Leading Up

Hi everyone,

One day during residency, I saw a patient with shortness of breath and hypoxemia. I was worried about PE, but her attending, a prominent pulmonologist, disagreed. Despite this, he let me order a V/Q scan, which returned “high prob.”

I recently flashed back to this case when an intern taught me about “leading up,” which conceptually means letting junior team members lead, for example driving diagnostic workups or guiding seniors to do better jobs.

Leading up doesn’t happen naturally. If we’re not careful, vertical hierarchies can silence juniors, who may hesitate to contradict supervisors. In turn, silence suppresses key discussions and diminishes our work.

We have many reasons to promote leading up. First, patients benefit because juniors generally know their patients best, having spent the most time in the chart and at the bedside. Second, seniors need help: I’m so grateful when interns and residents correct my faulty reasoning or fill in my knowledge gaps. Third, junior input diversifies our thoughts, enriches our discussions, and raises the quality of our work. Fourth, if we’re truly committed to developing leaders, we have to begin this work from the start of residency.

Both juniors and seniors have roles to play. Juniors must commit to speaking up, advancing their arguments, and pushing back when necessary. Speaking up comes naturally for some but not all. Too often, juniors remain quiet because they fear offending seniors or lack confidence. But we can easily overcome these concerns: faculty and residents are rarely offended by vocal interns, and confidence grows reliably with practice.

Seniors should embrace leading up, especially now. In just six-and-a-half months, today’s interns will be leading their own teams. To the extent possible, interns should be developing their own diagnostic and treatment plans, before residents and attendings weigh in. Interns should also be leading bedside discussions, sharing articles on rounds, and presenting at teaching conferences. To foster leadership, residents and attendings must invite opposing viewpoints and be careful not to confuse silence with agreement.

To read more on this topic, consider buying these two books: The first is The Effective Executive, which highlights ways to promote contributions from all team members. The second is Crucial Conversations, which shares practical methods for advancing your ideas effectively and constructively, especially when your goal is leading up.

Enjoy your Sunday everyone,

Mark

PS A special thank you to Peter Kahn for sharing this marvelous concept with his Program Director.

M