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Leading in times of crisis: Yale physicians on team dynamics and effective leadership

May 21, 2021
by Elisabeth Reitman

After more than a year, COVID-19 has changed the practice of medicine. Effective health care executives rely on empathy to create an inclusive work environment and deliver high-quality health care.

Tariq Ahmad MD, MPH and John K. Forrest, MD discuss their experiences with the American College of Cardiology’s (ACC) leadership development programs and how academic medical centers can navigate the global pandemic. They offer practical advice to inspire and motivate teams such as incorporating soft skills into medical training and the value of getting feedback from direct reports. The conversation has been edited for clarity.

Tariq Ahmad, MD, MPH, FACC

Tariq Ahmad, MD, MPH, an assistant professor of medicine, specializes in treating patients with end-stage heart failure and heart transplants. Dr. Ahmad completed his medicine training at Brigham and Women’s, with cardiology, heart failure, and clinical research training at Duke.

What critical leadership skills are needed in today's health care environment?

Participating in the ACC Leadership Academy has been incredibly rewarding. The process to becoming a doctor does not exposure us to rigorous training in leadership and people management. Getting into medical school, for the most part, involves getting high grades and MCAT scores but there is very little attention paid to the soft skills that you need to be an effective leader. In medical school you are in an extended period of intensive training, but it is generally a monastic existence focused on learning immense amounts of information. And then during residency and fellowship you are heavily focused on acquiring the skills needed to apply knowledge to take care of patients, but there is not formal training on how to function in teams.

For example, when I started residency training, I saw graduates from the top medical schools in the country walk onto the wards and immediately pull rank on the nurses who obviously knew a lot more than they did. This would invariably end badly. But I realized that this was not entirely the fault of the new residents; they had been launched into the high end of hierarchy without any guidance in critical people skills and were placed in the position of telling members of the team with a lot more knowledge and wisdom what to do. That requires an immense amount of insight and emotional intelligence.

Some physicians are lucky enough to be born with these skills, but the majority of people have no training in these principles and really struggle in this regard. Since assignment to leadership positions in academic medicine can depend on the quality of your training and research funding, it is quite common to have inexperienced leaders in a position of great responsibility.

As a result, one sees a lot of misuse of human potential and team unhappiness in medicine that directly results from poor leadership skills. The ACC Leadership Academy focuses on this aspect of professional life. The program picks people who they feel have potential, and I was honored to be thought of as one of those people. The program then guides you through a leadership development course where you learn the basics of how to lead teams and deal with difficult situations. Next, you pick a challenging project that will put this training to the test that you tackle with the help of an assigned mentor. Mine was Dr. Jim Januzzi from Massachusetts General Hospital, who has been an incredible guide and resource for me throughout my training and even today remains one of my closest mentors.

During this process I have learnt a lot about how to motivate people to work together effectively and how to better understand team dynamics. I now have a much better sense of the many moving pieces that allow for an organization to improve. I am far more conscious of all the people who make up the clinical programs and realize that for us to achieve our goals I need to bring them all along willingly. I have also realized the critical importance of leading from the front.

How has your experience at the ACC Leadership Academy helped prepare you to lead effectively during COVID?

I was tasked with leading the Advanced Heart Failure Program during the COVID crisis and this has been immensely challenging. Our team and patients were extremely scared by the uncertainty surrounding the virus. We were concerned about infections but did not know the risk and benefits of proceeding with transplants and left ventricular assist devices (LVADs) in sick patients versus postponing. Additionally, the team was feeling burned out with issues at home, including home schooling of kids and concerns about the the health of their parents.

However, we stuck it out as a team with the shared goal of doing what is best for our patients. By doing so, we were able to keep up our morale and ended with being the highest volume and best quality transplant center in New England. As a result, we ended up stronger as a team and now take great pride in how we handled the hardships with direction and poise.

Personally, I made sure to connect with our team every day. I also realized that it is exceedingly difficult to lead a team unless you genuinely care for about them, which I did, and they reciprocated. Hopefully, we are now at the tail end of the pandemic, and we will continue to do the amazing things we were able to do during the most trying of situations.

There is truth to the saying “what does not break you makes you stronger.”

Who do you look up to as a good example of a leader?

I really look to my mentor during fellowship Dr. Christopher O’Connor quite a bit. He remains one of my most important life coaches and I still call him quite frequently when I need advice. Despite being super busy, he always calls right back, and goes over details of the question at hand for hours at a time. I interviewed him for the New England Journal of Medicine Catalyst some time back and we discussed many of the principles that drive him. Recently, he recommended that I get a leadership coach. I mentioned this to Dr. Velazquez, another long-term mentor who I look up to immensely as a leader, and he went out of his way to get me a highly recommended leadership coach.

How do you fight against burnout?

The most important thing I’ve been working on is spending time with my family. My boys are 7 and 9 and I cherish every second I spend with them. Also, I’m actively working on spending more “hang out” time with my wife when we are not running around taking care of life tasks. I try to talk to my close friends daily. Dr. Nihar Desai and I have been best friends since residency in 2010 and I am extremely fortunate to have him at Yale. He is always the voice of reason and is wise beyond his years. Finally, I talk at least weekly with Dr. Lawrence Cohen, who is one of the most important people I have ever met in my entire life. He is the wisest person and most impressive human I know and talking to him leaves me so much more content and peaceful about life.

John K. Forrest, MD, FACC, FSCAI

John K. Forrest, MD, an associate professor of medicine, serves as director of the Interventional Cardiology and Structural Heart Disease Program. Dr. Forrest received his medical degree from the Yale School of Medicine in 2005, and remained at Yale for his residency and fellowship training. During his fellowship, he trained with Michael Cleman, MD, Criag Thompson, MD, and John Elefteriades, MD.

