Leadership

8
Eneida O. Roldan and Joel Dickerman

“To be nobody but yourself in a world which is doing its best, night and day, to make you
like everybody else means to fight the hardest battle which any human being can fight; and
never stop fighting.” – E.E. Cummings, Poet

Our Stories and Our Paths into Leadership – Eneida O. Roldan

My journey in leadership began with the fortunate opportunity to have a wonderful
mentor, my grandmother. She taught me the importance to develop certain “people skills”
(emotional intelligence) that carry me to this day. Much of her teachings could be perceived
as “common sense” yet very vital to survive today’s environment as a woman and especially
in the field of health care. Her teachings, together with the innate passion of life-long learn-
ing, propelled my career in different directions beyond being a practicing physician, but
more importantly helped to adapt to an ever-changing world of health care: the world of
VUCA. At every path of my journey, I learned from experience but in addition completed
formal learning by returning to school achieving different degrees, all of which, I currently
put to use in my daily work. My choice of specialty in Medicine was Pathology. The oppor-
tunity to learn disease processes at the core of tissue diagnosis was fascinating. During my
residency, I took advantage of all assignments brought to me mostly in academia. In addi-
tion, I was able to learn management skills through training in Clinical Pathology. Hindsight,
this provided an avenue to understand processes and develop skills as a manager. A
Pathologist is the manager of a lab. During training in clinical pathology, I found great
interest in diabetes and nutritional disorders, hence why I decided to practice in this area for
fourteen years. During this time in practice, I developed skills in public speaking, focused
on population health management, and learned the challenge of morbidity cost in our US
health-care system. This incited my motivation to pursue formal education and training in
Public Health and Business of Health Care. This was accomplished upon my successful
completion of the Master of Public Health (MPH) and Master in Business Administration
(MBA). I now had different tools in my armamentarium. I have experienced Medicine from

E. O. Roldan (*)
Florida International University Herbert Wertheim College of Medicine, Miami, FL, USA
e-mail: [email protected]
J. Dickerman
National Board of Osteopathic Medical Examiners, Inc., Chicago, IL, USA

© Springer Nature Switzerland AG 2020 89

J. P. Sánchez (ed.), Succeeding in Academic Medicine,
https://doi.org/10.1007/978-3-030-33267-9_8
90 E. O. Roldan and J. Dickerman

many angles: academia, private practice, and management. My journey is a testament to

skills built on experience and formal training. It opened doors well beyond the practice of
Medicine. Each and every aspect of my journey taught me never to be afraid to say yes to
different opportunities even if it means stretching my abilities. I live by value-based leader-
ship approach, which includes leading by humility not fear; to rise in the face of challenge;
to be kind to self and others; to laugh at faults, for they make me better; and always stay
present for the opportunity to serve. Yes, leaders reach very prominent levels. However, the
journey has rainy and lonely paths at times. Lessons learned in the leadership journey are
valuable and priceless to those that seek their own answers to becoming leaders in an ever-­
changing world. The opportunity to be able to give back is humbling. It is a great gift to
share my journey with others that can learn from it. The mentee becomes the mentor and
passes the baton. Now it is YOUR turn.

Our Stories and Our Paths into Leadership – Joel Dickerman, DO

When I was offered the opportunity to serve as a program director for a family medicine
residency program I felt honored and unprepared. I had not received much training in pro-
viding feedback to residents or students, and even less as a team leader charged with devel-
oping the careers of others. The opportunity helped me to realize serving as a leader
required a special set of skills and competencies that would require additional training.
Fortunately, I was given a chance to undertake formal leadership training – a program that
transformed how I saw myself as a peer and team leader. I learned that being a leader meant
I was to work with others in my program to develop a shared vision, and more importantly,
to assure my co-workers had the resources and skills to get their respective work done. I was
to facilitate change and improvement, not demand it. My opportunity to serve as a program
director provided me a means to develop these skills and opened my eyes to ways I could
affect a larger scope of health-care delivery. My training and experience has led me to
become a medical director for a clinic, a member of a hospital leadership team, and an
appointment as a chief medical officer for an accountable care collaborative serving over
160,000 patients. My focus changed from that of a single patient or trainee to serving thou-
sands of patients and hundreds of providers in a way that would positively influence the
health and well-being of my community.

