspective. Do your commitments match your convictions?12 What is valued in your practice and in your life need to be in alignment. What you value most may be personal or professional, or a combination. Just because you’re good at taking out spleens doesn’t necessarily mean that particular skill fits with your value system or the task at hand. It may well, but keep the possibility in mind. Ask yourself a few more questions. What is your personality type? Are you an introvert or an extrovert? Are you intuitive, or do you rely upon data collected with your senses? Are you more analytical, or do you act on your emotions? Do you thrive in big organizations or small? These are all things that must be considered as part of your own values and your own development as a leader. Taking your own personality inventory with a tool such as the Myers-Briggs Type Indicator (MTBI)13,14 may give you insight, as it has for me. Based on the philosophy of Carl Jung, there are 16 MBTI personality types comprising eight preferences constructed from four domains and two sub-domains. I am an “ISTJ,” which I share with President Harry Truman among other historical figures (Table 3). Through such an analysis, I have been able to inventory my strengths and identify areas where I need to focus my personal growth.Table 3: Characteristics of Myers-Briggs Type Indicator “ISTJ” (Introverted-Sensing-Thinking-Judgmental)For academic trauma surgeons, our natural strengths are our technical skills and our teaching abilities. There is divergence between the natural skills, aptitudes, and strengths of trauma surgeons and those of business managers. Surgical skills are not necessarily adaptive leadership skills. Ask yourself several more questions. How do you perform? Are you a reader or a listener? Many surgeons are listeners, accustomed to assessing and reacting to fluid situations. Do you perform best under stress or with the predictability of a controlled environment? Much can be learned about leadership from the pantheon of U.S. Presidents (Table 4).15 Dwight Eisenhower was a reader; his press conferences in the European Theater of Operations were masterful because every question posed to him by the press was submitted in advance in writing, and he knew all the answers. He could not think as well on his feet. One of the reasons why he was perceived to be a mediocre president was that in his press conferences in the 1950s, he had to think on his feet and he wasn’t good at it.Table 4: Lessons of Presidential LeadershipJohn F. Kennedy was also a reader, and had great speechwriters. One of his greatest skills was learning from his mistakes. His tragic successor, Lyndon Baines Johnson, possessed an encyclopedic knowledge of government and in particular the workings of Congress. He had marvelous timing, understanding when to move forward with new social programs that affect us to this day (e.g. Medicare). Johnson was most definitely a listener, but he kept JFK’s speechwriters, and he didn’t understand a word they wrote. He struggled in communicating the Vietnam War to the American people, which was a far different skill than orchestrating the passage of legislation. Part of the reason that many consider him to have been a powerful man, but a failed president, was this gargantuan mismatching of skills and tasks. Building a Power Base The power and influence you possess as a leader are crucial in defining your effectiveness.2,16 Power can be abused, so real effort must be made to harness and channel it for good-influencing people and accomplishing your goals. Powerful leaders can intercede favorably on behalf of another, get approval for expenditures, influence policy through access to other top decision makers, and generally “stay on top of things.”2 Power emanates from personal characteristics and from your position (Table 5). Accumulated power is translated into influence over others through the selection of proper strategies, assertive responses to inappropriate attempts by others to gain influence, and increasing one’s authority via upward influence. So in addition to managing yourself, you have to manage your boss.17Table 5: Determinants of PowerBosses need from their subordinates cooperation, reliability, and honesty. Managers need access to resources, someone to set policy, and access to others so that they can grow their own personal network. The concept of managing your boss, or managing up, stands management top-down on his head. It’s not about getting ahead. It’s about getting along. When the relationship between you and your boss becomes difficult, it is your responsibility, managing up, to manage your boss. Understand your boss as well as you understand yourself, including strengths, weaknesses, and work styles. Define and meet mutual expectations and critical needs. Your boss is flesh and blood as well, and has goals and objectives. He’s under pressure. She has strengths and weaknesses, certainly has blind spots, and may be under as much pressure as you are. Hopefully, the blind spot isn’t to all of the good work that you are doing. Among the many things that you must understand about yourself is how much you depend and rely upon authority. If you are a person who is best managed by being left alone to do your work, you and your boss need to understand that. Relationship maintenance is as important with your boss as it is with the other people with whom you deal. You have to