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Leadership: The Good, the Bad and the Ugly

Ben Kligler, MD, MPH

Over the past three years, I have had the opportunity to be part of the development and launch of the new Leadership Program in Integrative Healthcare at Duke University.  Thinking through what Integrative Leadership means, both in theory and in practice—and how to effectively teach it—led me to re-examine my experience as an integrative healthcare leader over the past fifteen years. I wanted to share these reflections—the good, the bad and the ugly—in hopes that they might resonate and inform others traveling on their own paths.

My first real experience in leadership was in the late 1990s as the founding Medical Director at the Beth Israel Center for Health and Healing in New York. We had the opportunity to hire a talented group of integrative practitioners and build a practice in a beautiful new green space on Fifth Avenue in Manhattan. We knew what we wanted to accomplish—create a new model of integrative care, a different experience both for patients and for the providers who worked there.

There were plenty of challenges to solve at the start: how to bring together practitioners with years of experience and established practices into a coherent team; how to run an office efficiently and create an atmosphere among the staff of positive healing energy amidst the hustle and bustle, “get it done now” atmosphere of New York City. Honored to have been chosen to help lead the effort, I felt I was up to the challenge. But I had very little experience in team building, in how to bring a group of independent-minded leaders together in a collaborative effort.  So I applied the strategy that had always worked for me in my professional life to that point: put my head down and work hard. Take responsibility for the challenges and problems. Come up with solutions. “Be a leader.”

The practice opened in May 2000. About a year later, we were building nicely, but beginning to experience some of the challenges of a growing medical practice. Phones were not being answered on time. Patients were frustrated at not getting through and providers were unhappy with trying to build practices in the face of access problems. There was tension between providers and staff—on the one hand, we wanted every patient who walked in the door to be greeted by a present, mindful, unhurried front desk staff person; on the other, we needed the phone answered by the third ring for people trying to make appointments. According to the hospital standards, we had enough staff and could not hire more. And we had a commitment—at least a theoretical one—to work as one big team, providers, management, and staff together. We held a series of meetings, breaking into small groups of practitioners, front desk staff, and managers to brainstorm with the intent to be “solution-oriented” rather than just complaining. I was pleased with myself for having created a process that (I thought) would engage everyone in problem solving.

But at the end of a particularly long and challenging meeting of staff and providers, as I finished summing up what steps I thought we had all agreed would address the problems, one of our medical providers raised her hand and said, “This is all fine, but what are you going to do to solve this problem?” My heart sank. Here I thought I had been leading a process that put the team in the center of problem solving, only to be told in the end that they still held me, “the leader,” accountable for solving the problem. I was angry, disappointed, hurt, frustrated — and at that moment I said to myself that the medical director role was not for me. In fact, a year later I had moved on to direct our research and education program, and happily left the job of medical director — the person to whom everyone looks to solve the problems and who never has the real ability to do it — to someone else.

However, as the years have passed, I have come to realize that there really was nothing wrong with the fact that I was asked that question. Even a team that is solution oriented and engaged has a right at times to demand leadership in organizing the solutions. The problem was with my expectations. I wanted to be loved, admired, respected, and thanked. I wanted the leadership role to be “ego-syntonic.” These expectations — not the provider’s question — were the source of my hurt and anger. A more mindful leader would have been able to absorb that expression of unresolved frustration without internalizing it as hurtful.  A more mindful leader would have understood that leaders are not always loved or appreciated, and moved on with working out solutions. But at the time, I was not that leader.

The ability to hear the difficult things your team has to say — and not need your team to build your ego — while still having the openness and flexibility to share the power the team needs to find the solutions is a hallmark of the mindful leader, which (I hope) I am closer to now than I was fifteen years ago. I think this balance between ego, vision, and egoless-ness is the core challenge of leadership. Two of the three qualities will not be sufficient; achieving the right balance between the three is a lifelong journey.

