Episode 8: Caring Inspired Leadership with Joshua Hartzell, MD
Rahul
Welcome to Learning to Lead, a podcast about leadership, teamwork, and reimagining healthcare. This podcast is for learners, educators, and healthcare professionals interested in building leadership skills in a supportive community.
We are your hosts Rahul Anand, Maya Doyle, Peter Longley, Amber Vargas, and Brooklynn Weber.
Together we bring you conversations with emerging and established leaders, deep dives and hacks to help you become the best leader you can be.
Rahul
Welcome everyone. Our guest today, Dr. Joshua Hartzell, (MD, MS-HPEd, FACP, FIDSA) is a retired Army Colonel with a distinguished 25-year career in military medicine. He earned his medical degree from the Uniformed Services University of the Health Sciences (USUHS) and completed both his Internal Medicine residency and Infectious Disease fellowship at Walter Reed Army Medical Center. Josh has held many leadership positions, including Program Director for the National Capital Consortium Internal Medicine Residency at Walter Reed, as well as roles in Graduate Medical Education and Faculty Development at USUHS. He also deployed as a Battalion Surgeon with the 82nd Airborne Division in Afghanistan. His latest book, “A Prescription for Caring in Healthcare Leadership: Building a Culture of Compassion and Excellence,” highlights his passion for developing leaders who really truly care in healthcare and beyond. Josh, welcome to the show. It's an honor to have you here.
Josh
Wow. Rahul, thank you so much for having me and thank you for that very kind introduction. I'm definitely looking forward to this discussion.
Rahul
Wonderful. And with me as always are Pete Longley, Maya Doyle, and Amber Vargas. So let's get into the conversation and get our listeners to know you a little bit better. Josh, take us to the beginning, how did you get into healthcare, how did the journey begin.
Josh
Sure. So healthcare for me really began back in, I would say like high schoolish time period. And I had a sort of personal experience, my mom had breast cancer at a fairly young age for her and that was probably my first profound introduction into healthcare. And I had sort of been interested in science before that, but I think going through that with her really sort of led me to this like, hey this might be a a career. And then over time as I went to college and experienced other things related to health care and got to do some shadowing, I realized that this is where I wanted to sort of be with my career.
Rahul
Wow, yeah thanks for sharing that with us. I'm listening to you and reminded of Ikigai, that Japanese phrase, a reason for being. And how you found something that you really truly cared about and then as your journey was progressing, you were like, “Yeah I'm good at it, and I love doing it, and the world needs it,” and here we are.
Josh
Yeah, no I think that's true, and I think the other thing is that you know medicine was the sort of beginning of my career and that's also evolve to other things that I really am passionate about which is, you know, teaching and leading. So that that Ikigai has kind of evolved over the last 20 plus years.
Rahul
Yeah. We would love to go on that journey with you, your Ikigai, going through a time machine. So how does it go from there? So you're interested in medicine and then how do you get into military medicine?
Josh
Yeah. So when I was in high school, and really even before that, I was a huge reader. I mean I loved to read and most of what I read was biographies and history and a lot of military history. I just happened to be interested in those topics or genres, if you will, and I think that got me thinking about the military. I actually only had like one uncle who had served the full career. My dad had spent a couple of years in the military, but no one other than an uncle had spent 20 plus years. But I was interested in the military, and I also came from a very small town. I graduated with like 62 or 63 kids in my class. And so when I was getting ready to go to college, I was thinking the military is gonna offer me a lot of opportunities in terms of, you know, it's like almost like a commercial, and getting to see the world and getting to do different unique and interesting things. And again, most of my, I don't know, childhood, teen, sort of idols were people who were in the military or historical figures. So it was a nice blend. And then, you know, quite honestly the other thing was my family was, you know, we weren't poor but we certainly weren't rich, and I did the Reserve Officer Training Corps. Which afforded me the opportunity to go to a really good school and not have to pay for it, you know. And and I went to Duquesne undergrad in Pittsburgh, and then at that point my experience in the Reserve Officer Training Corps was exceptional. I had great cadre or faculty as we would call them and they really invested in our careers and helped us develop as you know not only military officers, but also students. And when it got ready to go to medical school, the Uniformed Services University, which is our nation’s military medical school, just seemed like the dream to me. Like I get to combine this, you know, being a military Medical Corps Officer with becoming a physician. And fortunately, everything worked out that I got accepted there and then was able to go to school at that school.
