Life Is a Series of Useful Lessons

In 2012, just as I was about to announce my retirement as CEO of Denver Health, I received the invitation to update the original 1995 monograph Women in Medical Management: A Mentoring Guide. That update (Lessons Learned: Stories from Women in Medical Management) provided an opportunity for me to reflect on all the events, people, attitudes, and beliefs that helped shape my entire career.

I realized then that there are no major differences in the guiding principles of my personal and professional lives. The previous editions and this new one allow me to pass on the advice I have derived from many good and wise people over the years and share the lessons they taught. Moreover, now that I have spent the last nine years in retirement, I will add some new thoughts about what I call “my coda.”

Because these lessons were not read from a book or taught in a class, they underscore that the first step to success is to seek friends and mentors from whom you can learn at every point in your life — nothing else will serve you so well both as a person and as a professional.

I decided to name the people who helped me as a kind of tribute to each of them. Some of them may have thought I was not particularly attentive to the lessons while they were being taught, and there is more than a grain of truth in that. Sometimes, I failed to follow the advice when it was given, and some lessons have “sunk in” slowly. Nonetheless, having these lessons has been invaluable and it is in that spirit that I share them.

Although we cannot choose our families, we all know that they have an enormous influence on our futures. I was very fortunate to have an exceptional and warm extended family who taught me most of the important lessons for success.

My grandparents came to this country from Italy in the early 1900s. Both my grandfathers arrived as adolescents — alone and with nothing. Their experiences inspired me and taught me not to be afraid to take a risk. My mother reinforced this willingness to accept risk, encouraging me to attend medical school — something virtually unheard of in the rural Italian immigrant community in which I grew up. This reinforcement or restating of a lesson has been a common occurrence; wise people often seem to espouse similar philosophies.

My maternal grandfather was a wonderfully wise, peasant philosopher with insights into all aspects of life. He had an array of old sayings that embodied long-held truths. Let me share one that greatly influenced me from childhood through this day: “If you have a gift and you don’t use it, no confessor on earth can absolve you.” Hearing this repeatedly ingrained in me the concept that any talents a person has carry with them the obligation to use them in service.

More than 30 years later, Dr. Samuel Thier, another mentor, taught the same lesson. He believed that medicine was a learned profession in which practitioners are given valued information from the previous generation that we are to use, enrich, and pass on to the next generation without undue rewards. Lesson: Use your talents in service.

Using Your Gifts

My parents taught me that natural gifts and talents require hard work to be brought to fruition. In my school days, this was translated into “If you have the ability to get an A by working very hard, a B with minimal work is not acceptable.” Lesson: Always do your absolute best.

My mother taught me another valuable lesson while I was in grade school. My school was in a rural area of Pennsylvania, and many children in my class were so poor, they often came to school day after day in the same dirty clothes. My mother, who was a schoolteacher, reached out to everyone, especially these children, putting into action what she told me: “Be nice to everyone, especially the poor children.” Lesson: Reach out to everyone.

I have seen people in leadership positions, often physicians and academicians, who consider themselves above the crowd and deserving of different treatment than housekeepers, food service people, clerks, etc. This class mentality does not serve a leader well. This lesson, displayed at Denver Health in work and deed by so many employees so many times over many years, may be the single most important reason I have spent my entire academic career in a safety net healthcare system.

Still another lesson came from the older generation of women in my extended Italian family. By today’s standards, they had tough lives. They had very large families; they did all the work themselves — the cooking, cleaning, washing, canning — on and on. I can’t remember my paternal grandmother ever going on vacation or ever being taken out to dinner. My father was killed in World War II, and it was many years before my mother remarried. None of these women ever complained or were morose or bitter. In fact, they had great joy for life. Lesson: Don’t whine — look at the good things in your situation. My grandfather had a saying that took this life view one step further: “Not everything bad happens to harm you.”

Understanding the Truth

Sister Florence Marie Scott was my mentor during my four college years at a Catholic girls’ school where, at least in those days, every class started with a prayer chosen by the teacher. Head of the biology department, Sister Florence, began every class with a prayer that ended, “ . . . grant that I may understand the truth, and, when I understand the truth, fire me with the courage to use it.”

