Leadership and culture: Nurturing our immune system

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Bhagwan Satiani

Defining culture is amorphous, and mostly subjective. Being hard to define, it falls behind other measures of leadership—and team success or failure—like strategy or communication skills.

Michael Watkins, PhD, professor of leadership and organizational change at the International Institute for Management and Development defines culture as an organization’s “immune system.” He implies that if well defined, this keeps the “wrong” people from entering the group. We can assume he means people whose ideals and morals are different. Boris Groysberg, a professor of business administration at the Harvard Business School in Boston, and colleagues identify four attributes in the Harvard Business Review: Culture is shared, pervasive, enduring and implicit, in the sense that, although ill-defined, people recognize its elements and act accordingly. So, how does it intersect with us as practitioners and our society?

The culture within a practice is heavily influenced by the values to which the physicians collectively ascribe. These values (basic belief system) are not just rituals, and not necessarily part of a mission statement or a PowerPoint presentation. Some of these unwritten signals may be communicated by the incentives in compensation contracts, productivity measures such as work relative value units (wRVUs), or even promotion. Culture is much more.

The more powerful and longer lasting signals are embedded in the management of and by those of us on the people side of things. What should leadership behavior be like? Does the chair, division chief or leader of the practice group actually model the behavior against which everyone is measured? What type of employee behavior should be rewarded? What personality traits, or “fit,” should be given preference when hiring associates, employees, or selecting fellows? As an example, on evaluating fellowship or faculty/partner candidates, we are usually asked to assess for a fit within the practice. The problem is that, in most cases, leaders do not lay down principles of what that fit is. It is the leader’s job to demonstrate what is valued and rewarded.

One of the top three reasons for physicians leaving a practice is the culture. It is usually related to how people—including patients—are spoken of and treated. For colleagues looking for a job, I suggest you look at the people, not just the compensation. Do the physicians treat each other with respect? Are surgeons putting down colleagues in the presence of fellows/residents or nurses behind the backs of these individuals? Are they at ease with each other and staff? Watch unspoken signals and smiles that do not reach their eyes. Lots of eye-rolling? Are nurses and secretaries treated with dignity? Are different ethnicities and genders respected? Another hint rests in how conflict is handled. Is the leader too authoritative? What is the attrition rate like?

When I hired my first partner in private practice, I travelled to his place of work, spending a day there. I was not watching him operate because; he was from a great program. I was there to observe how he treated people around him, and how they talked about him. I felt blessed and lucky to practice for many years with three other amazing people. Our bedrock principles were few but important. That is not to say that there were no conflicts. We offered care to all, and no one asked callers about their insurance when they made appointments. I understand things are different now. For us, families came first. So we covered for each other regularly—even during procedures. When asked to assist in a difficult case, there was no hesitation or competitive behavior. All of us had total confidence in each other’s skills and would not hesitate to have them perform a procedure on us.

Recently, I heard from trainees in another program that hired a well-known surgeon as a division director based on the individual’s CV, experience and interview. Unfortunately, no one talked to people where the surgeon previously worked—other than the listed references. Too late: They discovered that an unkind and insincere personality had generated a toxic culture. This was a total mismatch with a genial, collaborative, caring culture where everyone’s view was respected. Inauthentic leaders are usually only a short-term success.

A former CEO once said, “The culture is in the how; it’s not in the performance or the results.” However, for us as a community of vascular surgeons and in the Society for Vascular Surgery (SVS), I believe it is both. An organization’s immunity has to be developed, nurtured and embedded into the culture.

Bhagwan Satiani, MD, is professor emeritus in the division of vascular diseases and surgery, the department of surgery, in the College of Medicine at The Ohio State University. He is an associate medical editor of Vascular Specialist.

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