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Building a Strong Foundation

Leadership is not something people are born with, says Dean Chip Souba. It's a skill—one that the Medical School is working to ensure every graduate has.

By Matthew C. Wiencke

Smack! The puck whips across the ice straight at you. Your heart is pounding. You lean forward, ready to stop it from going in the net. Suddenly the puck careens off another stick. Now another shot is coming at you from the far left. You lunge in that direction, trying to smother the puck as it flies in...

Matthew Wiencke is the associate editor of Dartmouth Medicine.

Playing goalie, says James Borchert (D'83), who played hockey at Dartmouth as an undergraduate and now plays in a local league, boils down to two things: being fully in the moment and being flexible. As goalie, "I'm keenly aware of my range of motion, my flexibility, my ability to be there and stop the puck from going in," he says. "Leadership is similar." When facing a challenge, good leaders need to be focused, in the moment, aware—and flexible enough to move in new directions they may not have considered or thought possible.

Borchert did not always think of leadership in this way. For years, when he was in industry, he thought leading meant "strategy, performance metrics and targets, and optimizing processes," he says. Then, in the summer of 2012, he took a course at Geisel: "The Science and Practice of Leading Yourself" and everything has changed for him. His family life is improved. He gets on better with his five kids. He approaches his day-to-day work differently as sourcing manager in procurement at Dartmouth. He now has a new view of leadership that "has really changed my life in a positive way," he says. "I am more powerful to make things happen."

The course is one piece of a broad leadership initiative that Dean Chip Souba is spearheading. It involves faculty, students, and staff across Geisel, Dartmouth-Hitchcock, and Dartmouth College. Next summer, Souba will again be teaching the leadership course to professionals in health care, academia, and business from Dartmouth and around the U.S. Leadership training will also be an important component of the new medical curriculum, which will launch in the fall of 2015. Geisel students already are taking a leadership elective that introduces them to exercising leadership in their own training, and they have created the Leadership Development Council, a group of students interested in leadership who meet monthly to listen to guest speakers (such as Dartmouth President Phil Hanlon) and discuss leadership concepts and how they can lead in their own lives.

Dean Chip Souba and Cathy Pipas are members of the Leadership Working Group, which guides the Medical School's implementation of leadership training.

Guiding the whole undertaking is the interdisciplinary Leadership Working Group, which is led by the dean and includes faculty, nurse educators, physicians, and staff from Geisel, the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock, and the College. The working group's main task is planning how leadership will be taught in the new Geisel curriculum; members also share and discuss leadership challenges in their own departments and across Dartmouth.

Souba began to think hard about leadership in the 1990s, as a professor of surgery at the University of Florida. He realized that academic medical centers were so complex and had so many different stakeholders and constituents that it was essential to get people to work together. If you could get everyone "rowing in the same direction . . . performance would go up dramatically," he recalls thinking.

Drawing on the work of philosophers, neuroscientists, and psychologists, Souba began developing a more formal approach to leadership. The model starts with this premise: in order to lead effectively, you first have to learn to lead yourself. To do this, you build what Souba calls a "foundation" for your "house of leadership." That foundation consists of four "ontological pillars."

Put simply, there are four pillars (or ways of being, as Souba also describes them) that will make you an effective leader: awareness, integrity, authenticity, and commitment. Awareness is giving your full concentration to a situation, paying attention with purpose and curiosity and without judgment. Integrity is about keeping your word, doing as you say you will do. Authenticity is about being consistent in what you hold yourself to be and what you believe, despite any challenges or predicaments you find yourself facing. Commitment means being part of something you believe in, a "future bigger than yourself," says Souba.

The world occurs for us, argues Souba, inside our "hidden contexts." This means that we see the world in a context based on our own set of assumptions, beliefs, and preconceptions that are usually veiled and not articulated. The hidden context in which we live determines "what we see and what we do not see, what we consider and what we overlook, what we are able to do and what seems beyond our reach," Souba wrote in Academic Medicine. The point of being aware of this context is to loosen the grip of the inner critic and see things in a new context that will open up new possibilities for action.

You have to learn leadership at some point, whether it's taking care of a patient . . . or running a business.

Souba emphasizes that leadership is not something that people are just born with—it's a skill. Contrary to popular depictions of leadership, being charismatic is not essential. "What matters more is knowing yourself and taking a stand," say Jason Vallee, PhD, director of achieving excellence at Dartmouth-Hitchcock. Vallee, who took the course in 2012, teaches physicians and administrators about improving the patient experience at Dartmouth-Hitchcock.

The summer leadership course, which will be held for the third time in 2014, combines large group discussions about the concepts with intense small-group sessions where people discuss and work out their own leadership challenges. At the end of the course, participants are asked to develop a short-term personal leadership plan. Three months later, they evaluate the results of their plan. Participants are also evaluated by people they choose both before and after the course to assess the effects of the course. Mary Turco, PhD, an assistant professor of medicine and director of continuing medical education, guides the course evaluation process.

Carolyn Hoban, ScD, the director of translational research at the Multiple Myeloma Research Foundation, took the course in 2013 and says it has changed how she talks with her colleagues. "I have a sacred trust now with my colleagues that when I deal with them, integrity will be a given," she says. "Leadership is not a title, it's not a signing page. It has a more profound meaning to me . . . . I do feel like I am taking a stand for things I believe in."