Rahul
Wonderful. Yeah, those early experiences and the role models you meet early on are so formative. Like they really define how you think of the field and what that quote unquote dream place looks like to you.
Josh
The other thing I would say, and I do this with one of the classes I teach for leadership, is that you know a lot of those early experiences, whether it's our parents, our neighbors, sports coaches, we learn a lot of leadership from them. We may not call it leadership, but when we actually reflect back on why we do certain things we do as leaders, it's because of those early experiences and how they shaped us. And sometimes that's shaped us in a good way, and other times it's shaped us in a way that maybe we need to adapt or adjust. But I was really fortunate that I had some very remarkable leaders early in my life that I think shaped a lot of how I think about and approach leadership.
Rahul
Yeah, that's a great point. So then how does the journey go on from there? You get into Uniform Services University, and then how do you get in from there to your first quote unquote leader position? Like take us through the journey where you first see yourself as a leader in healthcare.
Josh
I think when I was a student, I mean we talked about leadership, but I didn't, at that time at least reflecting back, didn't necessarily think of myself sort of fully as a leader. I think during residency is where this transition started. And I was very fortunate to have a Residency Program Director, Greg Argyros, who I interviewed for the book, who really empowered residents. So and we also had another faculty member I remember distinctly, his name was Keith Posley, who I believe still works at one of the Veterans Affairs hospitals in California. But they really empowered us to make changes in our Residency Program. And I think that was sort of this shift of, I'm not just here as kind of a participant, which I was, but hey, we can lead and make change in our program. So those were some early routes. And then, you know, I was blessed with the opportunity to be Chief of Medical Residents for our Internal Medicine Residency and that was a clear, distinct leadership role. And at the time, there was only one Chief Resident. We had 40 plus residents within our program, so I had the opportunity for a year to really be immersed early in my career, as someone who was leading other residents, interns, rotating medical students. But also leading up to our faculty and hospital leadership, in terms of getting what we needed to support our residents. So I think those experiences in residency allowed me to see myself as a leader and then that just sort of evolved over over time.
Rahul
So, what I'm hearing is that it was when you were a resident that the seeds of quote unquote agency were sown. That yes, we can make changes to make our lives and of those around us better. And then those propelled you to the next role, more formal, which was a Chief Medical Resident.
Josh
Yeah, absolutely. And I think that idea of going both with formal leadership title positions, but also informal roles. And we lead from both of those positions. And it's part of the reason why I love that Amber is on this call, right, is is she's already doing this in Med School. And I think as I've become more senior, I've tried to look sort of back and say, “Hey, how can I help medical students lead from where they're at? How can I help our Interns and Residents lead from where they're at?” And just sort of bring that to the surface so that they see themselves as leaders. And as you mentioned the word “agency,” I think that's critical, right? That they're here, and their input is valuable and that they can take the reins and lead things. They can make things better for themselves, for their classmates, for our healthcare organizations. When I was Program Director at Walter Reed, when I met with our new Interns, I would always tell them, “Look you're all coming from across the country. You're coming from different hospitals, different healthcare systems. I can assure you, without a doubt, you are doing things, you've done things, better than how we do them here. Like you just have to, there's so many of you, so many different experiences. You can make us better by teaching us those lessons, teaching us new processes.” And really sort of planting that seed for them from, you know, these are Interns, but day one, hey we expect you to lead, to have agency, a say in what you do and help us get better.