meet mutual expectations, keep each other informed, and most importantly, use time and resources effectively. Not every boss is a benevolent and courteous leader. Here is what the management literature says about abusive bosses.18 They are micromanagers and everything is a priority. They can be mercurial. They are obsessed with loyalty and obedience, when in fact the strong manager accepts diversity and actually builds upon it. They ridicule subordinates in public and they use power for personal gain. They are capricious, arbitrary, and hypocritical. One of the most powerful figures in history had perspective about power. We have all heard the aphorism that power corrupts and absolute power corrupts absolutely. It was Abraham Lincoln who said, “Nearly all men can stand adversity, but if you want to test a man’s character, give him power.” Leadership Styles There are many different styles of leadership-they are not mutually exclusive.4 Gifted leaders may exert influence through a combination of these styles. Visionary leaders move people toward shared goals, and act when clear direction is needed, or change requires a new vision. Coaching leaders align their subordinates with organizational goals, and act to help employees improve performance. Affiliative leaders create cohesion within their group, and act to strengthen bonds, motivate during stressful times, or heal rifts. Democratic leaders obtain commitment through participation, and act to gather input or build consensus. Pacesetting leaders meet challenging goals and act to achieve high-quality results from competent, motivated teams. This style is difficult to execute. The commanding leader soothes fears in crisis situations by providing clear directions, acting in a crisis, a turn-around situation, or with problem employees. This style is often misused by abusive bosses. The Player/Manager The concept of the player/manager is a valuable way to consider ourselves as practitioners, managers, and leaders.19 This is a sports analogy, but it is apt for us because it combines producing and managing. Teachers and academics, physicians and nurses are considered to be a sine qua non of the player/manager, of which there are many levels, depending on position and stature within the organization: Senior partners of law firms; investment bankers; accountants; management consultants; teachers and academics; physicians and nurses.18 Although there are many types of player/managers, I want to concentrate on the rookies (junior faculty), those young and new to trauma and to leadership, and the veterans (senior faculty, trauma directors), who have to manage while keeping their teams fresh and alive. The rookie is an expert, but may not have other well-developed management skills, so the rookie may rely too much on technical expertise (Table 6). Technical expertise can be a double-edged sword in a managerial system. Rookies do have expertise, such as better pattern recognition and the ability to see differently, but they may see problems stereotypically, miss subtle signs of trouble, or fall prey to the de minimus error, or explaining away the data. The de minimus error occurs when you collect a body of data but consider each datum (e.g., heart rate, hematocrit, urine output) individually. The de minimus error occurs when finding an alternative explanation for every piece of datum, to the point where the diagnosis is completely lost in the distracters and the differential diagnosis. The de minimus error, talking yourself out of something, is a very important source of error.Table 6: Player/Managers: The Rookie and the VeteranThe veteran is someone who comes in and builds systems, hones execution, steps in when crucial, and instills effectiveness-the surgeon’s surgeon (Table 6). But because veterans are player/managers who also must manage their own clinical practices, there is always the possibility that the veteran may over-manage and under-lead. The challenge for the veteran is finding the balance. Every player/manager is aiming for a target, has a game plan in mind, and has performance benchmarks, but also is working with a team, even as he or she manages their own practice. It is the interface between managing, for example, as a director of trauma or chief of a clinical service and managing one’s boss. The view from on high looking down can be very different from the view looking up. The player/manager has to manage “up” as well as “down.” The senior manager looks down and expects of his player/manager accountability for business results and the performance of the team (Fig. 2). The senior manager considers the player/manager to be empowered, to have the power to take action. On the other hand, the player/manager looking up may feel overloaded, may be responsible for human resource management with little or no training in the discipline, and perceive that there is little tolerance for poor performance. There is the potential for struggle.Fig 2.: The player-manager has to look up to the senior manager as well as look down for the management of the team being directed. The view from on high can be very different that the perspective of the person looking up. Balancing these roles is challenging, but increasingly the norm. HR, human resources.The High-Performance Team Now that we have begun to understand ourselves, and that most crucial of interactions with our immediate superior, let us consider how to build