The New Leader’s Landscape

What it takes to achieve promotion in academic medicine—being a highly regarded clinician and accomplished researcher—is no longer enough to lead.

By Christina Hernandez Sherwood

Illustrations by Graham Perry

“If you asked me, ‘What’s the first thing you’re going to do when you take this job?’” said Mitchell D. Schnall, MD’86, PhD’86, GME’92, chair of Radiology at Penn Medicine, “it would not have been in a million years: Figure out how I can communicate with my department. It should have been.”

Schnall became department chair in 2012, just as dramatic changes in the industry were putting pressure on his specialty, while other changes, such as advancing artificial intelligence systems, offered new opportunities. The catch: the 180 faculty in the department needed to think about their practice in a whole new way. Without formal leadership training in change management, he turned to the Penn Medicine Academy for help steering his department through a time of transformational change.

He was not alone in recognizing the shifting landscape—not just in the practice of radiology, but in the leadership challenges of academic medicine.

Today’s leader faces a far more demanding set of expectations than the archetypal leader in academic medicine in the past, who gained tenure and promotion through excellence as a clinician and researcher—often without any assessment or training in specific leadership skills. The modern leader is expected to shepherd her colleagues through the digital revolution, leading change in the brave new world of electronic health records and artificial intelligence, precision medicine and targeted therapies. That calls for understanding hospital finances and the complex regulatory and reimbursement landscape. She must also be comfortable having difficult conversations with faculty who are struggling and holding others accountable. And, of course, she must still practice medicine, conduct research, teach, or do some combination of all three.

Yet as the challenges faced by leaders in academic medicine are growing, so too are the opportunities to make progress. The Department of Medicine, Penn Medicine’s largest clinical department—it is home to more than 625 faculty—recently completed its first Enhancing Leadership program, a two-year effort to train its division chiefs and other senior faculty in the fundamentals of leadership. Last year, Radiology embarked on a three-day immersive retreat focused on leading change—resulting in Schnall’s revelation about the importance of communication. 

And, most notably, this year the Perelman School of Medicine launched a new program for academic medical leaders beyond the Penn Medicine community. Leadership in a New Era of Health Care is a partnership with Wharton Executive Education and included a personalized, four-day program designed for today’s chief executives, chairs, chiefs, deans and other types of administrative leaders in health care. “The evolution of the executive leadership program really mirrors the need to have more leaders in medicine, both academic medicine and medicine more generally,” said J. Larry Jameson, MD, PhD, executive vice president of the University of Pennsylvania for the Health System and dean of the Perelman School of Medicine, who spearheaded the initiative with Caryn Lerman, PhD, the former vice dean for strategic initiatives. “And, in part, this reflects the changing landscape of health care.”

Jameson and Lerman first delineated the challenges facing modern health care leaders in a perspective in the New England Journal of Medicine last year. The program in partnership with Wharton Executive Education was just one of Penn’s approaches to a much broader need they described as “a persistent and worsening disconnect between the capacity of the physician-leadership workforce and the needs of our expanding and increasingly complex health systems.”

New leadership roles in academic medicine are developing that simply didn’t exist a few years ago, Jameson said. The field needs leaders who can oversee quality improvement activities and clinical service lines across specialties, to have experience in health care disparities and in information technology. “Most people and most health care organizations haven’t thought in a strategic way about the need to develop a parallel skill set in leadership training,” Jameson said. “In the manufacturing sector or other industries these have been in place and maturing for a longer period of time.”

This is perhaps partly due to a stigma in academic medicine around leadership development or coaching, Jameson said. “Ten years ago, people would view this almost as though it was a punishment or you were having to do something because of a deficiency,” he said. “That’s changed. Most people now see it as a value add, a very positive thing.”

Assessing Leadership Skills

Leaders in any field need a sense of their strengths and weaknesses before embarking on improvements. The Department of Medicine began its program with each member of the leadership team, including division chiefs, completing a private self assessment of their leadership competencies, said Michael S. Parmacek, MD, the department chair. The assessments were used to help tailor the program, which consisted of a full day of classroom training, monthly three-hour meetings over two years, and assigned reading and homework.