Fast-forward four years to my next lesson in leadership, this one slightly less personal and more strategic. In 2004, the Academic Consortium for Integrative Medicine and Health, a small but growing organization of institutions dedicated to advancing the field of integrative medicine within conventional academic medicine, received its first project-specific grant: a donation from The Bravewell Collaborative to support the development of a curriculum in integrative medicine for use in medical schools around the country. As Co-Chair of the Education Working Group, I helped conceive this project, and so had the privilege of helping lead it with Dr. Victoria Maizes, my Co-Chair. It felt like an important opportunity, both to develop a useful tool for medical educators and to demonstrate to a powerful group of funders that the relatively young Consortium could deliver on a major project in a timely and relevant way.

So with (we thought) a clear charge from the Consortium Steering Committee, we set off to draft a set of consensus guidelines for curriculum in integrative medicine, a document we hoped we would publish on behalf of the organization and which would become a benchmark for medical educators in this new field. Again, we led with hard work — which I have come to realize is a necessary but not sufficient component of leadership — and this time, thanks to a bit more experience on my end and mostly to Victoria’s innate understanding and skill in working with teams — and with a clearly defined commitment to collaboration and group process. Together with a group of educators from 13 Consortium schools, we worked over the course of a year to develop and draft guidelines for medical school level competencies in integrative medicine. There was pressure, based on the timeline from our Bravewell funders, and a sense that this was an important task for the field. We negotiated, argued, compromised, and in the end produced a set of guidelines of which we all were very proud of.

But now came the next step, the one we had not adequately anticipated or prepared for: shepherding this document through the approval process by Consortium leadership. These were well-known academics running new integrative medicine programs at some of the most prestigious medical schools in the country.  They were all leaders at their home institutions with a personal sense of responsibility for the growth of this new field and also for the growth and health of the young Consortium. They had the best of intentions — but coming from the conservative environments in which many of them worked, they also had many legitimate concerns and fears regarding how far we could go with these guidelines and how hard we could push the medical establishment. So when we presented our document for approval at the Consortium Steering Committee meeting, we were told we had gone too far, that pushing the envelope as hard as we collectively had decided to do would lead to a backlash that could be dangerous for the organization and for the whole field.

What had we done wrong? At the time, angry and hurt (again!) I thought “Nothing!” — that the fault was entirely with those above me in the organization who were too conservative and cautious to let us move the field where we knew it needed to be moved. But again, reflecting back years later, I realize the mistake — not involving all the stakeholders early and often in an important change process — was mine. I had been too sure that I knew where we needed to go to bother finding out from the organization leadership what their concerns were and how we could address those concerns and still move the project forward. A crucial leadership mistake! No matter what the level at which we are leading, there are always people above us — hospital CEOs, medical school deans, health system leaders — who ultimately have to be willing to take responsibility for the work we produce. Involving these stakeholders early and often in the work, understanding and incorporating their concerns, is critical to ensuring that our work will have the impact we desire.

At the time though, it seemed like a disaster. The deadline we had agreed to with our funders was at hand. The process of returning to our group and revisiting our entire consensus process to address the concerns of the leadership would take months, and potentially undermine our funders’ trust in our ability to deliver on our commitment. From where I stood, there was no clear way through this obstacle.

Fortunately, this story has a happy ending. With some minor revisions to address the most controversial elements of our document — and mostly with the forceful intervention of one of the senior leaders who felt the time was right for a bold statement from the organization, and that the consensus process we had created needed to be respected and upheld — we were able, in a relatively short time, to get the approval we needed from the Steering Committee and complete the project. The guidelines were ultimately published in Academic Medicine. And I learned a lesson about strategically involving stakeholders and organizational leadership that has served me well on many other occasions.

