Leadership in Graduate Medical Education

Abstract

Graduate medical education (GME) is a very complex endeavor within an even more complex healthcare system. This chapter examines many questions that need to be considered and the role of the key individual with oversight of the GME, the designated institutional official (DIO). Topics examined are the leadership theories, practices and strategies for the DIO, dealing with change when the DIO starts, using authority versus power, effective problem-solving and decision-making, adaptive leadership style, the historical function of the DIO, as well as the many tools available to the DIO including networking. The chapter concludes with several pearls of wisdom to positively help the DIO meet the many challenges of this very important role in GME.

1. Introduction

Graduate Medical Education (GME) is a very complex operation within an even more complex healthcare system. In order to be an effective leader within both a complex operation and system, there are many questions that need to be considered. For example, what is the purpose of having GME programs in the organization? What are both the long term and short term goals of the institution? What are expectations and outcomes sought by having GME programs? In some cases, what is the relationship between the hospital doing the training and any medical school who has oversight of the education? Since there are often multiple personalities with whom one must work, who are the leaders and participants and what are their values and expectations? In this complex environment, what are other relationships where you must interact such as accrediting bodies, affiliated institutions and other training institutions in your area? These questions stem from the very origins of developing any curriculum and plan for instruction and should be used as starting points to be a successful educational leader [1]. In order to be a successful leader in today’s GME world, one must first recognize that this is not a simple role and requires skills, knowledge and the right temperament to deal with a multitude of issues.

2. The role of the designated institutional official (DIO)

In the middle of this complex system is the role of the designated institutional official (DIO). In this role, there are many individuals across the institution with whom the DIO interacts. Organizationally, the DIO is responsible for reporting to the Board of Directors of the institution (generally, a hospital), at least one medical school, hospital administration including the Chief Executive Officer, Chief Financial Officer, Chief Human Resources Officer, accrediting body requirements (in medical education, the ACGME), as well as the Centers for Medicare and Medicaid Services (CMS) and other funding sources to name a few of the most important ones. There are also consequences when there are issues of non-compliance that can lead to reduced governmental funding, loss of accreditation, National Residency Match Program (NRMP) match violations, and low resident and faculty morale.

In terms of an organization’s power system, the DIO works primarily in the middle but also flexes into various Tops, Bottoms, Middles, and Customer roles [2]. DIOs as Tops have designated responsibilities (ex. accreditation), as Bottoms experience problems that we think higher-ups should take care of (ex. residency clinic operations), as Middles experience competing demands and priorities (ex. service versus education), and as Customers when we are looking to another department for a service we need to move our work ahead (ex. HR support to onboard new trainees). The DIO constantly toggles in and out of Top, Middle, Bottom, and Customer roles. In each of these roles, there are unique opportunities for contributing to organizational effectiveness and pitfalls that readily lead us to forfeit those contributions. The DIO’s job within an organization’s power system is to recognize and mitigate common reflex responses such as taking on too much responsibility when we are the Top, holding higher-ups too responsible when we are the Bottom, losing our connectivity with other parts of the organization when we are the Middle, and not participating enough in improving internal service delivery when we are the Customer [2].

In terms of oversight, there are many who have reporting relationships with the DIO including Program Directors of each internship, residency and fellowship program, Program Coordinators, DIOs at both sending and receiving institutions, oversight of the office of GME and most importantly, the education and training of interns, residents and fellows. Furthermore, the DIO is responsible for the Graduate Medical Education Committee (GMEC), the Clinical Learning Environment, and multiple other responsibilities demanded by the accrediting bodies including completion of affiliation agreements, compliance with work hours, initiating and maintaining wellness programs, encouraging and supporting scholarly activity, oversight of moonlighting, continual review of the educational programs, identifying “red flags” and then addressing the concerns, and any citations with proactive strategies and action plans. Needless to say, the role of GME leader in this very complex “middle person” system requires much knowledge, strong interpersonal skills and highly ethical values to be successful.

After many years serving as the Associate Dean for Graduate Medical Education at a medical school, Vice President for Academic Affairs at a hospital, and Chief Graduate Medical Education Officer (DIO) for the last 18 years at a medical school/hospital, I want to reflect on those theories, practices and strategies that I have utilized which may help others who are in this complex “middle person” leadership role.

