1. Bolwell, Brian J. MD, FACP

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I start every day by doing a cardio workout in my basement. Apart from the obvious physical health benefits, it's become almost meditative in that it allows my mind to free up, roam, and create. I always listen to music while working out. I stay current, but it's always good when a Britney Spears tune shows up. I go so far as to rehearse conversations, meetings, appointments; planning as best as one can in the face of the unpredictable. I've found in the wee morning hours, with Britney belting in my ear, some of my best ideas and most creative solutions arise; less so when I'm at work.


As I think about this, several themes emerge. The first is a theme about anticipated challenges. Many times, these challenges involve the concept of how to execute or deliver results. Delivering results is obviously an important priority for any leader and is always, to some degree or another, how a leader is evaluated. Things are changing rapidly in health care, an always present issue for me to ruminate on. Key goals for health care organizations are how to become more efficient and how to manage populations of patients in a value-based care environment. The challenge for a cancer center is to define what this means and how to execute on such goals. It's my job to figure out the "how."


Another theme for me is the unanticipated challenges of my day-to-day existence as a cancer center leader. A big part of my job is knowing that, on any given day, one or more problems will spring up out of the blue. Sometimes these are operational challenges, sometimes they are about behavioral challenges, and sometimes they are about clinical issues. But, more often than not, on any given day unexpected issues arise that require my attention. Which again leads to the question of "how?" How does one manage issues that arise without warning? How as a leader do I prepare for the unknown?


The concept of contextual intelligence (CI) can assist when approaching complex issues. Matthew Kutz has written extensively on the subject. In his view, CI is comprised of several factors. The first is synchronicity, recalling lessons that you learn in one context and applying them in an unrelated or apparently irrelevant context. Another component is chaos theory, or non-Newtonian thinking. This concept embraces the idea that things are rarely predictable. Instead, randomness and instability are inevitable. In one of his articles, Kutz relates that the western perspective needs to "catch up" with what the rest of the less industrialized world already knows (and is comfortable with), that chaos is part of everyday life. CI includes the ability to be calm and flexible in unpredictable times. A hard-won skill for every leader.


Two additional CI concepts are tacit knowledge and 3D thinking. Tacit knowledge is what people know to be true, but have a difficult time articulating how they learned it. An example is doing "the right thing." It may be hard to determine how you know what the right thing to do is, but the key is to follow your instinct and, in fact, do the right thing. This is an interesting concept because doing the right thing depends to some degree on your perspective. Your chief financial officer might want you to slash costs for the good of the organization (in their eyes, the right thing to do) but you resist because you do not want to compromise clinical care (in your eyes, the right thing to do). In any event, tacit knowledge and doing the right thing are a big deal to me. If I stop doing it, I should find another job. 3D thinking is the ability to focus on the past, the present, and the future when making decisions. It states that historical knowledge and perspective should be as important as the present and the future when charting a new course of action.


These concepts resonate with me, especially non-Newtonian thinking. Clinical cancer medicine is always associated with unpredictability. This is unlike some medical specialties, and certainly unlike some other industries. All cancer clinicians know too well that their day can be changed with a patient who has an unexpected complication from therapy or an unexpected relapse. Successful cancer clinicians possess the ability to manage such unexpected events. The same is true about leading a cancer center. Stuff happens. All the time. Your job involves addressing and managing unanticipated events. To do this successfully, you need to be comfortable with the unexpected. You need to be flexible, and you need to realize that an endeavor will have hurdles and setbacks, even if you are on the right course. You need to be resilient.


The concept of synchronicity is useful when facing a challenging task. How can you apply lessons from your past to the current challenge? Which members of your team are skilled at similar tasks? Are there best practices from other initiatives that you can draw on? These can be both positive and negative experiences. I often reflect on leaders I have witnessed who managed challenges with skill, and others who managed challenges with anything but skill. I try to remember both when faced with a new challenge. Sometimes both the good and bad role models are me-I remember when I did a task well and I also remember when I messed up. At the very least, such reflections allow me to course correct when I make mistakes more quickly than I previously did. In a similar vein, 3D thinking truly helps you determine the "how," especially if you can apply organizational memory to a current issue. And clearly, tacit knowledge-trying to do the right thing-should always be your North Star.


The challenge of how to excel in a value-based environment going forward in cancer medicine is real. There is no playbook for this. We have to write a new playbook that describes how to achieve success. But I believe that there are many lessons learned from previous unrelated experiences that can help. The key is to open your mind and your imagination to be able to apply them. Maybe that is why I sometimes get new ideas when I am exercising-I am doing something totally unrelated to medicine that frees my mind to explore seemingly unrelated past events in a new light.


The other thing to remember when dealing with complex issues is that you have help. You have a team. Seek their counsel. Listen to them. Be open to honest feedback and change your course if better options than yours exist.


But, admittedly, sometimes it is up to you to develop a plan-a way forward-to address unexpected and challenging issues. You never know when a new idea will pop into your head, so remember to listen to your inner voice when it starts to speak up about value-based care, even when you're grooving to Britney Spears.


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

Brian J. Bolwell, MD... - Click to enlarge in new windowBrian J. Bolwell, MD, FACP. Brian J. Bolwell, MD, FACP