A Seasoned CMO's ‘Ten Commandments’ for Physician Leaders

Over the decades, these guidelines morphed from being well-advised suggestions to his rules to lead by.

I can still remember the assignment in Catholic elementary school when we had to memorize the Ten Commandments. It was somewhere around third grade and was a daunting task.

James P. Paskert

First of all, there was the pressure that these Biblical laws come from God directly to Moses. And on stone tablets, no less. And they had stood the test of time. I figured I’d better give this homework my best effort.

My father tested me on them in our small kitchen for several nights straight until I had committed them to memory. It helped that most of them were self-explanatory. That we shouldn’t kill or steal from another human being seemed obvious and would carry extreme consequences.

Some of the others were in the “gray” zone. I mean, was it so bad if Joey got a shiny new Matchbox car and I clearly coveted it for my own? Pretty harmless I’d say. But in general, following the Ten Commandments closely was a good life plan to ward off the forces of evil. And I can still recite them decades later.

When I first became a physician executive as vice president of medical affairs at a small two-hospital system in West Virginia, it didn’t take long to realize that there were some unwritten “rules of engagement” that, when embraced, served me well.

As my experience has grown and I have matured in the role of physician leader, these guidelines morphed from being well-advised suggestions to the lofty perch of being “commandments.”

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I’d now like to offer them to my fellow physician leaders in the spirit of sharing. Or putting them in print may be my therapy.

1. People may not remember what you say, but they always remember how you made them feel.

This came directly to me from an instructor at an American College of Healthcare Executives’ cluster I attended a year ago. It occurred in a breakout session on communication and conflict. It made such a great impression that it is now my first commandment.

Having been a surgeon for more than 20 years, my general tone in conversing was definitive, authoritative and borderline arrogant. This approach often played well in the operating room where hierarchical relationships were, if not embraced, tolerated. After all, in the operating room, the surgeon frequently is the only person who truly knows what needs to happen or come next. Physicians often rationalize such behavior as being the most expedient way to ensure a favorable outcome for the patient. And it did wonders for the ego—in case it’s new to you that most surgeons have big hungry egos. The message a surgeon seeks to deliver to the OR team is one that is immediate, episodic and peculiar to the moment.

As physician leaders, we are trying to put plans in motion that will be sustainable, culture changing and that will achieve “buy-in.” The most surefire way to guarantee that this won’t happen is to put people on the defensive. In this regard, tone and style are everything.

I’ve learned to put a “hold button” inside my head. Simply put, I try to anticipate how what I have to say and how I say it will impact the person or group to whom I am speaking. I learned this the hard way.

Because we interact with a wide variety of team members in our everyday work, this requires situational awareness. Different approach for different folks is the rule of the day. How we relate a particular event or decision can vary tremendously from talking to a physician to talking with a patient’s family member.

If your delivery is not matched to the audience, your message or comment can be rendered meaningless. It may not be heard at all if the person or group you are addressing is preoccupied with the tenor or intent of what you said. Perception is reality.

2. Happiness exists in the “gray zone.”

If you asked someone who worked with me regularly 15 years ago, one of the ways they might describe me is “black and white.” I used to think that was a compliment. It implies things like definitive, not wishy-washy, and decisive. I wore that characterization like a badge of honor.

However, black and white is a setup for underachievement and misery. Black and white allows you to ignore or misunderstand the gradations of good in most decisions and processes. Essentially, it’s an all-or-nothing approach. Over time, it fosters a bully attitude and makes the user reactionary. And from a practical point of view, most issues are really not that starkly black or white.

The middle gray zone is where collegiality and teamwork flourish. The gray zone collects the best parts of black and white to arrive at a process or decision that benefits the most. The gray zone is inclusive. It draws tentative team members into the conversation and encourages participation.

Black and white raises team members’ defenses and limits the discussion to the vocal and loud minority. It’s well-known that the best teams are composed of people with varying backgrounds and talents, but united by a common purpose or mission. That can only occur in a safe atmosphere where all contributions are welcomed and considered.

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All or nothing hamstrings a potentially great team. The most successful groups in which I have been involved took the brainstorms from the extremes and moved them toward the gray zone. Thrive in the middle!