Leadership in Health Care

Today’s health-care environment calls for a different type of leader with an ability to
stretch his or her comfortable patterns of leadership style. Physicians have multiple
skills and strengths by the nature of their long academic and training years required
to become a physician. Physicians are comfortable to face complexity that requires
difficult decision-making in diagnostics and patient care. They care about their
patients and, more importantly, have high ethical standards in how they practice. In
spite of these attributes, today’s physician faces challenges to evolve into a less
autonomous environment brought about by the fast-evolving health-care environ-
ment. Physician leadership once centered on heading a surgical or patient care team;
physicians now lead population-based management teams and serve on management
teams for complex health-care systems. New management styles are necessary to
combat the regulatory aspects of health care, such as knowledge of reimbursement,
health care reform, and other aspects that affect a population. However, management
and leadership are not the same. To acquire management skills is more of the how to
effectively complete tasks in an organization, whereas leadership is the why we do
what we do in an organization focused not only on tasks but also on people [1].
8 Leadership 91

Health care systems are highly susceptible to rapid changes through demographic
shifts, disease patterns, high impact technology, scientific innovation, public policy,
and processes that impact the financial viability and capabilities of health systems
to meet their mission. These challenges easily align with the VUCA teaching. The
term defines volatility, uncertainty, complexity, and ambiguity but more importantly
provides us with the opportunity to turn challenges into positive and reproducible
outcomes through a counter-balance of volatility with vision; uncertainty with
understanding; complexity with clarity; and ambiguity with agility [2]. In the world
of health care, the future is uncertain. This is not necessarily an unfavorable aspect
of the field, but rather implies the need for new types of leaders. The new health care
leader is not fearful or resistant in the face of change, but rather embraces change as
a means to innovate. The leader is able to apply leadership skills to all aspects of
health care, from education to delivery of care.

Leadership Versus Management

Management produces order and consistency, whereas leadership produces change

and movement. Whereas the manager counts value, has circle of power, and man-
ages work, leaders create value, have a circle of influence, and lead people [3].
Leaders may need to serve as managers at times and managers may need to take on
a leadership role, and both roles are vital to the success of a team or organization.
Leadership is vital for promoting positive change and continuous improvement,
which are essential in the rapidly changing health-care environment.

Leadership Theories

There are many leadership theories that have been studied throughout the centuries.
For the purpose of providing those most commonly used, we will focus on four
leadership theories: Transactional, Transformational, Situational, and the role of
Emotional Intelligence for the leader.

Transactional Leadership  Transactional leadership was first described by Max

Weber in 1947 and subsequently by Bernard Bass in 1981. This type of leadership
involves motivating and directing followers primarily through appealing to their
own self-interest. The power of transactional leaders comes from their formal
authority and responsibility in the organization. The main goal of the follower is to
obey the instructions of the leader. The style is mentioned as a ‘telling style’. The
leader believes in motivating through a system of rewards and punishment [3, 4].

Transformational Leadership  Transformational leadership was first introduced by

James Downton and later developed by James MacGregor Burns in 1978.
Transformational leadership goes beyond the more traditional style of transactional
leadership (which focuses on supervision, organization, and group performance)
92 E. O. Roldan and J. Dickerman

and emphasizes that people work more effectively if they have a sense of mission.
The transformational theory requires leaders to communicate their vision in a man-
ner that is meaningful, exciting, and creates unity and collective purpose; the man-
ager who is committed, has vision, and is able to empower others and is described
as a transformational leader. Transformational leaders are able to motivate perfor-
mance beyond expectations through their ability to influence attitudes [4].

