Author: David Langer
Health care in the era of the Affordable Care Act has evolved into a substantially different environment from which our mentors and teachers trained and worked. Physicians are tasked with taking on new roles in health care organizations that require performance in areas in which they have little formal training or preparation. Neurosurgical leaders must adapt to these new roles, and must define new goals not only for their organizations, but for themselves.
Health care has changed rapidly over the last 30 years as hospitals have increasingly become parts of health systems into larger and larger networks. This organizational growth has led to an explosion in the number of administrators compared to the number of physicians (Figure 1).1 This structural change radically altered not only health care delivery, but the goals of these large organizations and their leadership.
Neurosurgeons have trained since early in medical school to focus on themselves and their own distinctive skill set. They push themselves to work as hard as possible to master a unique set of procedures and surgical techniques with little thought given to the notion of "leadership." In the past, a "neurosurgical leader" was defined by case volume, technical skill, and financial productivity. However, as health care evolved, so has the very definition of what it means to be a neurosurgical leader.
Today, leadership requires focus upon creating, guiding, and elevating teams. One must define a vision and the requirements to fulfill it. Teams of people must be supported and nurtured, while the individual goals of the leader often must be secondary. No neurosurgical leader can be primarily focused on his or her own best interests at the expense of the team. Ego and selfishness need to be held in check, as a leader works to elevate those around him or her.
The transition from elite surgeon to elite leader is not guaranteed. In fact, the best leaders may not necessarily be the best surgeons. Too often, leadership as a surgeon is defined by title alone. Titles confer the optics of leadership, but does little beyond defining an opportunity to lead. Once given the title, the work begins. Leadership requires hard work in an entirely different way, with a skill set that vastly differs from what could be considered the "leading surgeon." Where the surgeon focuses upon a research project or surgical procedure, the leader focuses upon putting into place the pieces that will allow the group to achieve scientific and/or clinical success. In the book Ego is the Enemy, Ryan Holiday suggests the transition to leadership requires a revaluation and updating of one's identity.2 It requires a certain humility in which you put aside some of the more enjoyable and satisfying parts of your previous job, and accept others might be more qualified or specialized in areas in which you consider yourself competent-or at least, their time is better spent on those areas than yours.
Holiday also points out that seeing the big picture ought to be the focus, and less time spent on the little things that in the past may have made us feel important. These activities may have been endlessly engaging, flattering, or made us feel powerful, but they actually need to be de-emphasized as one embraces the mantle of true leadership. Managing this transition can be remarkably difficult, due to the methods of feedback and incentives, both financial and personal, accorded to leading neurosurgeons, and which often run counter to the ideal goals of leadership. Managing this transition requires that one identify and recognize the differences between being a talented leading surgeon, and an outstanding leader.
The pathway to transformative leadership requires patience, mindfulness, selflessness, and vision. It is often a slow process, with ill-defined feedback mechanisms. John Quincy Adams said, "If your actions inspire others to dream more, learn more, do more, and become more, you are a leader." In order to achieve success, one must make a concrete commitment to leading and must work diligently to avoid common pitfalls.
The earliest struggles often involve compensation and the existing financial structure. Leaders must address this issue directly, and help to create a compensation arrangement that allows them to lead effectively without fear of financial conflict. Leaders must not be in financial competition with their teams. It is remarkably difficult to be inspirational when you are competing for the same dollar as those you lead.
This early issue may be unique to health care in that department compensation models historically were inherently individually driven by cash or RVU contracts. Leaders cannot be as effective if success is measured by these metrics. With an appropriate financial feedback system in place, leaders then must confront their own inner wiring. As mentioned above, neurosurgeons are programmed to make themselves successful, and by definition, this requires competing with others. Leaving behind instinctive and longtime behaviors can be stressful and difficult.
The rewards of vision and day-to-day leadership is very different from the rewards received from surgical volume or research publications. Celebrating the success of our teams is what needs to be the focus. Success as a leader needs to be felt internally, with the usual mechanisms of external validation not relevant. Success as a leader with achievement of vision can take years. Consistent daily sacrifice and constant internal patience, mindfulness, and self awareness are essential to achieving a long-term goal.
Becoming a neurosurgical leader has some inherent differences from leadership in other, particularly nonsurgical, fields. It is somewhat important, but not necessarily essential, that the leader "leads from the front."
As one supports the clinical volume development of the service at the expense of his own, a slippery slope can occur, resulting in diminished personal volume, which can also cause anxiety. In addition, staff surgeons can lose confidence in the leader if he or she loses respect as a surgeon.
Leading from the front allows for observations regarding care, patient experience, and work flow that are more difficult as one pulls away from the point of care. An "undercover boss" concept is necessary for the leader to be able to not only make observations regarding points of pain, but to make good decisions from his or her own perspective in order to rectify them. Managing this transition can create anxiety that must be addressed. Many organizations use the services of executive coaches and mentorship programs to help alleviate some of the psychological strain that can occur during these transitions.
Maintaining skills and success in the operating room should be an essential goal. Being a supporter of the team's volume, success, and aptitude is even more essential. Increasingly we see leaders who completely pull away from the clinical area, focusing entirely on administrative or educational metrics. These positions differ substantively from those of a clinical leader. Clinical leaders often need to wear two "hats" as they navigate both the clinical and administrative environments. Balancing these two very different arenas requires a structure that allows the neurosurgeon to be equally comfortable in both settings.
Medical care also becomes increasingly challenging as neurosurgeons are asked to do more and more with diminishing resources. Leadership in health care, neurosurgical or otherwise, requires new approaches and concepts that were inconceivable less than a decade in the past. New metrics, new forms of payment, and new goals of care have radically altered the medical landscape, and are likely to continue changing in the foreseeable future. Expansion of our field into subspecialty divisions with new areas of focus, technological advancement, and increased competition adds an additional layer of complexity which did not exist in prior generations of leaders.
Leadership is evolving in areas outside medicine as well. Nelson Schwartz explored the evolution of corporate CEO in a New York Times article this summer.3 "The Decline of the Baronial CEO" illustrates the changes that have impacted corporate leadership. New business and technological change radically altered the C-suite landscape, resulting in CEOs with less power and more diverse challenges that didn't exist for the previous generation of chief executives.
Medicine has its own new challenges and stressors putting new, unique demands upon its leaders. Transcendent leadership in health care will require each leader to firstly commit to and identify leadership as a unique skill, while at the same time altering their sense of self as he or she moves into a new way of behaving and thinking. Becoming a "leading neurosurgeon" is wholly different from becoming a neurosurgical leader, and our field depends on our finding and nurturing this new breed of neurosurgeon. The success of our field depends upon it.