If you’re considering a leadership position in medicine, you are not alone. Leadership positions in the field of medicine are plentiful, and given the inherent hierarchies in medicine, it’s natural to find oneself tapped to lead one group or another eventually. This does not mean that you will be a good leader or that the leadership position is the right one for you. But not to worry, most often there is another, and another, opportunity, and you usually won’t hurt yourself too badly by failing in your first leadership position or even failing to take it. You always have a choice, although sometimes the choices can seem incredibly hard!
Before you take on a leadership position, you should ask several important questions: (1) What is the position, and do you fully understand what it entails? (2) What is your “phenotype” as a leader or, rather, your skill set or areas of strength? (3) Is the leadership position a good “fit,” for you and for them? (4) Do you have the desire to lead? Why? (5) What is (are) the next step(s) after this move? Is it a bridge? It could be a bridge to a higher or more appropriate position, or a bridge to nowhere. And it’s often difficult to tell at first.
This chapter will set the table for your personal decisions when considering taking a leadership position, and explore what should go into your thinking as you’re weighing your options. Keep in mind that, although you may be paralyzed with fear, it is pretty uncommon to make disadvantageous choices when it comes to leadership opportunities, at least early in your career. But the onus is on you to follow through and make the most of the opportunity!
What Is the Position?
Too often, I’ve seen people get starry-eyed about a potential leadership position. Maybe they weren’t expecting to be offered the position, and it may have come as a real boost to their ego. Or perhaps it hit them at the right time, and they were eager to leap at the opportunity. A bit of unsolicited advice: slow down. I would be hard-pressed to think of an instance in which you would need to make a critical decision about a leadership position quickly or under duress, unless it were stepping in on a temporary basis due to extenuating circumstances for a leader who abruptly left the position. Otherwise, you should take your time to gather as much knowledge about the position as possible. If you’re considering the role, that’s because someone (maybe only you!) feels that you might be worthy of it. But is the position worthy of, or right for, you?
Do your homework. If there is a job description, ask for it. If there isn’t a job description, consider whether one could or should be created, and ask for it. In other words, know what you’re getting yourself into and what the expectations of you will be. Get as granular as possible – what will be required to do the job, what kind of resources will be made available, what kind of support or team will you be able to assemble? Hand-in-hand with the work goes the time – if the tasks are large, you will need to clarify how much effort will be required and how much time should be allotted, both in the short and long terms. Will you have protected time to do the job, and will that time be adequate? Are the deliverables reasonable? Do you have a legitimate chance of getting the job done, based on what you find out about what is required?
Consider establishing metrics for your success over time, and make sure that whoever is evaluating your performance agrees with the metrics. If you establish these metrics ahead of time and they’re agreed to, it leads to far less confusion down the road and also allows you to recalibrate as you progress or, alternatively, if obstacles set you back. With all this said, however, sometimes there are things that cannot be “metricized” about a job, such as HR issues or dealing with problematic group members. These things become more common the higher you go up the food chain, not less. As they say about children, “the older the kid, the bigger the problems.” The same applies in medical leadership as well – the egos become bigger as the CVs grow longer, and thus the HR and personality issues become more prominent. The earlier and better you learn to deal with this in your leadership career, the more successful you’ll become (see Chapter 8, “Having Difficult Conversations”).
If possible and feasible, talk with the person who held the job before you. Hopefully you will get an honest assessment of the position, warts and all. But keep in mind that, if the person left under inauspicious circumstances, you may not get a fair and unbiased assessment of the position, and you’ll need to take their comments with that in mind. An example would be the person who has reluctantly agreed to step down after being asked to resign, who may have negative thoughts about the job, their boss, or both. A better situation is when the person leaving the position is rising to a higher or “better” position and might give a more balanced view. Regardless, vetting the position with the person who is leaving it, when possible, can be invaluable. This is the person best suited to probe for information about the most challenging parts of the job, including working with their supervisor or group. You can clarify time and effort commitments and any positive or negative impacts the role had on their career, as well as their morale. Even information from the “negative” person, that is, the reluctant leaver, can be valuable, as this information can provide leads to important questions for others, most importantly, the people considering hiring/promoting you. Rarely will you find a situation in which you get zero valuable information. It’s just that sometimes you’ll have to take the info with a grain of salt.