and nurture and transform a team to achieve high performance. First, the leader must develop credibility and articulate a vision. Team members must be chosen on the basis of talent. Expectations must be set by choosing the correct objectives and the desired outcomes. The individual must be motivated by building on his or her strengths, and developed by ensuring that the person and the job are the proper fit. It is crucial to build your team based on talent. The leader must define the correct outcomes, focus on strengths, find the right fit, and match skills to tasks. Building for talent is somewhat counterintuitive to our natural roles as teachers and mentors, but it is absolutely crucial for leadership success. No less a leader than John Wooden, who led the University of California at Los Angeles to seven consecutive NCAA Division I basketball titles, said “Although not every coach can win consistently with talent, no coach can win without it.” Manage to recognize and maximize the strengths of your people. The micromanager has a management style that suppresses creativity. The academic instructor naturally focuses on the less talented. In an educational environment, that is absolutely appropriate, but the catalyst is the coach who inspires his team, leads her team, and makes the best better. Remember also that people are difficult to change, unless they want to change. If you try to change people who are unwilling, you won’t get very far. As the coach of your team, draw out what is there, and make it better. Of course, you must stay in touch with your people and what your people are asking of themselves and of you. A vibrant, vital, and highly effective workforce is defined by the answers to six key questions (Table 7).1 Team members will ask themselves if they know what’s expected of them, and wonder whether you as leader care about them as team member. The leader, of course, has to provide that guidance. Do they have the resources they need and are they in a position to do their best work everyday? Praise and recognition for truly good work is absolutely essential.Table 7: Recruiting and Retaining Top Talent: 12 Questions the Top Talent AsksHigh-performing teams have core competencies and a shared purpose.2 High-performing teams have credibility and engender trust. Tasks are carried out efficiently with the participation of all members of the team. Roles are coordinated and distinctions are blurred. Desired outcomes are understood clearly. Results are of high quality, and there is accountability for performance. Performance and outcomes are constantly reviewed to achieve continuous improvement. No one remembers Brigadier General Don Flickinger, but his is one of the greatest stories of team building of the twentieth century.20 General Flickinger was tasked with putting together a team of seven people in the late 1950s. The job description was unusual: age <40 years, height <6 feet, excellent physical conditioning and endurance, great mental stability, high tolerance for pain, and 1,500 flight hours in experimental aircraft. These people became the seven men with the “right stuff”—the original seven Mercury astronauts. Alan Shepherd, Gus Grissom, John Glenn, Scott Carpenter, Wally Schirra, Gordon Cooper, and Deke Slayton were chosen. They had the best of everything—exhaustive training, and state-of-the-art technology. NASA provided excellence in project management, and ultimately there were six missions. Two of those six missions could be considered textbook operations: Alan Shepherd’s first sub-orbital flight and Wally Schirra’s flawless mission. My own small, personal connection to NASA is that my uncle Walter Davis led the crew that fueled Alan Shepherd’s Redstone rocket with liquid oxygen. Two of these people had heroic missions. John Glenn, of course, is a hero’s hero; I am certain that everyone in the room knows his story. Gordon Cooper was so composed and so confident of his ability to carry out his mission that he actually fell asleep in the capsule during the countdown. Despite meticulous preparation, two people had mediocre missions. Gus Grissom, who later would die in an Apollo capsule fire, panicked. He blew the explosive bolts off his capsule hatch, flooding the capsule before it had righted itself and stabilized. Grissom nearly drowned. Scott Carpenter was having such a good time flying around that he depleted his fuel, with almost none remaining for reentry maneuvering. If he had been one degree more shallow on his reentry, he would have skipped off into space, and into eternity. Carpenter landed 250 miles from his recovery ship, but the Mercury space program is considered one of the greatest successes of American technology. The message is that the strong team allowed highly trained, but under-performing individuals to complete their missions. The Dysfunctional Team Forming an effective team is at the heart of what we do, but teams can become dysfunctional.21 There is classical literature describing the five reasons why teams may become dysfunctional: Absence of trust, fear of conflict (getting along for its own sake rather than really getting to the issue), lack of commitment, avoidance of accountability, and inattention to results. Avoidance of accountability and avoiding interpersonal discomfort is not usually a problem for trauma surgeons. However, inattention to results and avoidance of accountability lead to low standards. A