Fast forward again, five more years this time to 2010. After taking a break from leadership involvement in the Consortium, I was elected as Vice Chair of the organization. With strong support from Chair Adam Perlman, and with skilled guidance from Tony Rucci, Professor of Management at the Fisher College of Business at Ohio State University, we launched a strategic planning process to guide us into the next 3-5 years of what we anticipated would be rapid growth in the organization.  Many important concepts and new directions emerged, but perhaps the most important was the realization that we needed to move to an entirely new and more efficient process of governance. The Consortium had been founded on a set of principles and values based on the tenets of integrative medicine: collaboration, transparency, egalitarianism, true participation from all parties involved, openness, and community. Our process of decision-making — basically deciding everything by consensus — was meant to reflect these values. Decisions were made by a Steering Committee comprised of one representative from each member institution. But by 2010 we had grown to more than 40 institutions and a number of decisions critical to the organization’s growth and well-being — for example, whether to be open to new types of members beyond the traditional academic health centers, or whether to rethink our name and “brand” — had stalled in the difficult process of reaching agreement among a group of 40 plus strong-minded leaders.

So as one of the priorities emerging from the strategic planning process, we developed a governance committee, whose job was to study our current system and then propose reform of some type that would lead us to a place of more effective decision-making. This group worked hard for a year, and ultimately proposed an Executive Committee structure, comprised of officers, members at large, and working group chairs, which would be empowered by the Steering Committee to make the major decisions affecting the organization. The Steering Committee would continue to vote on major structural changes to the organization, bylaws changes, and new member applications—but operational and budgetary decisions would now fall to the Executive Committee.

By now, I was Chair, and Margaret Chesney was Vice Chair. It fell to us as leaders to guide the organization through this process of governance reform. The challenge was that we were asking the Steering Committee — now comprised of over fifty of some of the most influential leaders in the field — to endorse a change which would ultimately lead to that body yielding some of its power over the organization. Not necessarily a simple process! But Margaret’s wisdom and experience — she had recently emerged from a stint helping lead the National Center for Complementary and Alternative Medicine at NIH — and my own earlier “lessons learned,” helped us develop a strategy. We decided to personally call every Steering Committee member to talk through the plan with them and get their input and feedback. When Margaret first proposed this, I could not imagine finding the time or energy to manage it.  How much time would this take? Didn’t we both have “real jobs” as well as our Consortium ones? Was she crazy?

But thankfully, Margaret’s wisdom prevailed, and luckily, we were able to enlist others on the governance committee to help with this process. Some of the Steering Committee members were happy enough to sign off without much input, but others had significant concerns about how this reform could change the core values of the organization. Several had years of experience in running other organizations, and pointed out aspects of our plan that might work better with just some small changes. Not every suggestion could be incorporated, and for those that could not we made sure to loop back to the member and explain why. I think this was one of the most critical steps because it meant that everyone felt heard and included, even those whose opinions were not incorporated into the plan. In the end, we had a much-improved proposal, and a process that had engaged everyone involved.  The proposal was approved unanimously by the Steering Committee and the more effective governance process that emerged has since helped the Consortium grow and thrive.

Once again, the lesson was about balancing ego, vision, and humility. I needed to be confident enough as a leader that the reform process was critical to mobilize the organization’s resources and energy. But at the same time, I needed to acknowledge that I did not necessarily know best how to do that, or what the reform should ultimately look like. I had to hear the sound advice from a fellow leader (Margaret) on how to make the process inclusive and flexible. I needed to listen, rather than just act.

There is so much to learn about leadership, and I feel so grateful to have had and to continue to have these opportunities for growth. But as I reflect it seems clear that it comes down to a few fairly simple — though always challenging to achieve — ways of being and acting. We have to know ourselves well enough to know when we are acting out of ego rather than vision. We need to not be afraid of having a strong vision. We need to be present, calm, and mindful. And we need to listen deeply to everyone at every level of engagement with the projects we lead.

 

AUTHOR BIO

 

Dr. Benjamin Kligler is Associate Professor of Family and Social Medicine at Albert Einstein College of Medicine and Vice Chair and Research Director of the Beth Israel Department of Integrative Medicine. Dr. Kligler is the author of Curriculum in Complementary Therapies: A Guide for the Medical Educator, co-editor of Integrative Medicine: Principles for Practice, and Co-Editor-in-Chief of Explore: The Journal of Science and Healing

 

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