I recall a specific instance many years ago in which I was running a search committee looking for a new chair of another academic department. I had a lengthy discussion with the exiting chair about their impressions of the job and what information would be helpful for the prospective candidates for the position. The outgoing chair was feeling wounded; they were leaving before they felt ready, and being asked to step down was an unexpected and unwelcome shot to their ego. The information they provided me consisted primarily of a list of grievances against the administration – how the department’s decline was the administration’s fault, not the chair’s, and that the department deeply loved them and was “devastated” that they were leaving. Despite my efforts to get information about the department that would help the next chair, they kept turning the conversation back to themselves. Nevertheless, the conversation was not a complete waste of time, and I patiently procured a few nuggets of information that would indeed prove helpful in future conversations. Probably most helpful among these was actually trying to corroborate their grievances when I met separately with the faculty. Not surprisingly, they were quite vocal about wanting a change, including hiring someone from outside their own department, as they realized they were victims of stagnation and insular thinking. The impressions of the outgoing chair and the faculty were two complementary pieces of the puzzle and really helped me to advise the chair candidates of what the faculty really wanted and needed.
Be unafraid of asking the difficult questions about the job. When you’re trying to figure out if the position is right for you, kick the tires a bit. The person/people looking to hire you will probably respect you more for trying to understand the job as well as you can, including asking the crucial (and sometimes uncomfortable) questions about the challenges the job poses, not just for you but for anyone who might be considering it. Understand that there are those out there who would sell you a lemon; have your radar up, and try to sense whether people are being completely open and honest with you. Ask the same questions of multiple different people, and see if you get the same or different answers. If the latter, you need to circle back and get clarification and consistency. If you can’t, they may be hiding something from you. The drawback of this, potentially, is that they might be turned off by your asking too many questions, or questions that are too probing or uncomfortable. If you’re on the fence about the position, and there aren’t drawbacks to not taking it, then being choosy is wise. However, if you really want the job, are worried that you might not get it, and sense that you might be pushing too hard, then it might be better to back off and reweigh your options. If it’s a very prominent or prestigious position and there are a lot of good candidates, you may find yourself becoming more seller than buyer. Only you can determine how much to push versus when to cave.
Vet your boss. In almost every leadership position, there’s still someone above you to whom you’ll answer. That person (or people) may be the chair, the dean, the vice president, the CEO, or even the board. Your understanding of this relationship is crucial. Although you don’t have to be best friends (or friends at all) with your boss, you should have a clear understanding of each other’s needs, clear communication lines, and some degree of trust in one another. Getting information about your potential boss is not always easy, but whenever you can get ancillary information from others who have worked or are currently working with them, you should. At some point, it becomes a leap of faith, but that leap becomes a lot more comfortable when you have the beginnings of trust in your future boss: you believe in their ethics, and your visions and missions are aligned.
I have had some wonderful leadership relationships in my career, likely because I believe most people in medicine are in it for the right reasons, and it’s relatively easy to align goals, specifically around the patient. This includes not just patient care but patient-centered (clinical) research and patient-centered education. But remember, medicine is not a haven from people with big egos, and sometimes very successful people can get swept away by their own achievements, their thoughts ending up centered around themselves rather than what’s best for the patient/division/department/institution. This is the boss to worry about – blinded by their own sense of self-importance. This leads to selfish decisions, questionable ethics, and, ultimately, the demise of the group and your relationship. I always like to say that the most powerful quality in medicine is humility and the most dangerous is arrogance. Beware the arrogant boss the most!
What Is Your “Phenotype”?
We all have our strengths and weaknesses; we just rarely have insight as to what they are. Before taking any position, you should take a hard look at yourself and gain a strong understanding of what traits make you successful and which ones hold you back or cause you to fall short. Peering into one’s character traits comes easier to some than others; it takes an open mind, a willingness to explore, and a great deal of humility. But even the most introspective and self-critical leaders can have blind spots, only uncovered by working with and seeking the feedback of others. This is where the 360 evaluation becomes essential, as well as working with a coach. I will discuss both of these in detail in Chapter 2.
You have to decide if this leadership position will make you happy or ultimately result in greater fulfillment. Some leadership positions are traps or dead ends, perhaps called leadership positions but actually a form of labor to make someone else’s life better. Will you actually be given an opportunity to lead, to innovate, to expand your skill set? Does this step follow logically for what you see as your career path? For example, you could head down an administrative pathway, but the position will take you away from your true passion, which may be more clinically, educationally, or research-oriented. Can you actually see the next step after this one? Does it follow logically? Or is this your ultimate goal, which will provide you with the fulfillment you’ve been craving? Only you can answer these questions. And your mind may change over time, and that’s okay. What you saw as your career goal, such as being a residency program director, may get trumped by a higher position that becomes available to you because you became a successful program director.