Amber
Thank you for sharing your story. As you were speaking a lot of things that you said resonated with me, in terms of like, you know, your first experiences with leading teams as a Resident. I'm curious to know, is there anything that you were exposed to in medical school or that happened during medical school that prepared you for those leadership positions as a Resident? And on the other side of the token, is there anything you wish you had done, or you wish you were exposed to in medical school to be better prepared for that?
Josh
Wow, that's a great question Amber. I think part of it for me, like I had already done 4 years of ROTC, so that was definitely part of it. And our school, like we're blessed at the Uniformed Services University, that leadership is part of the culture. This idea that you're going to lead, and that we're going to teach you how to lead, that's part of the culture at the school. So I think that empowers our students to think of themselves early as leaders. And then then the question becomes, OK what does that look like? What are the skills I need? So I think partly having a culture that is supportive, you know, much like I mentioned the culture of our residency like, our goal is to empower our residents, to give them that agency, to help them figure out how to push ideas and lead from where they're at. So I think for me, it was just being immersed in that, and having prior experience that I had learned from my time in Army ROTC. Things that I wish I would have maybe done differently; I don't know that there would be. I, you know, I felt very blessed in my medical school time. I had great classmates, we had amazing faculty who listened to us, and they would take input and advice. And I think for most of us, like that's really what we need when we're in follower positions. I do think one of the things I would if I could go back now, I didn't really learn about the term “followership” and what it was to be a follower. And some of the specifics around that honestly till probably, I don't know 5, 6, 7 years ago. Lauren Weber, who was a Chief Resident of ours and now is out of the Navy, but she's really sort of an expert in followership and she taught me about it. I think if I had known those follower skills that probably would have made me have more agency. And think about like just more intentionally how I approached leading from that follower position. I think the good news is people are becoming more familiar with followership and what it means and how followership is really the cornerstone of becoming an effective leader. And also, that no matter where you're at in your career, you're almost always going to be a follower to somebody. So I think that would be the only thing that I could really think of is just knowing more and learning more about followership.
Rahul
That's a fantastic concept. So before we go ahead, just for our non military listeners, what's ROTC? And then I'm going to ask you about followership.
Josh
Sure. So ROTC is the Reserve Officers’ Training Corps so the Army, Navy, Air Force all have a program that basically pays for your college if you agree to serve, I think it's still 4 years, but 4 years after you've completed college. They have 3- or 4- year scholarships. But it's a it's a great way to go to school, get military experience, serve your country and then, you know, if you want to stay in great, and if you want to get out after your commitment is up you can also you know move on after that.
Rahul
Thanks. So let's come back to followership because a core value for a medical student or health professional student or trainee even attending in their first 5, 10 years is survival. And so the instinct is, you know, I'm doing my work, I'm doing excellent work, but I'm gonna do my work and go home. I'm not gonna get involved in all of these politics and tangles of leadership. So tell us what followership means to you and what are the concepts or elements of followership that our trainees and early career professionals can use to build these early experiences of leadership.
