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Machiavelli Is Out. Here's How to Lead in Medicine

Op-Med is a collection of original articles contributed by Doximity members.

There comes a point in every resident’s training when, at the stroke of midnight on July 1st, they magically transform from “junior” to “senior.” With this change comes new responsibilities for teaching, mentoring, and managing. Earlier this year, the transition happened to me — and it’s made me think about the kind of leader I want to be.

The traditional view of the physician’s role is rife with hierarchy; doctor at the top, above midlevel clinicians, nurses, and patients. Historically, as a trainee goes through medical school, residency, and fellowship, their place in the order of authority is clear and strict. This was especially true in surgical fields, wherein the Machiavellian approach to leadership ruled, as stereotyped in countless books, movies, and anecdotal stories (think Dr. Cox in “Scrubs,” half of the characters in “Grey’s Anatomy,” and the 2013 gem “Do No Harm,” wherein a neurosurgeon is literally overcome by his evil alter ego). The underling trainee in this model is motivated by fear of a dressing down, speaks only when spoken to, and never contradicts their superior.

After my own experience in training, however, I think the paradigm is shifting — and for the better. 

Lately, the most common question posed by prospective residency applicants to current residents is about the relationship between attending physicians and current residents in the program. The dynamics of leadership are clearly on applicants’ minds, and I can only assume that what they are looking for is a place with less “old school” rigidity. When I’m asked this question, I can say with absolute honesty that there are no staff members I feel uncomfortable talking to. In fact, I always feel that my contributions and concerns are at the very least listened to, if not actively influential in the plan of care. Conversations are candid and open, like those between colleagues rather than a strict superior-inferior relationship.

That said, there is still a recognition of expertise and authority. When residents are transitioning into leadership, our program director asks that they read a book called “Leaders Eat Last,” which looks at why some teams are successful and others aren’t. In good teams, leaders put their team members first, often at the expense of their own comfort or success. I have seen this manifested in real life, and it leaves a lasting impression. I have developed a deep respect for the knowledge and experience of the senior residents and staff members I have worked with, deepened only by their openness to conversation and ability to admit their mistakes. The people I admire the most are those who I know will answer my call whenever it comes, and who will step up and show up when it matters. 

As I took on leadership roles after training, I had to think about how to incorporate the traits of the good leaders that had been my role models. How do you foster respect from less senior colleagues without turning that into intimidation? How do you motivate people to be independent and proactive, but also willing to ask for help or admit mistakes? These are the guidelines I’ve developed:

1) Set expectations. The best teams I have been a member of started with clear expectations, explicitly laid out (e.g., which parts of procedures I could expect to do, and which they needed to be responsible for). If I was prepared, I would get more opportunities. Good chiefs of services sat down with each member of the team at the beginning of the month and talked with them about their role. The most junior member? Make the list. Midlevel member? Teach the interns. Fourth-year? Be the right hand. Simple. No guessing or mind reading.

2) Always answer the phone. The most terrifying experience as a junior on call was to be on call with a senior who you knew would be less than helpful if you needed them. You were on your own. By contrast, a “good” backup was someone who would not make you feel bad for calling (it is their job, they shouldn’t make you feel bad) and would show up when you needed help. A good senior gave clear responses to questions but didn’t micromanage. Just knowing someone was there in your court was empowering. When I started backup call, I endeavored to tell the junior to call me, to answer the phone without grumpiness regardless of the hour, to talk through plans but also give specific direction when it was critical for patient safety. I tried to help them learn to swim without throwing them into the deep end.

3) Recognize the efforts of others. So much of medical training – and life – focuses on your weaknesses and failures. The leaders that stick in my mind are those who take the time to acknowledge the successes and work of their team members. I want to work hard for the leader who said, “Seriously, you’re doing a great job” during the week I was responsible for the sickest patients while half the team was on vacation and everyone kept trying to die. I stood up a little straighter when they said they let me handle a difficult airway because they knew I could do it. Now, in turn, I try to thank the other members of my team for knocking out tasks on the list, shout them out when they handle a difficult situation well, and talk openly about how their skills have improved.

4) Do the hard things. The hardest part of being a leader is managing people who fail to meet expectations, or, worse yet, are actively disrespectful. As a person who does not love confrontation, I struggled with this. The leaders I saw in training bit the bullet and were willing to be uncomfortable when issues needed to be addressed. These are the people who made the phone calls when you, the very junior resident, were getting nowhere; the people who talked to the difficult patients or families to spare their subordinate. Recently, my willingness to do the hard thing was put to the test. A medical student on my team was openly aggressive and disrespectful to me. I will leave the details of that interaction vague to preserve anonymity, but suffice it to say I set the line and made it clear that the behavior was not acceptable without being angry or aggressive in kind. Several of the more junior residents witnessed the interaction, and I was incredibly gratified when one of them came up to me after and said they hoped they would be able to react as I did when they were in a senior position. 

Good leadership is something that can be modeled — and these are the things I’ve seen good leaders do. Machiavelli is out. Ruling by fear is out — hopefully for good.

Who modeled “good leadership” for you — and how? Shout out your role models in the comments!

Heather is a fourth-year otolaryngology – head & neck surgery resident at the University of Kansas Medical Center. Her clinical interests include patient communication, medical education, and facial plastic and reconstructive surgery. Heather is a 2021–2022 Doximity Op-Med Fellow.

Image by ProStockStudio / Shutterstock

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