3. Think “and” − not “or” − for the win.

I don’t know if we self-select as physicians or if we become this way over time, but most docs are “win-lose” by wiring. It may be in our DNA. Each proposition is viewed as a zero-sum game. It’s cultivated in us from early on.

Many of us can remember a biology professor in pre-med telling us to look at the classmate next to us and that only one of us would likely get into medical school. The same was true when preparing for match day for residency training. There was a distinct feeling that spots at the prized training programs were limited and we were competing in many cases with our classmates.

Become an attentive listener and avoid the desire to dominate a discussion. As a physician leader, it’s important to bring out the best in the people, and that means not drowning them out or talking over them.

For many of our early years in medicine there had to be winners and losers. For many physicians, that perception never changes. They must have the last word, make the loudest point and overachieve. We feel the need to stand out, to impress and to show how much we really know. It’s the exact reason why plaintiff’s attorneys in malpractice cases love to cross-examine the “know-it-all” doctor. They eventually will hang themselves.

As a physician leader, it is critical to learn how to craft win-win solutions. This requires a stakeholder view of problem solving. By that I mean all stakeholders should be identified at the beginning of deliberations about a topic, whether on paper or in your head. The goal is to maximize the benefit to the most parties affected by the decision. To accomplish this, the physician leader must suppress his inborn competitive nature and work toward a greater good. It often means being a minor or supporting contributor to the overall process.

You must avoid the desire to dominate the discussion. You have to take the Michael Jordan approach and make the players around you better. As a physician leader, it’s important to bring out the best in the people in the meeting or in the discussion. That means not drowning them out or talking over them. These are favorite tactics of some doctors in the operating room or in their offices.

In the leadership role, this is stifling and intimidating, and will only serve to inhibit dialogue and muzzle the more timid members. Think horizontal, not vertical. Check your ego at the door and forget that “captain of the ship” thing.

4. Fifty-one percent is rarely enough — build consensus

“Majority rules” sounds like a great idea. After all, it is widely accepted in formal and informal circles as signifying that a certain rule or measure has been adopted. We used it as kids when something needed to be decided in the tree house. But trust me on this one, you can never have too many proponents when dealing with issues that affect physicians. And a simple majority will rarely provide the support you need, particularly on the difficult ones.

This is where background work is indicated. You need to think like a lawyer before critical meetings where controversy is likely. Lawyers never enter the courtroom without knowing the answers to the questions they’ll be asking. Similarly, take the temperature of the medical staff before any critical vote or debate. Find out who the dissenters are and analyze the source of their dissent.

Casual conversation in the physicians’ lounge may be all the investigation you need to do. You may find that it’s a lack of information or transparency. Simple explanation may be quite persuasive. Some can’t be converted. But at least you’ll know what the arguments are against and what the pushback is all about.

This preparation may provide what you need to craft a compromise solution or position. And compromise is not a four-letter word. It’s often a way of benefiting the most and hurting the least.

Resolutions that pass by the skin of their teeth are rarely successful. There’s not enough positive energy to satisfy the large minority, and the discontent just festers. Always seek a landslide victory. It limits the number of docs who will spread the tale of an unfair process to the rest of the medical staff. And you have more disciples to propagate the success with a healthy majority.

Your future “bench strength” often comes from the supporters on just these battles. Sometimes, a big victory is not possible. You have to weigh those circumstances and decide if you should push on or retreat. I have called off votes at times based on the temperature of the medical staff. If you lose a vote, it may make it difficult or near impossible to resurrect it in the future. Knowing where you stand before you go in is mandatory.

5. Become an attentive listener.

I have always been an extrovert. That may be a euphemism for saying I talk too much. Talkative people can develop some bad habits, like ending another person’s sentence for them. That just shows the speaker that you’re impatient and want to get to the end of the conversation. Or when you talk over someone, the message is that you really don’t think that what they have to say is important enough to hear the whole thing. Or the worst is constantly interrupting the speaker. This is the ultimate show of disrespect and tells the other person that what you have to say is more substantive than what they have to say, and they should know it.