Situational Leadership  Dr. Paul Hersey and Ken Blanchard created situational
leadership. Situational leadership style is an adaptive style. The leader using this
style focuses on how best to get “buy-in” of its followers observing all existing
variables in the environment to reach its goal. It emphasizes leading your team
based on the following factors:

(a) Develop people and workgroups

(b) Bringing out the best in people
(c) Uses persuasion rather than negotiation to reach its outcome

This type of style is very useful in crisis, when the leader needs to be vigilant
regarding resistance to change from the group. In this manner, the leader is an
observer and easily adapts its style of leadership to “bring in” the followers. If used
effectively, leaders will identify champions for change from the group [5].

Emotional Intelligence  Emotional intelligence (EI) started gaining popularity in

the 1990s after Daniel Goleman wrote about superior performance of leaders, in
which 67% aligned with their emotional intelligence rather than with their technical
expertise. Emotional intelligence is defined by how well we can read others and
manage our own emotions. In general, it includes three important skills: self-­
awareness of own emotions; using emotions for positive thinking and problem solv-
ing; and regulating our own emotions and those of others. Leaders that have high EI
are said to be successful in creating positive cultures and create a more “human”
environment. Vulnerability is a feature of emotional intelligence. This doesn’t mean
being submissive, but rather being flexible and aware that the logic part of the brain
can block our emotions [6, 7] (Table 8.1).

Table 8.1  Leadership styles

Leadership style Description
Transactional Motivating and directing followers primarily through appealing to
leadership their own self-interest
Transformational Emphasizes that people work more effectively if they have a sense of
leadership mission
Situational leadership Focuses on how best to get “buy-in” of its followers observing all
existing variables in the environment to reach its goal
Emotional intelligence Defined by how well we can read others and manage our own
emotions
8 Leadership 93

Case Studies in Leadership Styles [8]

1. Jeranil was elected as one of three chief residents of her psychiatry residency
program 2  weeks ago. Since the announcement, she has been approached by
several individuals with requests. An intern has asked her to enhance faculty
teaching efforts, a second year resident would like for her to advocate for depart-
mental adherence to resident work hours, and a senior faculty member has asked
for her to speak with residents about partaking in more research. Jeranil is feel-
ing overwhelmed by the multiple requests.
(a) Which leadership style(s) reflects Jeranil in this case and why?
(b) How can she be a more effective leader?
Discussion: Jernil feels overwhelmed by the requests of her peers and her fac-
ulty. This is common when employing a transactional approach to leadership –
trying to lead by attending to the self-interests of those you are trying to lead.
Focusing on a shared vision with her fellow residents (i.e. improving overall resi-
dent education) and recruiting them to participate in the development of an
action plan can create an environment that is energetic versus draining, collab-
orative versus self-centered, and innovative versus problem-oriented. She has an
opportunity to develop leadership skills in Communication and Relationship and
Management. Serving as a chief resident provides Jernil the opportunity to
develop leadership skills and perhaps continue a career in health-care
leadership.
2. Dwayne has been interviewing medical student applicants for the past 6 months;
which he finds personally and professionally gratifying. The Associate Dean of
Admissions has been impressed with his critique and write-ups of applicants and
has approached him about serving as the medical student representative on the
committee. Dwayne is excited because he has a number of ideas on how to
increase the number of applicants and matriculants from the surrounding inner-­
city community and is eager to implement these changes.
(a) Which leadership style(s) reflects Dwayne in this case and why?
(b) How can he be a more effective leader?
Discussion: Dwayne is demonstrating an Emotional Intelligence approach to
leadership. He is self-aware of his own emotions and uses his emotions for posi-
tive thinking and problem solving. He is looking to promote diversity and is will-
ing to participate in the development of a plan to increase the number of
applicants in the surrounding inner-city. Dwayne has an opportunity to develop
transformational leadership skills by helping others to become mission-driven
and to develop skills in Facilitator/Vision and Professionalism.
3. Mikaela has just assumed the presidency of a medical student organization. Her
members are passionate and she has decided to email her members and ask for
suggestions for activities and projects for the year. Soon after sending the email,
she received two emails asking to speak at this month’s Board meeting about
organizing a sexuality workshop at a local college and a breast cancer fundrais-
ing walk the following month.
94 E. O. Roldan and J. Dickerman