As you enter leadership positions, you will confront difficult problems. In these instances, it is critical to try your best to understand the truth and not just accept what you’d like to hear. Leadership positions at any level tend to be addictive; you like the role. It becomes difficult to be willing to put the job (or for that matter, advancement to the next job) on the line by defending with vigor and zeal a position that you see as true, but is unpopular.

In some sense, I have come to believe people who have leadership positions should be those who don’t want to keep them at any cost. These leaders feel free to make the right decisions even if it could cost them their jobs.

Sister Florence also reinforced the concept of risk taking. In those days, when nuns wore habits and were largely confined to convents, Sister was on the board of directors of the Marine Biological Laboratories in Woods Hole (the first and only woman at the time— let alone the only nun!). She spent every summer doing her research there. In this environment, she remained a nun—right down to wading in the water to collect specimens with her habit tucked around her legs. This sent a very loud and clear message: a woman can succeed in a man’s world without changing who or what she is.

Medical school and housestaff training brought many mentors and lessons and much advice, but I will focus on two special mentors: Dr. Samuel Schrier, head of the housestaff program, and Dr. Arnold Relman, chief of medicine. They gave the same, very clear message: set high standards for people you supervise, and they will work to meet those standards. In a leadership role, clearly stating those standards and goals sets the tone for everyone in an institution and tells your employees you believe in their abilities.

Being the Best

I clearly remember another lesson taught by Dr. Relman. One day, making rounds, he said, “There are many forces conspiring to kill the patient; the doctor should not be one of them.” Of course, no one was actually trying to kill the patient. The reference was about always giving the best care — no short cuts.

In a time when marketplace forces frequently result in healthcare institutions focusing on profits and not primarily on the best interests of the patient, this lesson must especially be embraced by physician executives. We have a professional obligation not shared by other non-clinical executives. The corollary to Dr. Relman’s lesson was to be the best physician you can be. From my perspective, being a good doctor may be the best possible training for being a healthcare executive—the operating principles are the same. To solve a problem, as in treating a patient, you need to make a diagnosis, develop a treatment plan, implement it, monitor the outcome, and change the treatment and/or rethink the diagnosis if you’re not getting the response you expect. Sometimes, in both medicine and administration, you have to start out simply treating a symptom, but you shouldn’t be fooled into thinking that the symptom is the disease.

When I was chief of medicine, I told the housestaff that it only took a few things to be a great house officer: listening to the patient, caring about the patient, being compulsive about getting the needed data, and being able to pick up the phone and ask for help when you need it. The same applies to being a good administrator, except instead of the patient, you need to listen to the people in the institution, care about its well-being, use data, and ask for help from your team and colleagues

When I started my working life at Denver Health and Hospitals and the University of Colorado School of Medicine, I was fortunate to have committed and exceptional mentors. From Dr. Schrier at the University, I learned to “hang in there.” An example of this tenacity was his efforts to get a cigarette tax on the state’s ballot to help pay for healthcare for the poor. He worked tirelessly on this for eight years. He responded to each failed attempt with a new strategy, and finally Colorado did get a cigarette tax which has provided many millions of dollars to healthcare in the state.

So the lesson is, if something is important to do, keep trying until you achieve it. In leading large, complex institutions, this is critical, because they change very slowly and with great difficulty. Persistence and long vision are necessary for success.

Watching Dr. Schrier recruit over many years, I learned another important lesson: surround yourself with the smartest and best people you can. People in leadership positions may feel threatened by those who are smarter or more talented than they are. This is a mistake. Having the best people on your team only makes you and your team better.

Another of his lessons was about pushing yourself. Many times, during the early days of my academic career, when I didn’t want to try something new, such as starting a research lab or applying for a grant, I’d hear the message, “If you don’t stretch, you won’t grow.”

The last lesson I learned from Dr. Schrier was about praising people. This goes beyond the pat on the back and the thank you note. Let me give you one example. When I was promoted to associate professor, Dr. Schrier wrote my parents a letter! My mother never forgot that. Personal caring like this creates a loyalty and esprit de corps on a team that is hard to beat. (Parenthetically, this is a recurrence of my mother’s message about reaching out.)