There are a host of reasons to avoid doing the above things when in a conversation or at a meeting. First off, it’s simply rude behavior. None of us should want to ever be perceived as rude and should avoid acting in a manner that would characterize us that way.

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More important, this posture suffocates teamwork and collegiality. The invalidating message it sends is a surefire way to squelch participation and hinder collaboration.

I have had to cultivate the art of active listening, as it doesn’t come naturally to me. This engaged form of hearing what another party is saying is very different from simply nodding your head as they speak or waiting impatiently for them to finish so you can again have the floor.

It is bidirectional and relational in that it requires that you hear what’s said, process the content and formulate a response that stimulates more from the speaker, encourages a dialogue or provides thoughtful feedback. Active listening requires participation.

6. Build a goodwill bank account with the physicians.

The first week of my first physician executive job as a vice president of medical affairs, I met with my CEO. He was a seasoned pro who taught me much over the course of my time with him. I asked him what sorts of things he wanted me to attack first. Was it bylaws, disruptive physician behavior, core measures?

He looked at me and smiled and told me what he wanted from my first three months. He asked me to get to know as many of the docs as possible. Get comfortable with the culture and how the docs fit into it. Although there were about 300 physicians on staff, there were only 70 or so who were very active and who accounted for the bulk of the clinical volume.

You can’t be a change agent until you are a trusted source. In the goodwill bank account, make as many deposits as you can and limit withdrawals. Many little deposits add up over time and become significant.

His words are still the best advice I’ve been given as a leader. I immediately began to visit the physicians’ lounge, the OR suite and the emergency department, introducing myself and striking up a conversation with any physician who would listen. This attached a face and personality to the VPMA role and planted the seeds for the relationships I would enjoy for the remainder of my time there.

It’s how your bench strength is constructed. You can’t be a change agent until you are a trusted source. In the goodwill bank account, make as many deposits as you can and limit the withdrawals. Many little deposits can add up over time and become significant.

As a kid, our local bank had a savings program aimed at kids called a “Christmas Club.” You could put in as little as a quarter a week and at the end of the year have $13 to spend on gifts. I funded that religiously from my paper route and watched it add up week to week.

The point is to not diminish the importance of small things you can do for your physicians because they add up. It might be something as simple as replacing a doc’s ID badge. I tell my physicians to call our office if they get stuck, and we’ll either fix it or point them to someone who can. But remember: If you overdraw the bank account into the negative, you’re on your way out.

7. Never let your boss be surprised.

Folks smarter than I have cited the importance of “managing up.” It’s a way of providing that heads-up your superior requires to do his or her job and be successful. Great organizations are built upon just this type of tight communication. When team members manage up, communication gaps are rare, handoffs are meaningful and complete, and you have good alignment.

I expect this same behavior from my own reports. I remind them at our regular meetings that if they even think I might need to know something, they’re probably right and should push it up to me. One of the worst feelings as a CMO is having one of your docs ask you about an issue, and you having to say you weren’t aware of it. It undermines the medical staff’s confidence in you as its liaison.

As CMOs, we function continuously on the interfaces: among administration and the medical staff, among nursing and physicians, and among case managers and the docs.

How well you perform in this role is partly a function of the amount and quality of the information that passes through you and how effective a portal you are for the various stakeholders who relate to you and through you. I probably send my boss three to five FYI-type emails a week just to raise his awareness of pressing issues.

8. Nonclinical administrators can never be good clinicians, but clinicians can be great administrators.

This is not meant to be a knock on nonclinical administrators. I’ve had the opportunity to work with many excellent ones whom I respect greatly. I just want to point out the unique frame of reference from which physicians can view health care issues.

Generally, when a physician contemplates moving into administration, he focuses on what he doesn’t know. He worries about whether he needs an MBA so he can understand the business-speak that is bandied about during meetings and about the complex financial considerations needed to run a health care organization where the laws of economics don’t always neatly apply.

Future physician executives get so bogged down in what they don’t know and what they have to learn quickly that they forget the special skill set they bring to the dance. Physician leaders, with the requisite knowledge base, can evaluate processes and aid decision-making from a truly multifocal perspective — financially, ethically and medically.