Consider the push and the pull. To clarify, the pull is the job you’re considering taking, and the push is why you’re considering leaving your current position. We’ve talked a bit about what might attract you to a position, but what’s the reason you’re considering leaving your current one? Once you’ve vetted your potential new position, it’s wise to consider vetting your current position in the same way: what opportunities is the current position providing? What is your relationship like with key people, particularly your boss? Are you growing and developing, and in ways that are helpful to you in the long run? Are you unhappy and running from a position, rather than toward another one? This is perhaps one of the most important motivations to be aware of, that you may be overly willing to compromise on a new position because you’re so eager to leave what you consider a bad situation. Sometimes the “push” is rather strong.
On the other hand, are there negatives to leaving your current position that you’ve not fully considered? What about the team you’re leaving behind – will they feel abandoned or that you’ve been disloyal by leaving earlier than promised? Have you finished the main parts of the job that you originally signed up for? Are you leaving the group better than when you found them, or are you leaving a trail of destruction? Your reputation will follow you a long way, so it’s important to consider what will be said about you after you leave. If you have a reputation as a builder of programs and a good mentor to your people, your reputation will continue to propel you. Alternatively, if your reputation was one of selfishness and using positions and people as stepping stones to higher positions, it will likely come back to haunt you at one point or another.
Consider your individual constraints, including your time and other commitments, both professionally and personally. Leaders commonly bite off more than they can chew, powered by a sense of invincibility, or perhaps just drive and optimism. But we all have limits, and so do the people in our lives. How will the new position impact your ability to tend to other important goals in your life? Your ability to work on that research project, design that new curriculum, or set up that new clinical program? And how about your personal life – will the new position impact your family time or your ability to do self-care such as exercising or relaxing? Does the new position involve a change of location, in addition to hours, and if so, will your partner/spouse/children be negatively impacted? All of these issues must be balanced when you’re considering a new position.
Is It a Good “Fit”?
The notion of “fit” is a very visceral one, and it can be challenging to put reasonable metrics to it. In the end, it’s still worth trying to do so – at the very least, you can develop a “pro versus con” list that you can utilize in order to provide some degree of objectivity. But it’s also good to realize that the “gut” or “gestalt” about a position is important; in fact, it may supersede the objective metrics you’ve created. If nothing else, the “good vibes” that you have about a position will allow you to carry positivity into the new role, which will likely lead to early successes; conversely, if you’re feeling hesitant or less than excited about the new position, you may come off as uncommitted or uninterested, getting you off to a bad start.
When trying to establish your pro and con metrics, remember to do so not just for the leadership position(s) you’re considering but also for your current position. That may sound silly, as you probably feel like you already know your current position inside and out, but the process of objectifying it can be very helpful as you force yourself to take a critical look at what you’ve been doing and what makes you happy versus what does not. One of the “columns” in addition to “pro” and “con” should be “growth potential,” assuming you’re interested in that. Does your current job contain growth potential? If so, is it growth in the right direction for your overall career goals? Can you get a good estimate for the growth potential of the leadership job you’re considering? Be explicit with those looking to hire you – what do they see as your growth potential, both personally as well as in this position? And is there room for growth beyond this position? Again, only you can decide how much you want to grow and climb the ladder, but it’s good to have doors opened rather than closed.
The “pros” column in medical leadership positions can contain such things as clinical experience, education, research, or administration, or even other things like mentorship, wellness, work–life balance, and productivity. The “cons” column may contain some of the same issues, but there’s often one main difference – we tend to put difficult or painful people in the con category. Each job will be a mix of people that you’ll need to work with, both “good” and “bad,” and there is no such thing as greener grass. And of course, rarely are people purely good or bad, but rather, their personalities, values, or quirks may work better or worse with your personality (and values and quirks). As much as you take a hard look at the people around you, take that same hard look at yourself and understand what you’re bringing to the table, warts and all.
Then comes the gut feeling, or as we say in Yiddish, the “gestalt.” What does the position/place/people “feel like” to you? What are your emotions after visiting the place, talking with the people, walking the grounds? Objective criteria start to wash away a bit, and the physical space starts to etch itself into your fibers. Do you love the town/city where the job is? Do you like the physical space? Does it feel like “home” in some way? You might walk away thinking that the physical space has made an outsized impression on you, more than it should have, but recognize that the physical space is where you gel your impressions from speaking with the people. In fact, it is likely that it was the people all along who were creating your impression. Of course, everyone is putting on their best face when they’re trying to recruit you for the position, but you can also get a sense of their genuineness. This also comes with more experience – the more you look at positions, the better your “BS-meter” becomes. Try talking with people who are not on your interview list, such as the staff who work in the area to which you might be hired – the residents, the students, the environmental services people. What do they say about the place? Do they seem happy?