The assessments were also used to define more than two dozen core competencies for leaders in academic medicine, such as managing difficult faculty and negotiating, said Cindy Morgan, Penn Medicine’s vice president for learning and organizational development, whose Penn Medicine Academy worked closely with the Department of Medicine on the leadership program. “In the days of old, there was the expert with the great CV that got promoted to chair or division chief,” she said. “[Now leaders need] the street cred to influence clinicians, educators and researchers. They also have to have leadership skills and a certain level of comfort with uncertainty, ambiguity and complexity.”

Lynn M. Schuchter, MD, chief of the Division of Hematology and Oncology, said her assessment showed she needed to improve her skills around delegating and setting expectations. But perhaps more critical for her was learning to understand and assess leadership capability in others. “There would be a situation where I have a faculty member who is leading something who isn’t able to delegate, or is too much in the trees and not seeing the big picture,” Schuchter said. “How do you help the faculty member change?”

Each division chief was matched with a coach, and Schuchter, paired with Morgan, performed a comprehensive talent assessment of the majority of her faculty, with a focus on those in leadership roles. Struggling leaders were then paired with their own coaches to work on skills such as running effective meetings. She called the results “transformational.”

Creating Communities of Leaders

In some of the Department of Medicine’s leadership program sessions, participants shared real-life examples from their day-to-day lives as leaders: situations including personnel problems, financial quandaries, programmatic development issues and more. They worked together in that safe environment to solve these problems, many of which were shared across divisions. “People were brave and courteous and earnest,” Schuchter said. “We learned a lot from each other.”

Thomas P. Cappola, MD, ScM, chief of the Division of Cardiovascular Medicine, called this new community the leadership program’s most valuable product. “We became much more comfortable calling each other with similar challenges,” he said. “You can feel alone in this job because everyone comes to you with problems and they don’t always tell you whether you’re solving them the right way. This provided a sounding board for situations like that.”

Cappola introduced the same type of leadership community to his division, a group of 144 cardiologists, up from 105 when he took the helm in 2015. The sheer size of the division required a team to share the load, Cappola said, and a chief who would hold them accountable. The division has different sections, each with its own leader, and Cappola established executive committee meetings to bring them together regularly for problem-solving conversations.

“In the past, individual programs or divisions often operated in a vacuum and didn’t consider the value of strategic partnerships,” said Jason Christie, MD, MSCE’02, chief of the Division of Pulmonary and Critical Care Medicine, reflecting on the Department of Medicine program. But, he said, working together and with leaders who are transparent about finances can lead to better decisions. Better understanding of sound financial principles through the leadership training has yielded results beyond just better collaboration, he noted. Now, he said, this knowledge can help ensure that a change, whether it’s a new hire or a new research or educational initiative, is sustainable.

Leading Transformational Change

It was during a three-day retreat for Radiology’s leaders in September facilitated by Morgan’s Penn Medicine Academy team that Schnall learned that he and his fellow leaders should focus on communicating with the department. The faculty needed to learn that pressures from reimbursement rates and time demands render the current, individualized mode of practice unsustainable.

From there, they could pilot test opportunities. For instance, in order to take advantage of new artificial intelligence technology the department is using in collaboration with an industry partner, Schnall said, everyone must agree to report nodules similarly. If individual clinicians used different language and recommendations, they would render the system moot. “The challenge is to balance the respect for the traditions that have made academia revered and successful over the years with the practical needs of large dynamic health systems and all the business pressures put upon them,” he said. “Getting that balance right and convincing all constituencies that you have respect for their position in the organization is really critical.”

Leadership’s Many Faces

The overarching leadership challenges of academic medicine are largely the same in both clinical and non-clinical departments, said Lisa Bellini, MD, GME’94, senior vice dean for academic affairs. But, she added, the domains are different for those whose charge is focused, for example, on basic science or medical education. For instance, financial conundrums in clinical departments revolve around issues such as health care reimbursement and physician productivity. For leaders overseeing basic science teams, top financial priorities are securing funding and grant management.

Of course, there are some challenges unique to non-clinical academic leaders. “The phenotype of traditional chairs and center and institute directors were really very internally focused and less externally focused,” Bellini said. “Now, it’s changed so much that you need to be both.” That external environment includes the National Institutes of Health, the Association of American Medical Colleges and other national societies and private foundations that provide substantial research funding. “It really does take a set of skills that are not necessarily intuitive for people,” Bellini said. Leaders in medical education, she added, face the challenge of serving as 24/7 role models for professionalism in the learning environment.

