1. Bolwell, Brian J. MD, FACP

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A few weeks ago, I was in a position that is becoming increasingly familiar-sitting in an airport waiting for a delayed flight to board. I started to read a leadership book by John Maxwell called, The 5 Levels of Leadership. Maxwell has written many books on leadership, but this is the first one I read cover to cover.

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Briefly, the book says that the five levels of leadership are:


1. Position. People follow you because they have to. This is an autocratic leadership style. People who make it to Level 1 and stop may be bosses, but they are never leaders. They have subordinates, not team members. They rely on rules and organizational charts to control their people. Their people will do only what is required of them. Position leaders often devalue people and do things to make themselves look and feel important.


2. Permission. People follow you because they want to. Level 2 is all about developing relationships. It is about developing trust. Level 2 leadership is also about self-awareness and self-improvement. Here, Maxwell quotes Jack Welch, former CEO of General Electric, "Good leaders are open. They're informal. They're straight with people. They make a religion out of being accessible." Maxwell later makes a vital point: people buy in to the leader and then the vision.


3. Production. Level 3 is about delivering results. People follow you because of what you have done for the organization. Critical to Level 3 leadership is developing teamwork and culture. Maxwell cites the well-known saying "a chain is only as strong as its weakest link," and says that rotten attitudes ruin a team. He further raises the issue of culture by stating that "teammates must be able to count on each other when it counts." You need high-functioning teams to deliver results.


4. People Development. Leaders must transition from producers to developers and they must delegate. They need to be willing to let go of some of their responsibility. Key to Level 4 success is inner confidence. Maxwell quotes, "no amount of personal competency can compensate for personal insecurity." Only secure leaders give power to others.


5. Pinnacle. People follow you because of who you are and what you represent. It is about respect.



The book has great insight into these concepts. Obviously the levels are not perfect equations with distinct boundaries, but rather a useful guide for anyone attempting to improve their leadership skills.


In my experience, many physicians are stuck in Level 1 and, whether from ignorance or delusion, are content to remain. Perhaps their world is defined by their title, their value in the position they hold. Or perhaps they simply lack self-awareness. Maybe, they have not solicited feedback or people were unwilling to be candid. Whatever the reason, in academic medicine, it is imperative that leaders become self-aware and challenge themselves to reach Level 2 to support others, increase the value of relationships, and focus on self-improvement. It's a challenge. If physicians are unwilling or unable to progress past Level 1, the solution is fairly obvious-hire better leaders. Get involved and coach your current leaders. Attempt to generate self-insight and honest self-reflection. Increase and value self-awareness. Good in theory, but for some it's a long and difficult journey.


One of my biggest challenges as a cancer center leader is that of shaping and leading our culture. My goal is to elevate culture for the entire cancer organization. When I first started my career, our cancer center had about half of its employees paid by Hematology-Oncology and half by the cancer center. It was completely dysfunctional. The people who worked for Hem/Onc were overworked and short staffed. The people who worked for the cancer center were leisurely, lacked performance accountability, and were unwilling to help out. Employees could be sitting next to each other and be part of two entirely different cultures. Turnover was extreme. Dissatisfaction was omnipresent. It was a disaster. Things immediately improved when Hem/Onc became fully integrated in to the cancer center.


OK, so culture matters. The challenge is that a big cancer center consists of many sub-cultures.


In a large cancer center, most people define their world by their specialty. We are organized into disease-based programs-the leukemia program, the breast program, etc. This has been useful for us to drive metrics such as Time to Treat. But by doing so, sub-cultures develop.


Without question, each program has its own identity-its own culture. The risk is that every program erects rigid silos. By doing so, communication and teamwork between programs are minimized. Thus, creating high-performing programs is a management and leadership challenge. Well-developed programs are good in that having pride and ownership of your program does help drive results. The risk of developing multiple program identities is a loss of citizenship in the cancer center as a whole. Ideally, the cancer programs would easily work with each other and help each other out. The cancer program leaders would see their job as not just developing their own program, but also elevating the culture of the cancer center and the entire organization.


The program leaders have the opportunity to develop such a culture-to count on each other-not just within programs, but also across programs. Unfortunately, this idea of collaborating across programs is frequently a challenge, as program members are often consumed by their personal career and the evolution of their individual program.


How can this idea of cross program collaboration be developed? There are likely many strategies and tactics that may work, but I believe the best way is to develop leadership growth. Leaders should aspire to reach Level 4 and truly desire to help others, and be secure enough to delegate and give up some of their personal responsibility. They must aspire to be leaders in a broad way. This is extremely difficult to do, and may be impossible given that many leaders are stuck in Level 1.


I increasingly believe that a key part of my job is to generate interest in the topic of leadership. Leadership can in fact be cultivated and grown. I need to focus more energy on fostering growth and leadership potential.


For those of you who think that such an exercise is pointless-because you are the boss, people do what you say-I suggest you buy Maxwell's book and simply read the 30 pages about Level 1. Be honest with yourself as you read. The bottom line is that Level 1 leadership fails. At the very least, realize that work is about relationships, that a leader has to be supportive of his or her people, and that teamwork fuels success. If you want to go beyond that, try being a student of leadership. But you must be willing to change, to admit when you are wrong, to be more self-aware, and to possess a sincere desire to always get better. If you do, then, for you, your leadership opportunities are limitless. And being a better leader will yield huge benefits not just to you, but for those you touch, in the workplace and beyond.


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.


Straight Talk: Today's Cancer Centers

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Brian J. Bolwell, MD, FACP, shares insight on the issues that impact cancer leaders. You can read all his articles online. Go to and click on the Blogs button to view all the archived features.