Josh
So to me, followership is how do I, as someone who's not in a position of leadership, support my leaders. In a simplest sense, that's really what a follower is. So Rahul, you're in charge, I am one of your followers, how do I support you and our mission so that we're successful? So I think you know there's a lot of ways you can do that. You can do that by doing your job really well. So if Amber is on a 4th year rotation and she does a great job supporting her, I'm just going to say Internal Medicine, because I think she should do Internal Medicine, but if she's on that rotation that, you know, like how does she support the interns and residents on her team so that they can get the work of the day done, so that they can better take care of patients. Maybe she volunteers to go meet with a family because they have a bunch of questions and she knows the patient really well. Maybe she agrees to write a discharge summary so that the intern and resident can go take care of something else. I think there's all these ways that we can support our leaders to make their jobs easier. And the fact is Healthcare is a team sport. So we need everybody to sort of play at the top of their game. And I think as followers we can do that I think so not just supporting your your leaders with the work you do, but if I'm Amber and I see that, you know, Josh is my attending and the way we're rounding is really taking too long, could she mention to me, “Hey Dr. Hartzel, can we, you know, think about running a different way?” Or can she give input on something else that she thinks might impact patient safety. So it's partly advocating as well. I think that's really essential for effective followers is to be able to bring up good ideas, bring up, give feedback, right, like we don't know if we're messing up if no one is willing to tell us. It also means that as leaders, we have to create a culture and environment where our followers feel comfortable telling us those types of things. So it's really a, you know, it's a 2 way relationship. But when we do it well, we can maximize our ability to care for patients, but also to care for each other in the healthcare team. I just wanted to add one story which I think is such a great example of followership. And I can't remember the students name, I feel bad about this, but several years ago we had a student who was rotating at Walter Reed. And he said one of the things he did as a medical student was at the end of each day, he gave positive feedback to the resident about something the resident had done. And the reason why he did it is because he knew that, one the resident worked hard and didn't necessarily always get a lot of positive feedback, so he wanted to basically give that resident positive feedback to put the resident in a better mood, to help that resident feel good about the work that he or she did. And of course that's not just the impact on the resident, right, because when that resident gets that feedback, how is their interaction going to be with the next nurse they interact with? Or the next patient they interact with? Or if they go home after that, is their interaction going to be a little bit better with their spouse or partner or kids? And again, this is a medical student rotating on a service and making a positive impact as a follower by thanking and recognizing the work that one of the health care team members did.
Rahul
What a great story. And in that there's something that every one of us can do no matter where you are in your training or work. That's a granular hack that everyone can use: take a moment and give positive feedback to the person who helped you that day because that's gonna make their day so much more better. Thanks for that. So let's come to the concept of caring inspired leadership. That's something that I'm learning interacting with you and reading your book. So let's begin by just starting with leadership before we go to caring inspired leadership. What does leadership mean to you?
Josh
It's evolved overtime for me. And the definition sort of that I've landed on is going to go back to your other question of what caring inspired leadership is. And to me, leadership is simply taking care of your people, so that they can take care of the mission. I think everything else we do as leaders, falls sort of under and within that. I mean it's ultimately about influence and how we get people to do things. But if I take care of you as a follower, as someone who I need to do certain things, you're going to be motivated to do them because you feel cared for. So to me, it's just ultimately, how do we take care of our people so that they can optimally take care of the mission.
Rahul
Wonderful. And so of all the ways that leadership can be done, there's many many theories, styles, you name it, why caring inspired leadership? What's so special about this brand?
Josh
So I think what I have sort of seen, and learned, and realized over time is thinking about all the leaders that like, if you ask me today, like would I do something for them? Like I, I like to refer to these as like run-through-the-wall criteria. These are leaders that we would run through a wall for if they asked us. And sort of the one thing that keeps coming back to me, that I could easily answer about those leaders, was that they cared deeply for me, personally and professionally. They wanted the best for me professionally, but they also cared for me as a person. And in some cases they cared for me and my family. And, you know, so I think when we think about, how do we get people to want to follow us? Well we can inspire them through our caring. If we take care of them, they're gonna wanna do great things. You know, we talked about the idea of how do you motivate people? Well, people are motivated by knowing that you want the best for them, and that you're going to create opportunities for them, and you're going to support them. That's what motivates people.
Rahul
Maya, you have a question, go ahead.
Maya
I had a thought reflecting on what Josh just said, and thinking about that, you know, what motivates people. And I, I've always thought about, right, that idea of sort of intrinsic and extrinsic reward of why we do things, right. And yes, it's nice to have the extrinsic reward of getting paid, and getting titles, and having those things. But that sense of doing things because you're valued. And because you're treated as if you're valued is such a crucial piece. And I think, you know, well I the 30 years I've been working in healthcare now, we've been in bigger and bigger institutions and more complex institutions, which maybe from someone on the military side, isn't so surprising. But like for me, I went from working in one hospital being within a huge network, right, and how you keep that sense of kind of intrinsic value going when you're a smaller and smaller cog and a bigger and bigger healthcare wheel, is is challenging. So just reflecting on maybe, what other things you've sort of done to be able to provide that sense of intrinsic value and reward.