Mark Williams, MD, a chief pediatric surgeon at Le Bonheur Children's Hospital in Tennessee and a course participant in 2013, adds that it is important to be aware of the voices inside your head that constrain you. It's important, he says "to be aware of other people's perceptions of a problem which are different from your perception of a problem. To try to work through those things makes it easier if you are aware of that."

This is exactly what happened with James Borchert soon after he took the course. He was at odds with a vendor over the workings of a contract with the College. Borchert realized he needed to create a new context so that the two of them could see eye to eye. He had to step out of his shoes—and away from his strong feelings—to see the other person's viewpoint. The methods discussed during the leadership course came in handy. "I had to listen so intently so I could hear it from where he was speaking," he says. They ended with a "solid, common understanding."

Souba, Turco, and Cathy Pipas, MD, a professor of community and family medicine and director of the leadership component of the new curriculum, all believe leadership training for medical students is essential. "Coming out of medical school, students will be asked to lead change at many, many levels," says Pipas. "With individual patients, if you sit on any boards in your organization, if you participate at any level of your school system . . . you will be called upon as a leader."

"To have physicians in leadership roles is critical," says Norman Payson, MD ('73), former CEO of Apria Healthcare Group and Oxford Health Plans. "To get some formal education in that can be incredibly valuable to society and to the doctors who receive it."

"Medicine is a very unique profession," says David Fett, MD ('80). "You have to learn leadership at some point, whether it's taking care of a patient . . . or running a business."

Medical students are facing a "complex, volatile, and unpredictable" health-care system, Souba adds. There is huge change happening: physician reimbursement rates are going down, there is greater use of complex technology, private practice is slowly disappearing, and medicine is becoming more of a business. Physicians and medical students "need to have a thorough understanding of where health care is headed," says Souba. "The courses we teach are important because they provide physicians and students with a set of tools to deal with rapidly changing circumstances that they don't have any say over. . . . If you're not pretty square with yourself it's tough to lead effectively out here."

Medical students have played an important role in determining how leadership will be taught.

Taking the elective has been an intense and rewarding journey for Geisel students. Second-year student Aaron Steen, a co-leader of the Leadership Development Council, says the course helped him identify what's important to him. "If I believe myself when I identify what's important to me and when I stick to that, I have control over it," he says. "But if I define success or meaning to things that everyone else does, regardless of how I feel about it, I'm liable to fall short because I don't have any control over that." Don't get caught up in "easily identifiable signals of status or accomplishment," he adds. Rather, "pursuing what's important to you can be sustaining in perpetuity."

Many students who have taken the elective talk about the leaders they see in their clinical rotations. Aaron Grober, a third-year student and a teaching assistant for the elective, talks about a patient he saw in his interventional cardiology rotation. The patient was flown to DHMC after having a heart attack due to a rupture of plaque in an artery. The physician talked with the patient, a long-time smoker, about how her smoking was destroying her arteries. In that scary setting, the physician convinced the patient to quit, on the spot. "He took that step of understanding where the patient was coming from, what caused this, and how do we move forward with a solution," says Grober.

Like the elective with students, the summer leadership course has struck a chord with faculty as well. Steven Esons, MPA, a political science professor at Roger Williams University who took the course twice, has made attendance an integrity issue for his undergraduate general education course. As a result, no one has missed class and everyone arrives on time. "It's remarkable," he says.

David Nierenberg, MD, a professor of pharmacology and toxicology at Geisel who also took the course, uses concepts from it in teaching his students how to prescribe medicines effectively. In his pharmacology course, he has students pick an idea or principle they have learned and write a paragraph describing why they chose that principle and how they anticipate they may apply it in their practice. "I'm trying to lead them away from the concept that pharmacology is just memorizing a bunch of facts about a bunch of drugs to what's the larger context. How can you be a leader . . . in making the way we use drugs in this country wherever you go, more effective, safer, and more cost effective?" he says.

The course has also been useful for Sarah Johansen, MD ('90), who teaches in Geisel's On Doctoring course, which introduces students to the practice of medicine. She says that she now brings the concept of integrity much more into her teaching, telling students "to take the time to really think about what they value and about their ability to commit and their ability to follow through."

After years of teaching the principles of leadership, Souba continues to use the lessons he teaches on a daily basis. As an example, he cites the importance of soliciting input from others, "even if you think you know what to do," he says. On a personal level, he notes that studying leadership has helped him not to take himself as seriously as he used to and to become more aware of his own inherent tendencies. "I have learned to accept me for who I am and to lead from that position, because it's what works for me," he says.

Tim Lahey, MD, an associate professor of medicine and project leader of the curriculum redesign effort, has taken the course, and he is curious about how the leadership initiative will play out at Geisel in the next five to ten years. He believes it could bring about widespread cultural change at the Medical School. "The more people who operationalize some piece of this, the more the way this institution works could change," he says. "If you have more people who just accept the principles of it, I think there would be more accountability, more authenticity, more integrity. If Dean Souba could really change the way we approach our work, that's hard to measure, but it could really be a revolutionary difference in our institution's history."

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