lack of commitment leads to ambiguity of the mission. Fear of conflict leads to artificial harmony, and absence of trust can lead to invulnerability, but it’s a false sense of invulnerability. What can the leader do about these five team dysfunctions?22 The leader creates the environment, and by demonstrating vulnerability, he or she sends the message that it’s okay, we’re in this together, creating bonds, creating the right environment, and rebuilding trust. Fear of conflict is remedied by demanding debate, but be a supportive communicator by listening actively and focusing on the problem, not the personalities.2 Demonstrating restraint is important; don’t come in with guns blazing, but rather allow for the possibility that things will sort themselves out. A lack of commitment is resolved by decisiveness, insisting on clarity, and being comfortable and accountable for making the decision. Accumulation of unresolved issues is another sign of dysfunction; inattention to results is remedied by a focus on collective outcomes. Push for closure, even in committee meetings. Change Management If your team is focusing inward rather than outward, if your team does not have clear-cut roles and responsibilities and accountability, or if your team becomes complacent, your team is in trouble. The classical patterns of dysfunctional teams need to be recognized and integrated into an action plan to get your team back on track. Albert Einstein said, “Insanity is doing the same thing over and over again and expecting a different result.” The management of change is one of the biggest, most complex challenges a leader can face. When change is needed and there is change management to be done, there is always going to be resistance to change. To paraphrase an old bomber pilot aphorism from World War II, you know you’re getting close to the target when you start picking up the heavy flak. Resistance to change is inevitable, and it must be dealt with. Anxiety about change occurs when the risk or the uncertainty is high and the skill and confidence in dealing with change are low. It is the anxious people who will be resistors. On the other hand, boredom occurs when risk and uncertainty are low and skill and confidence is high, and it’s important for the leader to keep the team refreshed (Fig. 3).5Fig 3.: A change-management paradigm. Balancing the forces of change. Adapted from Reference 5.Pilot projects, small victories, performance measurement, building on strengths, envisioning new ways to operate, being willing to change, and being willing to abandon old systems are all very important in leading change. Sometimes bringing in an outsider, a new member of the team, can be very helpful in stimulating an environment in which change can occur. Meaningful challenges are needed. The status quo needs to be questioned all the time. Probe your organization. Search for opportunities outside the box and get everyone involved in the search for those opportunities. However, as a leader you have to pick your fights. Stay alive—don’t fall on your sword.22 Don’t argue if you can’t win. Build resources, not obstacles to yourself. Stay optimistic. Sometimes, though, the change is within us. Trauma surgery is a somewhat nomadic existence, particularly in academe, and it may be yourself who is moving and changing and going into a new leadership position. When you’re in a new position, you need to act fast. The clock is running and there is not a finite amount of timed—perhaps 90 days—to get your feet planted firmly.23 Acquire the needed new knowledge quickly, establish new working relationships, balance organizational and personal transitions, and maintain equilibrium. The danger in a new leadership position is in falling behind the learning curve, which can happen by focusing too much attention on detail rather than the big picture, becoming isolated, not building collaborations, not building a team, and by coming in with the answers and not considering all viewpoints. The hardest but one of the most important things to avoid is sticking with a dysfunctional existing team too long. Also, be cognizant of something called “successor syndrome.” When the old boss sticks around and you start changing things a little bit too much, there’s a possibility that the old leader may try to put the brakes on change. When you move, you have two, perhaps three, years to make real progress.24 Form hypotheses about your new organization and begin testing them immediately. Decide if the organizational structure must change. Build personal credibility and momentum with early wins or small wins. Earn the right to make change by building coalitions, and always shape your approach to your situation by balancing your skills with the tasks at hand. Stress Management The most common reason that poor decisions are made is information that is unreliable because it is missing, incomplete, conflicting, or too complex to assimilate.25 Poor decisions are also made when confirmation bias intrudes on the decision making process—we tend to believe and affirm that which we already “know.” The third major factor that leads to poor decision making is stressors that intrude on the ability to collect data and ponder the solution to the problem. Stressors may take several forms, each of which has discrete consequences (Table 8).2 What are our sources of stress? There are time stressors, encounter stressors, situational stressors,