1. Bolwell, Brian J. MD, FACP

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I recently re-read one of my favorite books on leadership entitled The World's Most Powerful Leadership Principle-How to Become a Servant Leader by James Hunter. It is a wonderful book, with many practical tips on how to improve. More importantly, it frames the entire topic of leadership in ways that make sense, and is filled with illustrative anecdotes.

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While common in other industries, dialogue about leadership principles is extraordinarily rare in medicine, and I'm not sure why. Maybe we docs think we already know everything about everything. Indeed, I know many physicians who truly believe that they do. Maybe it's because our field is so complicated administratively-our economic models are complex and tied to bizarre reimbursement models that are evolving rapidly. Or maybe it's because we are tied to scientific advances that constantly change practice. Or perhaps because academic centers are tied to universities and all the idiosyncrasies that go along with universities. Whatever the reason, I think that the complexity of medicine makes the study of leadership even more important, on all levels.


On all levels? Yes, on all levels. The vast majority of people leaving any organization do not quit the organization, they quit their immediate boss. So I believe that not only do medical organizational leaders need to focus more on leadership development, organizations should teach leadership principles to people at all levels of the organization. Docs, nurses, research coordinators, managers, just about everyone.


Once you accept that leadership is important, and improving leadership skills in your team is crucial, how do you elevate your leaders? Well, step one is to take a look at who you hire for leadership positions. In general, we promote docs into leadership positions because they write a lot of papers. Somehow we think that the skill of writing papers will translate into being a good Division Chairman. I disagree. Hunter says "just because a person can do a job well does not mean that he or she can inspire or influence others to do a job well." The correct approach is to promote people of character, and people who are willing to change. Hunter continues, "Leadership development and character development are one." If you want to be a better leader, you must be willing to change, and improve, your character. And that is not easy to do.


Much of this book is about the importance of hiring people with emotional intelligence, and the value of giving people what they need (if you do so, they will get you everything you need as a leader and make you look good). These are themes that I have discussed before.


Several parts of the book struck a chord as I was re-reading this book. The first is about autocratic power. Hunter says "power works." If you have a boss who is a command and control type and orders you to do something, odds are you will do it. If you do the same to your employees, so will they. But there is a downside to this type of command and control leadership-it damages relationships. And work is about relationships-especially in medicine. Healthy organizations consist of healthy relationships between customers, owners, and employees. In medicine, as an example, forming relationships with referring physicians leads to more referrals, business growth, and loyalty to your organization.


I think we see such uses of power all the time in medicine. A physician who is a jerk yells at a desk receptionist, and he/she gets away with it because there is no accountability for bad behavior. An obnoxious office manager is rude to a secretary. A nurse does not acknowledge the existence of a janitor. And in academic medicine, it's frighteningly common for a full professor to be condescending to a junior faculty member.


The solution is simple. Treat people well. Little things matter. Say hi to people as they enter the elevator. Smile as you pass strangers in the hall. On a larger level, support your employees. If you need to hire more nurses, do so. If somebody needs a new computer, buy one. If there is a political battle to be fought that requires your involvement, get involved.


Hunter spends a lot of time on this topic. He says leadership requires kindness, respect, selflessness, and forgiveness. He also says that leadership requires humility. As an example, he says that many leaders are incapable of saying things like "I don't know," or "what do you think," or "challenge my thinking," or "I'm sorry, I was wrong." Is this important in medicine? I believe it is.


Very few physicians say "I don't know."


What physicians do, when faced with a question they do not know the answer to is ask more questions. If I am presenting a clinical case at a teaching conference, and I ask a clinical question to our fellows, the universal response if they do not know the answer is that they will ask more details about the case. They answer the question with a question. Somehow, while a medical student or resident, this is what they have seen, this works, so this is what they do. But I think there is a better way. I stop them and say not only is that not the right way to answer a question, I tell them that my favorite answer is always "I don't know." It takes a while for this to sink in, but eventually it does. A few months ago, at my first teaching conference of the year, with both returning fellows and some who were new to our cancer center in attendance, I asked the returning fellows if they remembered my favorite answer to questions, and the returning fellows collectively smiled, and said in unison, "I don't know!"


The new fellows thought we were all nuts.


I say "I don't know" all the time. I say it because it is pretty easy for a subject to arise about which I truly do not know the correct answer, but also because it invites honesty and transparency. It is authentic. It can be disarming to those who do not know me; however, it generally relaxes the room.


The second part of Hunter's book that hit home was when it's OK to be autocratic. He says that serving leaders need to be very clear and unwavering about mission, values, standards, and accountability. Accountability is very important. I mentioned this earlier in this essay. Too often leaders, especially in medicine, let poor behavior persist. Bad behavior persists, in part, because the employee over time does not expect you to do anything about it-which also makes you a hypocrite if you talk about holding people accountable but fail to do so yourself. Hunter quotes Colin Powell, "ironically by procrastinating on the difficult choices and not making anyone mad and treating everyone equally, the only people you wind up angering are the most productive and creative people in the organization."


Accountability is one of the hardest jobs as a leader. But if you want to keep your fabulous employees, on every level, it is vital. Failing to do so generates a culture of mediocrity. It happens all the time in medicine.


Servant leadership will benefit everyone in your organization and professional acquaintance as the principles are simple. So simple, in fact, it has the power to improve all your relationships.


In short, define the mission and vision. Hire great people-be very picky about recruiting. Give your team whatever they need to succeed. Remove obstacles for them, especially if political problems are in the way. Hold all accountable to your high standards. Celebrate their success by giving all the credit to them and sit in the back row as they receive the accolades. And, importantly, get better. Try to improve, try to be a better leader by being a better person. Character growth is synonymous with leadership growth. Talk the talk and walk the walk when it comes to honesty, integrity, and empathy. But most importantly, be authentic and genuine.


The rewards of leadership development and character development are huge. Give it a try. Maybe start by saying "I don't know."


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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