(a) Which leadership style(s) reflects Mikaela in this case and why?
(b) How can she be a more effective leader?
Discussion: Mikaela is demonstrating a situational leadership approach to help
nurture the passion in her medical student organization. She adapts to the situa-
tion at hand to encourage others and bring out the best in her team. Her recogni-
tion of the passion and emotion of others may help her to develop skills in
Emotional Intelligence leadership. The requests of her team can provide Mikaela
an opportunity to develop skills in Business and Knowledge of the Health-Care
Environment.

Assessing Leadership Style

There are a number of different assessment tools that may provide insight to leader-
ship styles and adaptability. These tools can help individuals to align a leadership
style with their own traits and strengths and may help one identify areas of weak-
ness and future development. We will cover three most common tools: the Myer–
Briggs type indicator, 360 assessments, and the StrengthsFinder Assessment.

Myer–Briggs Type Indicator  MBTI© is an efficient and effective way to analyze

personality types and preferences – your own and of others. It is based on the psy-
chological types by C.G. Jung. It gives comprehensive feedback on areas of strength
and aspects of one’s style. Understanding our personality preferences helps us find
the right fit for a job, why we prefer some aspects of the job and not other aspects,
helps us in our relationships and communication, and makes us learn better and
teach better by adapting our styles in a suitable manner. It offers real insight into our
comfort zones as well as zones of discomfort. The assessment indicates your per-
sonality type based on: 1 of 16 types. An example would be: E(extroversion) I
(Introversion) T (Thinking) J (Judging). Understanding your personality type as
well as that of those you work with can improve communication and personal inter-
action [9].

360 Assessment  This assessment first was originally used in the 1950s. By the
1990s, human resource departments were using this assessment as part of the organi-
zational feedback. The 360-degree feedback is a method of systematically collecting
opinions about an individual’s performance from a wide range of coworkers. This
includes peers, direct reports, the boss, and boss’ peers – along with people outside
the organization, such as customers. The benefit of collecting data of this kind is that
the person gets to see a panorama of perceptions rather than just self-­perception,
which affords a more complete picture. Research clearly indicates that 360-degree
feedback systems give a much more accurate picture than self-­assessment of what
executives really do and how executives actually behave [10–12].

Strengths Finder Assessment  The Clifton Strengths assessment is the culmina-

tion of more than 50  years of Dr. Donald O.  Clifton’s lifelong work. It helps
8 Leadership 95

Table 8.2  Leadership style assessments

Assessment Description
Myer–Briggs type Provides comprehensive feedback on areas of strength and aspects of
indicator one’s style
360 assessment Provides a systematic method of collecting opinions about an
individual’s performance from a wide range of coworkers
StrengthsFinder Helps identify areas of greatest potential for building strength
assessment

identify areas where you have the greatest potential for building strength. It is mea-
suring your re-occurring patterns of thought, feeling, and behavior. Knowing this
information is a starting point, and where we come along side individuals, teams
and organizations to help leverage your talent, and turn it into sustainable strength
(Table 8.2).

Understanding one’s own personality styles along with understanding the con-
text in which leadership is needed in the health-care environment can help the indi-
vidual determine which leadership theory should be explored. This information can
help one pursue formal leadership training and identify leadership opportunities to
practice leadership skills.

Examples of Leaders in Health Care

Leaders in health care can take many forms. You are probably most familiar with
physicians serving as team leaders. For example, as you enter the operating room,
surgeons play a central role in leading anesthesia, nurses, scrub techs, and OR desk
staff. The following are examples of leadership roles in health care (Table 8.3).
Many medical students, residents, and faculty have gained an appreciation and
experience in serving as team, group, and organizational leaders. Developing lead-
ership skills provides you great opportunities to fill these higher roles as you prog-
ress through medical school, residency, and as a faculty member.