3. Leadership theories, practices and strategies

My definition of leadership is followership. Unless we can get others to follow, we cannot lead. Goffee and Jones coined the phrase, “Authentic Followership” explaining that leaders need to convey Authenticity, Significance, Excitement, and Community to followers in order to truly lead [3]. I believe that people want to follow someone who is “authentic,” someone who they can trust, someone who will actively listen and hear their issues, and someone who believes in action, not just words. True leadership takes time to develop and is not accomplished overnight. Flexibility is a key component to building trust and caring relationships with those with whom we interact.

One of the first questions to think about is what if you are new at an institution and are entering for the first time. I believe that you need to look at three levels of maturity: (1) your experience, professional background and leadership ability, (2) the institution’s maturity, and (3) the employees experience and background with whom you will be working. Analyze how experienced you are in the DIO role. Ask some of the following: have you been in this role before? What was the size of the institution? How experienced do you feel? Regarding the institution: what is its historical background? How much does the administration of the institution know about GME and what is their support? How long have they had GME programs? What is the accreditation status of the programs? And finally, regarding the people at the institution: what is the maturity of the individuals in the Office of GME? What is the range of experience of the Program Directors and Coordinators? What do they expect from their leader?

There are several key thoughts here. Let us assume you have been in GME for many years and are considered mature. If so and you are entering a new system, you can take a directive role of leadership because you are the most mature. However, that is rarely the case. In most cases, the leader is entering a mature system, one that has been in existence for a long period of time with the employees and Program Directors already in place. The leader is a newcomer to the system irrespective of his/her maturity. In that case, the leader has to enter very gently. The leader needs to meet with key people, listen carefully, ask many questions, assess their needs, and ask what they expect from you and how you can help them. If possible, you may want to meet with the person who preceded you to learn as much as you can about the system from that person’s perspective. Note, when coming into a new system, it is important to ingratiate yourself to those around you until such time as you can gain the respect of those with whom you will be leading.

4. Dealing with change

I also believe that organizations, like people, have difficulty dealing with change. Organizational management experts note that basically, people resist change [4]. The greater the change, the stronger the resistance. Change is inevitable, but so is the resistance. Thus, if you are coming into a new institution, you must be prepared for the reaction to you. As the new person, there is an expectation that there will be change. I believe that organizations go through the same stages of change similar to those described by Elisabeth Kubler-Ross when referring to those experiencing death and dying. The stages are (1) denial, (2) anger, (3) bargaining, (4) depression and finally (5) acceptance [5]. It is reasonable to expect these earlier stages will occur with a new DIO entering an institution before there is acceptance of his/her role, responsibilities and actions.

As the middle person in a complex system, where do we start. I have learned several things in my career. In a previous role, I sent out a questionnaire to many individuals that would take 5 minutes to complete. None were returned to me. In frustration, I called and asked if I could come to speak with them for a few minutes. In every case, the person said yes and the conversations often lasted an hour with much valuable information gained. What I leaned from this was to go to their space where they are comfortable, secure and open. Another example comes from early in my career when I was a 27 year old principal of an elementary school. Being young, inexperienced and in a role of responsibility, I developed a philosophy of what I called “management by movement.” I made sure I was in every classroom, every day. I believe that even though it is more comfortable to sit in our office and wait for issues to come to us, I am amazed with what gets accomplished by going to other people’s space. By doing so, this facilitates building bridges and leads to more long-lasting relationships in the future. They are more comfortable and willing to share in their area than what may feel as intimidating when in my office/space. I use this strategy even to this day.

5. Using authority versus power

As a leader, I like to think of the difference between power and authority. Power is what you can make people do. Authority is what you can get people to do. Power is authoritarian and while it is needed sometimes, it often yields resentment and anger. I rarely ever wanted to use power to get things done, however when I had a trainee with drug or alcohol issues, it needed interventions immediately. I had to be more assertive and pull the person from service in order to get the individual the required assistance as soon as possible. However, in most cases, I want to use authority to get things done. I always want to base my relationships on trust, honesty, fairness and compassion to accomplish my goals and objectives and using power rarely yields this outcome.

6. Effective problem-solving and decision-making

A major aspect of leadership is problem-solving and decision-making. I often call upon Dewey’s four stage model of problem-solving: (1) problem sensitivity (2) problem formulation (3) search and (4) resolution [6]. Problem sensitivity is the recognition that there is a problem in the first place. Problem formulation to me is the most important. Clearly determine what is the question being asked. If this is not articulated specifically in the beginning, we will search and not find the correct solution. It is important to make sure that the right question is being asked or an incorrect solution will be found and not be useful. If the problem formulation is carefully articulated, then a search can be made of alternatives and here is where I use a different model. I decide whether I want to maximize or satisfice. If I maximize, I want to generate as many options as possible and choose the best one. This takes time and should be used when making the most profound decisions. Some examples include:

1. A program has lost some of its faculty to another institution. Should we voluntarily withdraw the program and orphan the trainees or attempt to find new faculty to continue the program?