A diverse set of leadership training opportunities offer lessons for faculty leaders of all kinds. Advance, an umbrella program of Faculty Affairs and Professional Development, is designed to teach skills and competencies to Perelman School of Medicine faculty based on their interests, Bellini said. The program includes teaching excellence, career management and mentoring. Launching this July is the Program to Advance Clinician Educators (PACE), which will aim to arm recent hires with an understanding of the resources available at Penn for them to be successful.

Other training opportunities empower leaders to advance equity, diversity, and inclusion. FOCUS on Women’s Health & Leadership at the Perelman School of Medicine holds monthly sessions for both women and men on leadership-related topics, such as conflict resolution and negotiation strategies, plus hosts an annual conference on women’s professional development. Penn’s Office of Inclusion and Diversity provides training on unconscious biases and how to mitigate them for members of hiring search committees. Bellini herself has been through the workshop more than once. “No matter who you are,” she said, “you have biases that you may not appreciate.”

Handling Difficult Conversations

Doctors might be accustomed to having difficult conversations with patients, but talking to colleagues about their shortcomings is perhaps a trickier endeavor. That’s especially true when the conversation is with a challenging, or difficult, personality. There’s the person with the “narcissistic” dynamic, whose ego gets in the way of the greater good, and the “bean counters,” who are known for their controlling and micromanaging behaviors. “That was an area where many of our division chiefs, and I, would struggle sometimes in how you approach, communicate with and change the behavior of valued, but also challenging or difficult, faculty members,” Parmacek said.

Enter Jody J. Foster, MD, MBA, Penn Medicine’s assistant dean for professionalism, chair of Psychiatry at Pennsylvania Hospital, and author of The Schmuck in My Office: How to Deal Effectively with Difficult People at Work. It’s common in any high-stress field for people to regress to what Foster calls their “less appealing selves” and act impulsively. Unchecked, hot tempers can lead to interactions rife with misunderstandings and miscommunication. It can happen anywhere, even among highly accomplished and talented teams. Foster says faculty are eager for a framework for having uncomfortable conversations. They want to learn how to get at the underlying issues causing the problem, and how to mitigate them.

In the instance of a one-time aggressive interaction on the floor or in a meeting, Foster’s advice is surprisingly straightforward: start by talking to the transgressor. Talk through the situation and try to determine the underlying cause. “A lot of correction of bad behavior is accomplished by simply directly outlining the bad behavior,” Foster said. “What we do as a culture is we note it, we get upset by it and then we talk about it, but we don’t talk to it.”

Industry Experts

As a physician academic herself, it wasn’t a heavy lift for Foster to draw her examples from the world of academic medicine. But key to the Department of Medicine’s leadership program was that every consultant who led a presentation for the group was either part of the Penn Medicine system or educated on the world of academic medicine to ensure they were speaking in the language of their audience, Morgan said. Wharton professor and corporate finance expert Joe Perfetti, for instance, used the Department of Medicine’s balance sheet in his financial presentation, pointing to several divisions as exemplars.

“We know physicians,” Morgan said. “They don’t want to learn from a generic case study. They don’t want to have different industries being metaphors for what we do from a leadership perspective here. They are much more practical and concrete. They want to be in scenarios they are going to be facing… We built the program and customized it to hit that need.”

The Perelman/Wharton program launched this spring, Leadership in a New Era of Health Care, was similarly tailored to its audience of clinicians and medical directors, professors and deans, program managers and department chairs who traveled to Philadelphia in late March from health systems across the country. Faculty speakers included management and operations experts from Penn Medicine and Wharton. A follow-up program, Health Care Innovation, meant for senior-level clinicians and health care executives, was held in late April.

Physicians, by simply choosing the field and by the training they receive in medical school, are primed for leadership, Jameson said. They are good listeners who are tuned into reading the verbal and nonverbal communications of patients and families, and who frequently communicate with their colleagues, often in teams. “We’re, in general, in good shape to be effective leaders,” Jameson said, “but it doesn’t mean you don’t work on formal training and continuous improvement.”