Promoting Diversity in Leadership

Increasing diversity in leadership roles is key to creating diversity in the workforce.

At many academic health centers, the higher ranks of Associate and Full Professor
are afforded greater leadership opportunities, including sitting on committees that
determine the vision, mission, and strategic planning of the medical school or aca-
demic health center. Diversity in these leadership roles can promote diversity in
strategic planning, medical education, and patient care
Unfortunately, many obstacles in academic organizations too often discourage
diversity in leadership. Obstacles include a hierarchy of department chairs that reduces
transparency of decision-making, impedes advancement by way of a bottle-­neck
96 E. O. Roldan and J. Dickerman

Table 8.3  Leaders in health care

Team leaders Group leaders Organizational leaders
Attending teams Departmental University
 Attending  Section chief  Dean of med school
 Fellows  Division head  University chancellor
 Residents  Vice chair
 Medical students  Clinic director
 Lab director
Clinic teams Hospital Governmental
 Physicians  Partnership leader  Secretary of Health & Human
 Front desk staff  Medical staff committees Services
 Nursing staff  CDC director
 Ancillary staff  NIH director
Hospital teams Educational Hospital
 Physicians  Student rotation director  President/CEO
 Nursing staff  Residency director  Chief officer
 Ward staff  Fellowship director
 Ancillary providers
Operating room Administrative
teams  Chair faculty council
 Surgeons  Chair of search
 Anesthesia committees
 Nursing  Medical society
 Scrub techs  Committee chairs
 OR desk staff

effect, negatively affects inclusion across professionals, and appears to be more con-
sequential among women [13, 14]. A lack of clarity for promotion and advancement
policies and procedures may also impede the inclusion of diverse individuals [14].
Leadership in academic medicine has often been viewed as hierarchical, tyrannical,
intimidating, abusive, malignant, and inflexible [15]. As we look to develop the future
leaders in health care, we should be mindful of these obstacles and cultures and pro-
mote diversity both in future leaders as one of the key skills of a health-care leader.

Leadership Opportunities and Leadership Skill Development

Teaching physician leadership in the medical school is a daunting proposition

although inevitable if we, as a health-care system, want to contribute to its success.
Medical students come from years of competing for entrance into medical school.
They arrive with the traditional notion that medicine is about diagnostics and
patient’s health outcomes. In addition, they usually come from an academic science
formation focused on excelling on the MCAT, the standardized exam that is key to
successful medical school acceptance. Unless they have participated in leadership
roles as an undergraduate, the idea of becoming a leader may be daunting to them.
In addition, the challenge to persuade traditional medical school teaching to incor-
porate formal leadership training may be a challenge as well. In addition, formal
clinical training takes approximately 8  years and sometimes longer, making it
8 Leadership 97

challenging to incorporate either added leadership training or post-graduate training