2. We have interviewed several people for the Program Director role. Each has different strengths and weaknesses. Which one shall we choose?

Satisficing is generating options and deciding on the first satisfactory one. An example: we want to have a luncheon for the house staff. What kind of food should we order? The real issue here is deciding at the beginning if we want to maximize or satisfice. Many people make the mistake of maximizing on issues where they should satisfice and visa-versa.

As leaders, we are continually called upon to make decisions and solve problems. As a leader, I use the Dewey model in three ways—how I solve problems, what I expect from employees and how I deal with problem trainees.

For me as the leader, I first try to articulate the problem as carefully as possible. I then determine if this requires maximizing or satisficing. I generate alternatives. If maximizing, I want as many alternatives as possible and want to pick the best solution. If satisficing, I accept the first alternative and move on. Leaders are best served who can differentiate and use these problem-solving skills. It will save much time and energy and yield better results.

When I first met new employees, I often shared this model with them. I indicated that I want them to think independently and want them to bring me problems they cannot solve themselves. So, when they came to me with a problem, I would ask them to articulate their thinking. I would then ask the person to tell me his/her resolution and invariably, the solution was almost always exactly what I would have selected. Both of us walk away being very satisfied with the process and the conclusion.

When I was dealing with trainees facing difficult situations and challenges, I tried very carefully to listen to what was the issue. I found several keys that I used in finding the problem resolution. The first step was, were they blaming others or were they taking some responsibility for the problem? If they were blaming others, I realized I could do little to help them. However, if they were seeing themselves as some part of the problem, I might be of some help. The second step was if they were taking some responsibility, were they willing to do something about it? If so, I could be of help.

A former Dean for whom I worked called upon me for what he considered his most difficult problems. He indicated that after I investigated a problem (I used the Dewey method noted above), I was always “honest and fair.” I think this is an important learning as a leader in GME that we are honest, fair and compassionate and certainly do not play favorites.

7. Adaptive leadership style

It is important to note that no leadership style is best. I believe the best leaders are those who are able to evaluate the situation, be adaptive and use the appropriate style for the situation. I always tried to understand the styles of those above me and below me and adapt accordingly. An example—While I am an individual who thought about what I wanted in a meeting with my superior, I would prepare my rationale in advance in order to lead into my conclusion. However, when I met with him, he would constantly say, “Get to the point.” I finally learned that I would present my conclusion first and if he wanted the particulars, I already had them prepared. Since there was a trust level between us, he would often accept my conclusion without an explanation. The lesson here is that we may have to adapt our style to meet the expectations of others if we want the positive results we desire. In other words, try to understand the dynamics between you and the other person and then work with it not against it.

I think that a leader must show high moral and ethical values. I think we all want to work with people like ourselves. How do we know if a person is like ourselves? I do not believe that it is one’s gender, race, etc., but their values. When I interviewed a potential candidate, I ask the following: “Tell me about yourself.” I am quiet and wait for an answer. I am not looking for what already is listed on his/her resume but rather any value words that I hear. If the candidate has difficulty articulating, I then ask them to give me 10 words that their best friend would use to describe them. I think we all want to work with people who have our same high values. Good team members are those individuals who have the same common goals and values.

Because the role of the DIO is so complex with multiple interrelationships, many responsibilities, time lines and expectations, time management is critical. Consider priorities and try to reduce chaos in the job. Obviously, we have all learned the value of making lists in medicine. Our minds will hold will not hold all the information we need nor the various tasks that need to be completed. Anticipate, plan ahead and complete tasks prior to the deadlines. Invariably other priorities will intercede so get things done as early as possible. This will reduce the natural stress of this very stressful job. Many years ago, I made a presentation at the Association for Humanistic Psychology entitled, “Slowing Down the Process and Learning to Ride Your Biocycle” [7]. The premise was that we have various times in the day when we are most productive and we should determine when those times are and work accordingly. I happen to be an early morning person who is less productive in late afternoon. As a result, I do my most important and creative work at those times when I feel most productive. We cannot work at maximum productivity all the time. Pick your best times and schedule the items that require your most attentive awareness during the most productive periods.