The life experience of our having been on the frontline caring for patients acts as an ever-present counterbalance once we enter the administrative role. Patient-centered care means something slightly different to a clinician administrator. We possess a context that is at once complex and practical. This comes with an important responsibility.

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We need to inject the clinical viewpoint into every discussion and meeting in which we participate. In a way, we are the patient advocates at the executive level. Cutting service lines, changing implant vendors and scrutinizing physician resource utilization all reach close to home for physicians. We’ve spent time on the other side and are in a better position than our nonclinical colleagues to predict and understand the impact such decisions will have on direct patient care and safety. It is our obligation to be unyielding proponents of quality and safety.

9. Above all, maintain transparency.

In communicating with staff physicians, ambiguity and opacity are destructive and counterproductive. If a physician doubts how trustworthy you are or the veracity of your words, he can hardly concentrate on the message. The components of transparency are timeliness, content and follow-up.

As an example, let’s consider closing one of the operating rooms at your facility.

Timeliness: It is important to get physician input as early as possible. The docs should know that this closing has been brought up as a solution to inefficient OR use and their thoughts are required as important stakeholders.

There may be another answer other than closing the suite. Perhaps volume can be moved to the facility by some surgeons to better utilize the room. Or closing the room either temporarily or permanently may be the best alternative. But they will appreciate being in the conversation at the earliest time.

Content: The information provided to the surgeons should include all the elements they need to know to participate in the discussion. This might include financials demonstrating the rationale for discussing this in the first place.

The physicians should also be told that, while their input is valued, it is only a part of the process. The ultimate decision will be in the best interests of the patients, the surgeons and the community. Being open and free with information is not the same as giving physicians their way.

Follow-up: As a decision is made, be prepared to share it as soon as is reasonable. Provide the supporting rationale for the decision and anticipate questions you may be asked. This is the step that is often ignored because it is felt to be insignificant once the process is concluded. But closing this communication loop with the physicians means everything.

If you follow the three elements above, you avoid a classic administrative mistake—enrolling docs instead of engaging them.

10. Use email and other social media respectfully and cautiously.

Email is a double-edged sword if there ever was one. On one hand, the ability to instantly transmit a message is an indispensable asset to any computer user. It has revolutionized marketing and information exchange, how we sign documents when purchasing real estate, and keeps us in touch with family and friends.

But there is a downside to email beyond annoying spam and junk mail. We now have generations of younger people who can, and often do, choose to replace social interaction with this electronic proxy. They can avoid difficult conversations, drum up bravado and insult other people, all while hiding behind the computer screen. It’s just too easy to put things into an email that you would never say face to face to the recipient.

And there’s the rub. When in a real conversation with someone or even a group, what you say and how you say it is molded by the gestures, body language and tone of those around you. It is immediately relational. The interaction itself aids us in knowing how persistent, how loud and how visceral we should be. Picking up on those cues is critical.

With email, that ability is lost. You may think you can sense someone’s feelings or tone in an email exchange, but it’s really a guessing game. You almost always know if you’ve offended someone or caught them by surprise when you’re sitting in front of them, but not so with email.

Just as important to remember is that email is traceable, long-lasting and open season for employers and others who are computer savvy and persistent. In the most extreme case, even email that you think you’ve deleted is retrievable in the right hands.

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So the best friend you have on your email page is the “send” button. It is your last chance to avoid doing something stupid. Before you send that message on its way, make sure it’s what you want to say, how you want it perceived and something you don’t mind having in print or potentially distributed and shared beyond its intended audience. You can’t take it back.

Every day jobs are lost and marriages are ruined in this country via ill-advised use of email and other social media . I have found that picking up the phone, as technologically archaic as it seems, and calling the recipient is often the wisest and safest choice.

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There you have it: rules to live by as a physician leader. If you violate them regularly, you won’t face eternal damnation, but there will be consequences.

_James P. Paskert, MD, is chief medical officer First Physicians Capital Group in Oklahoma City, Oklahoma. This article was originally published by the American Association for Physician Leadership in May 2014.

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