in formal leadership formation.
Leadership opportunities provide a means of developing leadership skills “in
situ” – that is, students, residents, and faculty may be able to develop leadership
skills when they are presented a leadership opportunity to serve on a committee,
lead a quality improvement project, or design a health-care delivery plan for a
patient population. This form of learning can be an efficient and effective means of
developing leadership skills and can provide feedback to the learner as to how these
skills may positively impact health care. Health-care leadership skills that may be
developed in these settings include: Communication and Relationship, Management,
Facilitator/Vision, Professionalism, Business, and Knowledge of the Health-Care
Environment [16]. These competencies were derived from the Dreyfus framework
and are designed to help leaders to be effective in the complex health-care arena.
These competencies stretch across the spectrum of physician leadership, whether
managing a small care team, or overseeing a large complex health-care system.
These competencies are designed to help physician leaders work better with all of
their customers, be it patients, colleagues, employees, and/or payers.
Identification of a leadership mentor can make the “in situ” form of learning
more effective. Mentors may be colleagues in your academic teaching center or
leaders in a hospital system, such as a department head or Chief Medical Officer. A
number of leadership books are available to supplement leadership experiences, as
well as online resources through organizations like Building the Next Generation
of Academic Physicians, the American Medical Student Association, the American
College of Physicians​, the Association of American Medical Colleges (AAMC)
MedEdPORTAL​, and the American College of Healthcare Executives. Formal
training in leadership, including an MBA, further promotes the development of
leadership skills in those individuals entertaining a career in health-care leadership.
The key to “in-situ” leadership training is identification of leadership opportuni-
ties. First, you may draw on your previous leadership experiences. Many medical
students have served as a scout leader, club president, or student educator/mentor.
These experiences provide insight into the skills needed to be an effective leader,
and serve to reinforce the importance of leadership in advancing the mission of an
organization.
Second, you may be able to identify leadership opportunities during your medi-
cal training – leading a study group, participating on a curriculum committee, serv-
ing as a class officer or chief resident. These experiences can help you to focus the
leadership skills you taught on improving patient care, reducing adverse patient
events, and improving the overall health of your community.
Finally, you may begin to identify professional opportunities for physician lead-
ership upon graduation. Physician leadership roles include serving as a physician
advisor, serving as a Chief Medical Officer for a medical practice or health-care
system, serving as a physician leader on a national organization such as the American
Medical Association, or contributing to a local or national health-care advisory
group. An increasing number of physicians are also serving as representatives on
local and national governing bodies (Table 8.4).
98 E. O. Roldan and J. Dickerman

Table 8.4  Developing leadership skills and competencies

Assessment Description
Identify Leading a study group, serving as a chief resident, participating on a
opportunities to committee, leading a quality improvement project
serve as a leader
Identify a mentorA number of leadership books are available to supplement leadership
experiences as well as online resources through organizations like Building
the Next Generation of Academic Physicians, the American Medical Student
Association, the American College of Physicians​, the Association of
American Medical Colleges (AAMC) MedEdPORTAL​, and the American
College of Healthcare Executives
Undertake formal Leadership courses, Masters in Business Administration (MBA)
training

Serving as a leader in health care can provide you an opportunity to impact the health
and well-being of many more patients than a panel of patients assigned to your practice.
As you progress through your training, take advantage of the opportunities that present
themselves and consider a career in health-care leadership after graduation.
We have provided a roadmap to begin your journey in leadership. We also shared
our own journey. Remember, this is simply a roadmap built on our experiences as
physician leaders. The key is to be flexible and cognizant that each journey is indi-
vidual in nature. In general, leaders learn first to lead self then subsequently lead
others. To lead self, one needs to be aware of one’s own attitudes, behaviors, and
biases in order to continue to grow. Through growth, we are open to options and new
ideas and, more importantly, are not afraid to face challenges. Challenges, after all,
provide opportunities to improve ourselves and the community around us. Growth
enhances our ability to accept change and is not hindered by constraints. Until we
face who we are and why we act the way we do, it will not let us face a new world.
The development of leadership skills is vital to assuring the complex health-care
system in which we work is truly effective in improving the health of our patients.
Complex systems require the coordinated efforts of highly trained and diverse
workers. Leadership is the most effective means of coordinating the efforts of the
diverse teams needed to deliver health care in our current system.
If your actions inspire others to dream more, learn more, do more and become more, you
are a leader. – John Quincy Adams

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Eneida O. Roldan, MD, MPH, MBA  Chief Executive Officer,

FIU Healthcare Network, Florida International University;
Associate Dean, International Affairs, Associate Dean Master
Physician Assistant Studies, Professor, Department of Pathology,
Florida International University Herbert Wertheim College of
Medicine

Joel Dickerman, DO  Vice President Assessment Services

National Board of Osteopathic Medical Examiners