8. Historical function of the DIO

As a DIO, you are not alone. Years ago, there was no such role as a DIO. The ACGME simply required that every institution have “a designated institutional official” (lower case). Our own institutions did not know what that meant. However, with much pleading, the function was moved from a responsibility to a role. As such, the administrators at our institutions now know or should know what is required by this very important role. No institution can maintain its accreditation status without having a very competent individual in this very complex role.

9. Using all the tools in your toolbox

I grew up living above my father’s hardware store. My grandfather was a very accomplished woodworker who made gavels for the United States Senate. Thus, I am a person who values tools. Tools make our lives easier. I believe that the more you use a tool, the more skilled and able you become. It is also important to use the right tool in the appropriate situation. A hammer and a screw driver do very different things. The ACGME provides many GME tools to help the DIO. There are also other tools in the market that make it easier to monitor work hours, evaluate residents, evaluate faculty, develop and maintain schedules, etc. Use them as they save time, energy and meet ACGME guidelines and requirements.

10. Networking

No DIO should minimize the importance of networking. As a result of our establishing a regional disaster plan, the DIOs in my area continue to meet to this day as a regional GME leadership group. There are now 23 institutions involved. Not only do we discuss the most pressing issues facing all of us, but we have contacts we can make with the DIOs of the other institutions who can help when problematic issues arise. Of course, we do not talk salary. However, we do discuss preparations for a CLER visit, how is your institution handling suicide prevention, how do you maintain confidentiality with feedback in very small programs, what is your process for the Annual Program Evaluations (APEs) and Annual Program Reports (APRs), and multiple other issues. On a regular basis, an institution will send out a query regarding an issue and many respond with suggestions. Not only is it important to attend the national meetings, but local networking is an excellent tool for the DIO. If you have a question, there is some DIO out there who has had that situation and is willing to help. Again, you are not alone.

While the DIO role may seem overwhelming at times, there are many exciting parts to the job. I love to think of all the practicing physicians with whom I have helped in their careers. I once estimated that there are over 6000 physicians whose certificates I have signed and the enormous number of patients for whom they provide care. I have seen some of my former trainee leaders now become Program Directors and DIOs. They now model and emulate many of the values they have learned by experiencing positive, upbeat and sensitive leadership.

11. Impact on trainees

In my career, I have measured impact of educational experiences. By impact, I mean that there is some external experience that changes the learner dramatically and internally. We rarely have the opportunity to know exactly the impact we are having on others. However, sometimes we are fortunate to find out. Recently, I received a call from a former student who indicated he was trying to find me because he was in the first class I taught 55 years ago. He indicated that I had made learning so much fun for him as a sixth grader that it influenced him to become a teacher, always make learning fun for his students. He indicated that he used this philosophy in teaching history, coaching and writing four books. It is nice to know that if we do the right things, sometimes we may have a major impact on those with whom we interact.

12. Several pearls of wisdom

There are three bits of advice I would like to share.

1. When I was in my early teens, I was required in school to learn a Rudyard Kipling poem entitled “If.” To this day, I cannot forget the theme of this poem which is “If you can keep your head when all about you are losing theirs, then you my son shall be a man.” Throughout the chaos that we experience being in the middle of a complex system, this quote gives me guidance and strength to keep me sane.

2. We are all achievers and want to accomplish much in the GME leadership role. One learns very quickly that everything cannot be accomplished immediately. Thus, I often remind myself of a Winston Churchill statement to Englander’s during WW II, “It is better do something than nothing while waiting to do everything.” As a GME leader, do not get mired in doing nothing and do what can be accomplished. Everything cannot be done at once. Start with the most important and then move on to the next task at hand.

3. Finally, while you will have wellness programs for the house staff, take care of yourself. I often advise others that “Self-care is not selfish.” If you are not healthy and let a role, job or responsibilities to disable you, then you will not be able to be of worth to the organization, your family or yourself. As noted many times above, this role is complex and you must take care of you so that you can be of help to others.

13. Conclusion

In conclusion, I have tried to articulate the difficult middle role that the leader in graduate medical education must play. However, if the leader uses his/her knowledge of how the system works, and employs his/her skills, appropriate tools and strong personal values, the leader will have much of the pride, meaningful highlights, and success that I have felt in my career. The subsequent chapters in this book contain substantial and practical skills, tips, examples, and research for GME leaders to improve their effectiveness and overall impact. I feel that there can be no more satisfying and fulfilling job than being a good leader in graduate medical education.

Jay M. Yanoff, Ed.D. was the Chief GME Officer and Designated Institutional Official at Drexel University College of Medicine and Hahnemann University Hospital for 18 years.