1. Bolwell, Brian J. MD, FACP

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Everyone is a leader of some sort. As a parent, you may be leading your family on a vacation. As a physician, you may be leading a team of nurses or house staff as you round on your patients. The topic of leadership is relevant to most adults.

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I have held a variety of administrative leadership positions, and now have a very large leadership job as Chairman of our cancer center.


When I was first appointed to another key leadership job over a decade ago, I realized I had never really been trained about the subject, and I knew very little about different leadership styles. So I did what I frequently do when I want to know more about something-I started to read books. I have now read over 40 books about leadership. These books are generally geared toward business and industry, but most of the lessons I have learned are universal and applicable to leadership in academic medicine. I also have participated in several intensive executive coaching sessions to examine my leadership strengths and opportunities for improvement.


In general, I believe the principles of a leadership style called "serving leadership" make sense. Briefly, this means I need to set the vision for our organization; recruit excellent people, both physicians and non-physicians; remove obstacles that are obstructing success (these are frequently political challenges with which I need to be directly involved); develop a culture of excellence, empathy, and importantly, accountability; and give credit to others when success is achieved. There are many excellent books about serving leadership. One of the best is The Seven Pillars of Servant Leadership by Sipe and Frick. As a corollary to this, there are individual characteristics I need to model, including demonstrating respect for others, creating transparency, being honest at all times, showing loyalty, delivering results, and continuously striving for self-improvement. All of these traits are discussed in one of my favorite books entitled The Speed of Trust by Stephen Covey.


While most leadership principles are valid across industries, academic medicine does have its own set of quirks, challenges, and principles rarely discussed in generic leadership books. The following is a list of lessons I have learned about leading a large academic cancer center. Many of these can apply to a range of leadership roles, no matter how large or small.


1. Set aside your individual academic career.


Leadership in other industries is assumed to be a full-time job. Not so in academic medicine. Top physician leaders are frequently expected to continue their personal academic career and carry a large clinical load. Even if it is not required, many academic physician leaders cannot give up the allure of their personal academic career. I strongly believe that little is more complicated or time-consuming than a large leadership job in academic medicine, and the only way to do it well is to devote at least 90 percent of your time to it. Those that continue to be first authors on papers or who are always on the podium at national meetings are usually poor leaders.


2. It is impossible to overstate the importance of internal communication.


The current pace of change in cancer medicine is unprecedented. Clinical therapies are constantly evolving. We have more metrics evaluating our clinical performance than ever before. The cost of cancer therapies is soaring and reimbursement is declining. Value-based care is changing the practice of oncology. In the midst of this change, it is imperative to communicate the priorities, and evolution, of the cancer center. We utilize multiple communication tactics in our cancer center, including monthly newsletters that include a personal blog from me, a weekly newsletter to physicians and non-physician staff about current issues, disease-based programmatic newsletters, and many more. There will always be those who claim they "never heard" about a new initiative, but your job as a leader is to do all in your power to communicate at all levels of the cancer center. It is not easy and it is time-consuming, but it is essential.


3. HR is a much larger part of the job than you might think.


Managing people is a large part of leadership. It starts with recruiting. Frederick Reichheld in his book Loyalty Rules noted that top management must stay involved in recruiting, and that emotional intelligence (the capacity to be aware of, control, and express one's emotions; to handle interpersonal relations judiciously and empathetically; and to see things from the perspective of others) is at least as important as IQ in recruiting employees. I totally agree. Building teams with high emotional intelligence will generate results and engagement. Great teams attract great people. The harder task is that of sustainability. Great teams stay great because "A" team members are supported. This means that a team member who is performing at a "C" or "D" level needs to be held accountable for his/her behavior. Keeping "C" team members is a bad idea. The first goal for the employees is to coach them and elevate their performance. If that fails, then sometimes a transition out of the organization is appropriate. Accountability includes managing physicians. In fact, managing physicians is one of the largest challenges of leading a cancer center. Setting high standards is important. Holding people accountable is more important. It takes work. It is constant. But it is the right thing to do.