Dr. Sbarbaro, my mentor at Denver Health and Hospitals, taught me two lessons when I first became chief of medicine: only touch the same piece of paper once (now you can translate that to if you read and email, answer it!) and don’t be afraid to make decisions. He went on to say that if you never make a decision, you’ll never make a good one. On the other hand, if you aren’t afraid to make decisions, at least some of them will be right.

To succeed in this fast-paced life, you need to make as many decisions as are feasible on round one, move on, and don’t agonize later. If the decision is wrong, learn from it, but don’t wring your hands over it. This principle is another one that has strong grounding in the practice of medicine and its teaching tool, the mortality and morbidity (M&M) conference.

As chief of medicine, I always told the housestaff that they must expect to make some mistakes, but they should not make the same mistake twice. The M&M conference teaches that it is healthy to put those mistakes on the table and discuss them. We, in fact, did some administrative M&M conferences, and I think physician administrators should use this tool more often.

Dr. Sbarbaro taught me another important lesson: You can have a knockdown, drag out disagreement about an issue with someone, walk away, and not be mad — disagreeing about a matter is not a personal attack by you or on you.

Equally important to the lessons learned from mentors and colleagues are lessons learned from my husband and children. One cannot be guaranteed a wonderful spouse, but I have had this blessing. I cannot overestimate the professional accomplishments that have been made possible by having a stable and happy marriage. There are commonalities to this human relationship and your institutional relationships.

Many people move from one institution to another as a means of advancing their careers. Although this is a valid path, being at one institution for an entire career is not unlike having one husband — you really get to know and care about the institution in a very special way. For me, starting as an entry-level physician straight out of fellowship and moving through the system has been invaluable. You know the system from the bottom up, with all its strengths and quirks. Even more important, you know the people in the institution and in the community. You can be a family.

My husband, Hal, taught me that when you’re uncertain about something, always assume the best. This especially applies to people. If you are fortunate enough to have children, they will teach more valuable lessons about administration than probably any other teachers — such great truths as don’t nag, don’t take yourself too seriously, don’t sweat the small stuff, don’t play favorites, one “bad” action doesn’t mean someone is a “bad” person, put some sugar in the medicine, and give lots of hugs and kisses (figuratively, of course).

Finally, their admonition I like best of all is “get a life” — which, I think, means to see the big picture, get out of your little world. Or maybe it doesn’t mean that. This, of course, is a critical point; you have to learn to live comfortably with ambiguity.

In addition to this long litany of what I have been taught by others, I actually think I learned one thing on my own (although, if I think about it for a while, probably someone taught it to me too). As I moved in my career from head of the renal division to chief of medicine to deputy manager to chief executive officer of Denver Health and Hospitals, it became apparent that my vision had to change for each new level of position. The higher you move in an organization, the broader your vision must become and the longer view into the future you must take. This is, in fact, the thrill of leadership.

In 2012, I found that the opportunity to continue to reflect on my career and its lessons was very timely. In 1995, when I first wrote about my transition from clinician to medical manager, I was at the beginning of my leadership career. With this latest update, I am nine years past the formal end of that career and have gained additional insights.

Four Decades, Four Lessons

When I retired, I had been at Denver Health for almost 40 years, was CEO for 20 years, and saw age 70 in my not too distant future. With these years of added perspective, I still affirm all of the leadership lessons I wrote about in 1995 and 2012. I have lived them and used them over more than four decades and they have stood the test of time. I will underscore four of them.

There are many lessons to be learned from wise people—some family and some strangers, some younger and some older, and some physicians and some politicians. No matter what your age or your experience, never stop listening to those who can teach and inspire.

If you have some success as a leader and have an opportunity to provide influence, try to understand the truth and have the courage to say what must be said.

Remember the words of one of my mentors, Dr. Relman: “As physician executives, we are here first and foremost for the patients, not to enrich ourselves or our organizations.”

My grandfather always reminded me that patience is a virtue — it is also a necessity for leaders. Few, if any meaningful accomplishments happen quickly. Transitioning Denver Health from a department of city government to an independent entity was more than a five-year journey with twists and turns. The effort was transformational; stopping at some turn would have cost Denver Health its future.

Embedding Toyota Production Systems or Lean into Denver Health and reaping the benefits was a multiyear journey. Yet, it too was transformational and stopping at some barrier would also have cost Denver Health’s its future. Over time, as efforts reach fruition, the barriers seem to fade from one’s memory and only the accomplishment stays vivid. (I suspect this is a particular quirk of the lens of time.) Take on the hard tasks and see them through to the end.