Finally, try to gather a sense for the mission of the place you’re considering. Mission can take many forms – some are research heavy, some more geared toward education, others community service-based. None of these missions is “better” than another; it’s simply a matter of what fits for your phenotype, and what you’re looking for at that stage in your career. For example, a talented physician-scientist may be highly attracted to a leadership position that might lead to a major advance in their lab’s capabilities, or at an institution where the philosophy is heavily biased toward generating great basic science research. A different leader might be very drawn to a safety-net hospital that cares primarily for the underserved or has a strong community outreach or global health program. Whatever the emphasis, it has to fit with your career goals and motivations, not someone else’s.
Do You Have a Desire to Lead? Why?
With leadership positions comes great responsibility. Remember, successful leadership is about the success of the people you’re leading, not just your own personal achievements (unless you’re a very arrogant and selfish person!). Before taking any leadership position, you have to ask yourself what your motivations are. I’d like to think that people in medicine are generally altruistic and that they carry this altruism with them to their leadership positions. If that desire to “help people,” which we all write about in our medical school essays, remains central as you start climbing the medical ladder, then hopefully it can be a guide to what kind of leader you’ll be. Sure, there is prestige that comes with leadership positions, and this grows with each rung of the ladder. But you likely won’t last very long in most leadership positions if you don’t make it about your group and the group’s success. Leadership takes sacrifice, both of time and energy, and may take you away from some of the things (for example, research, productivity) that earned you the leadership position. But usually the expectations of you change with the position as well, and in medicine most often the priorities are for the success of the team, not any one individual. In summary, take a hard look at your motivations before launching into any leadership position. You owe it to yourself but, more importantly, to the people you’re about to lead.
What Is the Next Step(s) after This? Is It a Bridge (to Nowhere?)?
Like chess, your career moves may dictate subsequent moves, so it’s helpful to try to see several moves ahead, if possible. Of course, the position you’re considering may be your last stop, or “best stop,” but especially if you’re junior, you need to think of what will happen to you in five or ten years in this job: will it continue to give you the satisfaction and happiness you desire? This is perhaps one of the hardest things to do when you’re considering an upward move – looking past that move to make sure that it will give you long-term fulfillment. Make sure that the new role will give you more options in the future, not fewer, as you may not have a clear idea what your ultimate career or leadership goals are; even if you do, they may change over time. So it’s always better to open a larger number of doors than end up pigeonholed.
An example of a role that can open more doors for you would be in the realm of education, such as serving as chief resident, clerkship director, or residency program director. All of these roles are typically filled by people with good leadership potential, a strong emotional quotient (EQ), and usually a passion for education and giving of their time to others. With the higher leadership roles (clerkship or residency program director), you’re often also seen as someone with education “chops,” an expert in some aspect of your field. As you flourish in this educational role and are seen as a good and selfless leader, you are recognized more and tapped for other departmental and institutional leadership roles, such as education vice chair or an associate dean role. Thus, doors are opened.
An example of a role that could be a dead end might be leading a small subcommittee that takes up a considerable amount of your time but does not lead to much recognition or tangible results, a “bridge to nowhere.” You need to analyze the amount of time required for the role, the support you’ll receive, the timeline, and the expected results; if these don’t show promise, you may be wasting your time or, worse, be seen as a failure for not leading the project successfully. Departmental or institutional leadership often has many small committees that need volunteers and leaders, and, without any malice, some of these committees have a low likelihood of success or accomplishment despite best intentions. These are the “buyer beware” proposals that you need to vet to ensure they’re right for you, at the right time in your career.
Now that you’ve done a good self-evaluation, thought about your motivations for wanting to be a leader, and decided on the right position and trajectory, it’s time to get into the next steps: understanding your personality as a leader. Although leaders often spend a great deal of time trying to mold their group into their idea of “functional,” the molding should actually start with oneself, understanding what personality traits and tendencies you bring to the group that will have a heavy influence on the group’s success. Even if you’re soft-spoken, you’re about to pick up a megaphone. You need to learn how to use it wisely.