How has your experience as a member of the American College of Cardiology (ACC) Emerging Leadership Faculty helped prepare you to lead effectively?

What's been clear is that it takes a coordinated effort. You can't do things on your own. You can't be the sort of leader who tries to implement all of the strategies. You'll be much more successful if you delegate the appropriate things to individuals and empower them to make to make an impact.

There's always ways to improve. One thing that we've recognized is that there is a difference between the perspectives and suggestions of people in the hospital all day and people who are in remote meetings. You can't just have top down leadership. You won't have success unless you involve the people who are at the ground level. Try to make sure that you're listening and actually empowering people to make decisions about how things occur. It's tough to let other people make those decisions, but it was certainly one of the things that was that was emphasized.

In the past twelve months I have spent a lot of time serving outside of work. I sit on the boards of several schools in New Haven and serve as the medical health director for one school.

Physicians have gotten an outpouring of support from society. But we've also asked other people to come back to work and haven't empowered them with a ‘Thank you for doing this because it makes a difference.’ In my experience, this simple task of saying thank you what you're doing is enormous. When you appreciate what somebody's in doing, it's empowering for that individual. It's important that as a society and as physicians we also look at other people who impact the health of individuals and recognize that they aren't always prioritized.

Learning how to be a good teacher and a good mentor must be a priority be for physicians. Being an amazing doctor should not be enough. You need to teach your abilities and what you've learned to future generations.

John K. Forrest, MD, FACC, FSCAI

That genuine appreciation motivated us as physicians. I think it can also help others.

The hospital leadership did an exceptional job at providing physicians with enough PPE (personal protective equipment), beds, ventilators, and critical aspects like that. But there are certainly lessons to be learned from the pandemic.

For example, could we have done more to address the fact that less patients came in if they were having a stroke or having a heart attack because they didn't know if the hospital could handle it. The pandemic also raised questions about our bed capacity. Does the hospital need to operate like a budget airline where you're always at a full capacity, and if everybody shows up, you have to give people a refund because you don't have room? Or do you operate like a non-budget airline where you don't oversell your room and you always have a couple of extra beds for emergencies.

It's tough and I don't know that I have all of the right answers. It requires people coming together and empowering people to make decisions.

What are some of the hard decisions you have had to make?

We were fairly fortunate from a from a patient care standpoint. We did not have to dramatically alter patient care in the Cath lab.

It took a little bit longer before procedure was done, but we're talking on the magnitude of less than an hour, not in terms of the days. The hardest thing was asking people to work longer hours and be on call. That's taxing on people. That's the thing that I worried about was how much can you can you push folks?

We're fortunate that there are people who can do a little bit more and who are willing to make sacrifices. We had fellows and some attendings who were willing to go and do call in the intensive care units an attendant in COVID wards.

And those fellows gave up part of their training so that other people who had conditions or other things didn't have to. And they weren't paid for it. There wasn't anything, just them doing it because they wanted to be good people and to help.

What are ways to improve at being a leader?

To be successful in a leadership position means that you are willing to get honest feedback from your direct reports. There is a hesitancy for leaders to reach out to those you are working with and say give me feedback about what I'm doing. And there can also be hesitancy on people to give to give that feedback for fear of I can't be honest. I can't be negative. I can't be critical. It’s important for us all. As soon as any of us says ‘I can't improve’ or ‘there aren't things that I could do better’ then you shouldn't be where you are, and you certainly shouldn't be leading folks. We all have the ability to improve and to do things better.

We're fooling ourselves if we always think we know how to make ourselves better or what we can do. It's often the people who are around us who see what we're doing who can be the most productive in giving honest feedback. Unfortunately, we have a tendency to seek feedback from the people above us. So we go to our boss to get feedback, and our boss goes to their boss to get feedback and so on. Instead of getting feedback from the people who you are leading.

If I'm in charge of the heart failure program are the twelve physicians there giving me feedback, sitting down, and saying ‘this is what is working with this program’ what's not working, and also, have we created an environment where those physicians can feel comfortable saying ‘this is what's not working’ without feeling that there will be retributions for it?

How would you identify as a role model?

Yale is filled with amazing individuals. Learning how to be a good teacher and a good mentor must be a priority be for physicians. Being an amazing doctor should not be enough. You need to teach your abilities and what you've learned to future generations.

The idea being a doctor is about being a teacher. We don't always reward those who excel at that. My core strengths are our procedures. When I look at how to get better, what I can do is teaching others how to how to do this. That's going to be much more powerful and impact a lot more patients than just me doing it on however many patients I can potentially do. Sharing your knowledge and skills with others in an invasive surgery or high risk procedures is not easy. A subtle movement can be catastrophic. That's very different than entrusting somebody on rounds to say, ‘I think we should start this medication.’ Unlike an invasive procedure, you have you have a clear place that you can stop and in check beforehand.

How have you learned to cope with uncertainty?

It’s important to have work life balance. With a 12-year-old, a 9-year-old, and a wife who teaches full-time, my home isn’t always a calm environment, but I would say it's nice to be somewhere where things are predictable. It's the type of chaos you understand. One of the big challenges with this pandemic is that you couldn't predict. You didn't know what was going to happen. When you have kids you want them to be able to develop. They have to do it differently now, but you don't want them to stop growing. And that's key.

In normal times a work life balance helps to maintain those things so that when there are challenges at work, they have loved ones and friends and people to lean on to support them. And if all they're doing is work, it's hard to build those other relationships that at times you need in your life. That’s something medicine does dramatically better now than we did even ten, twenty, or thirty years ago is recognizing that also helps to ground you.

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Submitted by Elisabeth Reitman on May 18, 2021