While these lessons from my early years remain guideposts, the later years also added new ones that relate directly to leading a large and complex organization.

One of the main obligations of a leader is to create a vision for the organization—a vision that inspires, a vision that is good and noble, a vision that imparts to all employees the belief that they can do great things. During my leadership at Denver Health, our vision was to be a model for the nation — both audacious and good at a time when our country sorely needed models (and it still does). The vision for an organization must be transformed into a path of actions that the leader and those she/he leads can walk.

Leaders of large enterprises must put out many fires every day. Without a path to walk to a greater end, it is easy to feel frustrated, beleaguered, and burned out. It is this advancement — no matter how small — along the path to achieve vision that gives the work joy. Leaders, like parents, must walk the path they espouse. They must be role models in their professional and personal lives; they must do what they want and expect of others and avoid doing what they do not want others to do. Leaders must commit to organizational transparency and openness. Information is power and it needs to be shared.

In 2012, I wrote that the hardest lesson for a leader must be knowing when to leave. I cannot say I learned it; I can only say I made that decision. But I know deciding to leave my leadership position and Denver Health pulled at my heart strings. Perhaps, in the end, truly loving your institution and loving what you do every day, is what it means to be a leader.

My Coda

Like many people of my vintage, I find that “retirement” doesn’t really capture the rhythm or activity of the phase of life that follows the period of being an organizational leader. Although I used the term “retirement” in 2012 when I was ending my time as CEO of Denver Health, I now think that “coda” better captures the last nine years.

The dictionary defines coda as “something that serves to round out, conclude, or summarize and usually has its own interest.” Each of these components has been realized for me during this time. While they represent both maturing of past efforts or new areas of focus, all the lessons that I articulated previously remain relevant for me now.

And I continue to pass on these lessons to others. Prime among these lessons was my grandfather’s saying, “If you have a gift and you don’t use it no confessor on earth can absolve you.” When we leave our position as an organizational leader our gifts don’t vanish. In fact, our coda period may give us the time to use them more.

Fulfilling the definition of coda, I have rounded out my career through four activities: board service, writing, lecturing, and mentoring. I have been privileged to serve on several boards, including the Robert Wood Johnson Board of Trustees and the Lown Institute Board, where I am now chair. This has enabled me to continue to think about health and healthcare and to interact with smart, concerned, and committed people.

I have written two books that served to summarize much of the learning and experiences I described in the previous editions. The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System (2015) detailed the principles and essentials of Lean (Toyota Production Systems) and the Lean transformation that my team led at Denver Health. Most recently, I published TIME’S NOW for Women Healthcare Leaders: A Guide for the Journey to pay forward to the next generation of women all the guidance others had given me as well as my own learnings.

These books and my interest in the social determinants of health have afforded opportunities to speak to different audiences, teaching them and learning from them. This has been so rewarding, I am starting my third book.

As I look at healthcare today, I have many concerns about where it is and where it is heading. One has to be dismayed by the fact that we spend twice as much as other developed countries but have poorer health for our population. The continued melding of big business with healthcare through for-profit and private-equity acquisitions raises urgent questions about how these fit with the long-held core value of putting the patients’ interest above our own.

The coda period for me indeed has had its own interests, which blossomed with the newly found free time. My husband and I have hiked, soaked up the culture, and enjoyed the food in most of the European countries—what a privilege. The newfound time has provided opportunity for spiritual growth and reflection. I am now in the fourth year of a bible study course and have discovered the solace of daily meditation.

But this time has also made it clear that there is a conclusion, a very real coda both to institutional leadership as well as to each of our lives. If you have spent many years leading an institution, as I have done, it is difficult to no longer influence its culture and decisions. This feels like a loss. As a reality of life’s coda, we have lost both sets of parents and many dear aunts and uncles. But my husband and I have been blessed to be together and to see our two children become admirable adults and to have married wonderful spouses. This has added much joy to this life period.

Any physician who has traveled the path of learner, practitioner, and leader and has lived to have a coda period has indeed experienced a priceless treasure. I am grateful to have been one of those.