4. All of your actions, behaviors, attitudes, and words will be closely scrutinized by those who work for you.


You are constantly watched. It is very important to not just be a leader, but also to demonstrate leadership behaviors. If you do not, it is a guaranteed fact that your questionable behavior will be effectively communicated throughout the entire cancer center in very short order. It is a good idea to be visible and present. Being present and saying hello can go a long way. A corollary to this is to try to find something about yourself that everyone can relate to and communicate it. This makes you more "real." About a year ago, I ended my monthly blog with a sentence about what music I was listening to. Ever since, scores of people will walk up to me and say "You really listen to Justin Bieber?" This month I said I liked a band from Australia called The Veronicas and now have a bond with several folks I typically rarely see. Sharing some aspect of your personal life resonates with your team.


5. I am increasingly convinced that the success of a cancer center is dependent on teamwork.


Developing a culture of teamwork is difficult. Physicians in academic medicine are rewarded for their own individual success and, to some degree, their own self-promotion. Yet, all important measures of a good cancer center, including access, quality, safety, and even research excellence, depend on teamwork. We have chosen to focus on driving down Time to Treat, which is a measure of the amount of time from the diagnosis of cancer to the first treatment. (If you are interested in learning more about Time to Treat, see "Enhancing Value for Cancer Patients: Time to Treatment as a Surrogate for Integrated Cancer Care", Bolwell & Khorana, JNCI 2016;14:1.) Time to Treat is getting worse by the year in comprehensive cancer centers around the U.S. It is now approximately 43 days. This is arguably at least 30 days too long. Some physicians claim it doesn't matter because it doesn't affect survival. Actually, there is emerging data to suggest that Time to Treat does affect survival; more importantly, such physicians who treat Time to Treat with disdain flunk the integrity test, because if their spouse winds up getting cancer, you can be sure their spouse will not wait 43 days for the first initial therapy, but rather be whisked in to be treated in 10. Time to Treat depends entirely on teamwork. A programmatic focus on Time to Treat generates a culture of teamwork and is also a great vehicle for leadership development.


6. Lead with empathy.


There is little more emotionally charged than the practice of cancer medicine. Patients are filled with anxiety and fear. Your core mission while leading a cancer center is to generate a culture of excellence and empathy for your patients. Time matters to cancer patients. Waiting in long lines to check in matters for patients who have 6 months to live. So eliminate long lines. Waiting 7 weeks to receive surgery for a new diagnosis of cancer is far too long. So study it and reduce it, which is why we are obsessed with Time to Treat. Treat patients and employees with dignity, respect, and empathy, which is why you might turn down the biggest CV and hire the physician who excels at emotional intelligence. Make sure everyone who touches your patients understands compassion and empathy. If not, transition them out. A cancer center must excel at empathy, and it is your job to make sure that it does.


7. The single most important leadership attribute rarely discussed in leadership books is courage.


It takes courage to try to do the right thing. There are many energy-sapping situations that scream for compromise: political challenges at all levels; turf issues; budgetary challenges; interactions with peers who have their own agendas; and many others. While certainly it is important to pick your political battles, it is more important to actually fight the battles that need to be fought. Most leadership books do not discuss courage. I believe that arguably the best thing I do as leader of this cancer center is to demonstrate integrity. This includes having the courage to address real and difficult challenges, or, said another way, to fight the battles that need to be fought. If you do this, you have the back of everyone who works in the cancer center. If you do it consistently, it is greatly appreciated. It also generates loyalty. It is not easy to do this. It is emotionally draining and isolating. But courage needs to be at your core.


8. The rewards are enormous.


Work is about relationships. A cancer center leader's job is quite social. The good news is that every day I am working with a whole bunch of smart, dedicated, compassionate, and emotionally aware people-much more talented than myself-and we are making things better for patients, for the center, and beyond. What a wonderful opportunity! The challenges are numerous and very real, but working with great people is a joy.


BRIAN J. BOLWELL, MD, FACP, is Chairman of the Taussig Cancer Institute and Professor of Medicine at the Cleveland Clinic Lerner School of Medicine. Cleveland Clinic is a top 10 cancer hospital according to U.S. News & World Report.

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