Musings on the nature of academic medical leadership.

"Confucius say: top of ladder nice, but lonely."

Thus read the Chinese cookie fortune sent to me by a senior colleague, upon my becoming chief of a section of the department of pediatrics. It was meant as a sort of congratulatory note and mentoring advice. It took me over 20 years to understand the true meaning of the sentence and the intent of the giver.

Those few words described one of the basic tenets of leadership: the assumption of ultimate and personal responsibility for one's decisions. At the time, I did not feel at the top of a ladder (or at the top of anything, for that matter); I faced my new job with a mixture of equal parts of excitement, apprehension, insecurity and a slightly enhanced sense of self-importance.

I suspected but not yet internalized that in "climbing the ladder," strong character, skill acquisition and behavioral adaptation are the leading factors for success. Further, I came to the realization that, ultimately, promotion is less about climbing the ladder than being given the opportunity to hold it for others to climb safely, and in this manner, secure institutional succession and continuity.

All of that notwithstanding, leaders, especially in medical academia, are perceived "on top" of some organizational construct and assigned powers and abilities that they may not actually have. But the powers are perceived as the organizational dowry acquired upon promotion to the new position.

So, over the years, I have continuously tried to understand and interpret the fortune, and have come to the conclusion that, in his wisdom (and assuming he actually said it), Confucius was describing leadership as a personal journey, a kind of intellectual ziggurat from whose crenellations we must observe our surroundings and make decisions for which we are singularly responsible.

I have, however, never felt lonely during my 20-plus years in academic leadership positions; to the contrary, I have been enriched by many people and I have been part of processes that made me feel supported and part of purposeful teams.

The lonely top became an allegory, then, for constant self-examination, a "stick-to-itness" on matters of principle, and a decidedly strong sense of purpose.

As academic medical leaders, we are singularly called to interact and work in concert with others in organizational constructs; we must, overall, follow the old papal principle coined by Gregory the Great of being "Servus servorum Dei"--being the servants of the servants of God (1)--or, in this case, the servants of the servants of patient care, of education, of research and of community.

Balancing act in academia

Biblical leaders, for example--as described in sacred texts--were reluctant and imperfect individuals, often given to fits of depression and self-doubt.

Unsure of their skills and their ability to fulfill their missions, they were lonely at the top but ultimately fueled by the certainty that divine intervention would help them carry their work. They were not allowed much latitude or dissent, as they were expected to carry out divine commands without much protestation.

Their inner conflict was expressed in their dialogues with the Supreme Being, more as a request for enlightenment or relief from a divine charge, than a challenge to authority. The dynamic of the relationship was in the parental--or mentoring model; it allowed for personal growth and increased adaptation to the leadership role, in some instances leading to the achievement of greatness.

Leaders act ultimately out of a need for historical transcendence, a need for personal reaffirmation, or merely out of adaptation to circumstance. All too often, the sublimation of personal insecurity translates in behaviors, which, while enhancing the self-affirming need, prove injurious to others, disconnected of reality or simply maladaptive. In the absence of direct calibration of their leadership by others, they risk becoming ineffective.

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Academic medical leaders have the unavoidable responsibility to create environments where individual efforts meld into collective achievement; intellectual discourse translates into action and imagination fuels discovery. They must constantly address the misalignment between the healing mission and economic reality, and the conflict between vocation and environmental aggression.

They must learn to resist the environmental pressures on their principles and stay true to themselves and their word, and not become accomplices or profiteers of a flawed system. "To value one's profession one must profess its values." (2)

They must learn to deal effectively with the issues brought about by faculty in various stages of professional and personal development, from the "angst" of an assistant professor over promotion requirements or mounting family and economic demands, to the search for change in priorities of more senior faculty, or the unforeseen resignation and departure of valued faculty members.

All of this must be done while keeping in sight the institutional goals. The need to establish clearly that "the needs of the many outweigh the needs of the few or the one" (3) often puts an academic leader in a conflictive relationship with faculty.

Physicians are naturally independent and egocentric so the often-perceived urgency of a faculty member's needs may interfere with the equilibrium between personal and institutional priorities. It is here that the most honed interpersonal skills and clarity are needed.

Academic medical leaders must constantly return in their minds to the principled kernel of energy that propelled them into their vocation; in doing so, they will be able to better demonstrate and promote professionalism, one of the most important core competencies asked of medical students and trainees. While at it, they must keep a sense of humility and perspective, recognize their limitations and generously acknowledge the contributions of others.

Insofar as action generates reaction, external validation will come from the positive impact of actions and the fulfillment of fundamental principles. Such validation must be divorced from a demand for personal affirmation by expressions of gratitude or recognition, and, of all things, from claiming ownership of others' enhancements as a result of their actions. "A man wrapped in himself makes a very small package." (4)

Achievement is undoubtedly more important than mere activity; so, how to act on one's convictions and realize change, without succumbing to exhaustion and becoming ineffective, is part of the challenge.

Leaders are expected to "take it on the chin" in the face of adversity, while being consistent, trustworthy and honorable. To negotiate successfully and achieve forward motion also requires willingness to listen and integrate information. The creation of an "inner space" to recoil to in times of confusion or high pressure is essential to keep perspective and calm.

Insightful warning for leaders of all kinds comes from some of Murphy's Laws of Combat: (5)

* You are not Superman.

* The important things are always hard.

* The simple things are always hard.

* The easy way is mined.

Daniel V. Schidlow, MD, is professor and chair of the department of pediatrics at Drexel University College of Medicine and physician in chief at St. Christopher's Hospital for Children in Philadelphia, Pa. He can be reached at 215-427-4801 or Daniel. [e-mail]

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References

1. Tobin G, Selecting the Pope, New York: Sterling, 2003.

2. AAMC President Jordan Cohen's address at MCP-Hahnemann School of Medicine's Faculty Day, June 2000.

3. Mr. Spock, addressing Captain Kirk as he sacrifices his life to save the crew of his starship (to be resuscitated later); in Star Trek II: "The Wrath of Khan" (Paramount Pictures).

4. Attributed to singer Dolly Parton 

5. Courtesy of William H. Nauta, LtC. U.S. Army (Ret).

By Daniel V. Schidlow, M.D.