Family physicians walk with patients through dark times and joyful times, at the beginning of life and at the end. It's an important, difficult job made all the more taxing when issues beyond the exam room make it harder to care for patients. For example, you open an email announcing a new convoluted policy from a payer or your own health system that will force you to spend more time on administrative tasks. Or you're late to finish seeing patients for the day because your clinic is shorthanded due to executive-level financial decisions.

You might wonder, not for the first time, “Do these people have a clue how their choices affect my patients?”

As a leadership developer and coach, I've worked with physicians and other health care professionals who have outstanding track records for patient care but say they feel powerless in the face of system-level challenges. The problems feel too big to solve, and their “leaders” aren't helping. They feel there must be a better way.

REDEFINING LEADERSHIP AND REDEFINING PROBLEMS

Most people think leadership is a position, meant for a select few. It's not. Leadership isn't a title, like CEO or “the boss,” or even a characteristic, like charisma or a servant's heart. Leadership is a practice, and anyone can do it.

The traditional definition that equates leadership with authority prevents too many people from leading. They tell themselves that because they aren't in charge, they aren't responsible. This leaves the creativity, risk, and responsibility for progress on big, systemic challenges to someone else. The person in a position of authority, such as the CEO of a health system, does have a role to play in solving problems. But leadership at all levels is necessary for the organization or health system to improve, in part because today's most challenging problems are often adaptive, not technical.¹

Harvard Kennedy School's Ron Heifetz, in his book Leadership Without Easy Answers,² defines adaptive challenges as follows:

• There is no clear solution, only progress,

• Authority and expertise are not enough,

• The work is not efficient or straightforward, but experimental,

• Progress rarely happens quickly.

With technical challenges, we know the steps to solve them or we can depend on someone else with the right expertise. But with adaptive challenges, we have to resist the allure of quick fixes, address competing values, examine the culture and norms, navigate loss, engage the right stakeholders, experiment, and codevelop solutions with those most affected by the problem. This requires patience, purpose, curiosity, and a willingness to take risks. In short, it requires an “everyone leads” approach.

The traditional model for change is “leader-centric,” focused on one person confidently directing others to solve challenges. But the “everyone leads” model is “challenge-centric,” with everyone acting within their sphere of influence to make progress.

Emerging research shows that cultivating an “everyone leads” mindset can transform organizations.³ The organizational culture becomes more adaptable, inclusive, and fair. People across the organization actively contribute to assessing risks and navigating losses. They engage more often in difficult conversations, and they recognize their ability to shape progress on adaptive challenges. They even report feeling more satisfied, fulfilled, and engaged at work.

FIVE STEPS FOR GETTING STARTED

How can physicians exercise this type of leadership to address challenging issues?

1. Authorize yourself to lead. No one has a better vantage point on the patient experience or works harder to provide high-quality care within a broken system than physicians. But too often, health care professionals defer to people higher in the chain of command to fix systemic issues. By authorizing yourself to lead, you don't wait for someone else to see and solve the challenge. You don't need to have all the answers or know the way forward. You just have to begin.

For example, Denis, a physician at a teaching hospital, noticed that there was persistent conflict between residents and floor nurses.⁴ He decided to exercise his leadership and explore the problem, even though this wasn't in his job description.

2. Put the challenge at the center. Identify a specific adaptive challenge that requires attention, and begin to orient people around that challenge. For example, when Denis recognized that persistent conflict and distrust between residents and floor nurses was impairing the team's performance and harming the hospital's reputation among patients, he started engaging key stakeholders (residents and nurses), asking questions, and exploring multiple perspectives around the problem.

3. Start where you have influence. Begin by focusing on the people you know (e.g., your care team, your partners, or your boss) and the areas where you have influence (e.g., your patient panel or your team work-flow). Denis approached the nurses and residents he worked closely with and began to ask questions about aspirations and values, make interpretations, and create conversation around the challenge.

4. Start with your part of the mess. Take a closer look at your role in the current situation. Consider your mistakes or privileges and the potential changes you and others can experience through collective progress. Embrace the good, the bad, and the uncomfortable. For Denis, this meant examining whether things he had done or said might have contributed to the conflict.

5. Start engaging others. Recognize that leadership is a collective endeavor. Seek out diverse perspectives and invite others to exercise their own leadership in addressing the challenge. Expand the circle of stakeholders and build new relationships to gain a comprehensive understanding of the problem and develop more effective solutions.

Issues like burnout and retention, for instance, look and feel different from the point of view of physicians, nurses, registration staff, administrators, patients, families, board members, and medical assistants. Because there are so many ways to look at a problem, taking the time to build new relationships helps you see the situation more completely and devise more comprehensive solutions.

For Denis, this meant expanding the conversation to include the patient perspective and talking to his physician colleagues about how they could be part of the solution. Recognizing that leadership is an experimental art in which some interventions succeed and others fail, Denis set a goal to get more physicians and team members talking about the importance of collaboration. He tried various approaches, watched for impact, and celebrated small changes in colleagues' behavior that eventually yielded significant results.

OVERCOMING RESISTANCE

When you decide to exercise more leadership, whether it involves building a high-functioning team, changing system norms, or reforming policies and practices for better patient care, you will inevitably encounter obstacles. You may face resistance from administrators and the entrenched hierarchical structures common in medical systems. Fellow physicians may cast skeptical glances as you step outside the confines of your designated role. Some staff members might resent even your most thoughtfully worded questions, and stakeholders might reject invitations to engage.

You also may confront inner resistance as you grapple with the personal and professional risks of stepping outside the comfort zone of routine interactions with patients and coworkers. Scarcity of resources may appear to be an insurmountable constraint, and it can be disheartening when administrators rebuff your ideas during budget discussions, or when stories from families seem to fall on unsympathetic ears.

How do you overcome obstacles and loosen constraints that impede progress? The answer is both simple and complex: Be persistent. Cultivate patience. Take good care of yourself so you have the energy to lead. Keep experimenting and seeking new perspectives. Stay curious. And seize opportunities to inspire collective purpose.

Here's an example of a success story. Four County Mental Health Center in southeast Kansas faced a number of disruptions in the last few years that are probably familiar to many family physicians. They weathered the pandemic, adopted a new EHR, and transitioned from mostly fee-for-service payments to payments based more on patient outcomes.⁵ Through it all, the center thrived, in part by embracing challenge-centric leadership.

By seeking input from external stakeholders such as the local Veterans of Foreign Wars post, the center increased services to veterans by 27%. By collaborating across three different locations, the center changed long-standing procedures that held up admissions, eventually achieving an 87% same-day admissions rate.⁵

Staff reported that two keys to these improvements were a culture in which everyone feels empowered to speak up and offer ideas (i.e., lead) and a change management committee that ensures major changes to day-to-day operations are communicated clearly and workers have a way to offer input about implementation, rather than just being told to “deal with it.”

Their example shows that redefining leadership is worth the effort. Although results take time and transforming systems is long-term work, centering important challenges and reshaping your approach to leadership have the potential to make a profound impact on your organization and the communities you serve.

As a family physician, your unique perspective, relationships, and adaptive capacity are crucial to improving the health care system. By embracing your capacity to lead, you can help drive meaningful change and shape a better future for patients and health care professionals alike.