Josh
Yeah that's a really good, I think, insight. And you mentioned cog in the wheel. We hear people say like, “I'm just a number on a spreadsheet. I'm a widget.” And, you know, those are sort of devaluing terms. Unfortunately, I think for a lot of us in healthcare because of the systems we've worked in, and in some cases because of the leadership we've had, it makes us feel like we are those things. We're replaceable, you know, we're only about the number of RVUs we generate. And I think when people feel valued and respected, they are going to show up motivated and they're going to do a good job. When they're not valued and respected, they'll show up and they'll do the work they have to do for the whatever period of time you're going to pay them. But I don't think that's what we want in healthcare. And I don't think that's fair to people. People want, you know, to have careers that they feel good about. And, you know, how do we do that, as leaders? I think a lot of it is reminding people of the value that they bring at every single level. One of the things I wrote about, this was actually several years ago, was that we often take for granted the amazing things we do in healthcare. I had a resident, who had kept a patient alive overnight, that had coded several times. And my initial reaction to this, because there were a couple emails of like, “Wow, what a great job, you know, this resident had done.” And my initial reaction was aren't they supposed to do that? Like that's why they're in the hospital. And then it just dawned on me, this resident kept another human being alive. And the response was simply like, “Well, that's their job.” Well, you know, that's not many people's job in this world. And you know everyone in healthcare, while this becomes routine for us, it is not routine for the people that we deal with. And that's not just coding a patient overnight. But it's having an end-of-life discussion with a patient and their family. While that might be the 3rd end-of-life discussion we have during the day, it's the only end-of-life discussion potentially that family is going to have with that family member ever. And, you know, there's so many examples of that. So I think one of our jobs as healthcare leaders is to not let the routine become routine. How do we remind people that the work that they're doing is life changing and life altering for the people that that do it. The way our, you know, cafeteria workers interact with patients and family members when they're there, has a huge impact, right. Family members there, they may have just been told they have a cancer diagnosis, they may be going to get something to eat because they have another appointment and they've got stuff stacked. And if that person treats them well, maybe smiles at them, maybe says something about like, “Oh I love your sweater,” or just something that gives them an ounce of positivity, that can make a huge difference in a patient 's life. And I think we we have to get to a point where as leaders, followers, everyone within our system, that we recognize that and we help people see the value that they bring every single day and not take it for granted.
Maya
Yeah. And every single person in our environment, right, needs that.
Rahul
Yeah. Let's say I'm somebody skeptical though. I'm not entirely convinced by hearing what you're saying. What is the evidence that this works? What are the benefits of being a leader that's driven by caring?
Josh
Yeah, and I actually recently been thinking about like sort of the term “evidence based leadership". We talked about evidence based medicine, but what is the evidence based leadership? And what I've tried to do in the book is really give not only like anecdotes or examples of things that I've seen work, but also provide data where we have data. And I think I can't quote it all off the top of my head, but there's very clear data that by doing some of these things, it improves outcomes. The other thing I would say is we know very clearly that the burnout data shows that physicians, nurses, others in healthcare, when they're burnt out, they have worse patient outcomes, they have worse patient satisfaction; we have worse retention issues, we have depression and suicide sort of at at the end of that as well. All of those things have huge costs to our healthcare system. Just to replace a physician, the estimated cost is somewhere between $500,000 to $1,000,000.00. When you think about lost revenue, severance packages, hiring somebody new, onboarding them, right. So when we think of those costs, what if we just treated people a little better? What if we invested some of that money upfront to change, you mentioned culture, I mean that's part of the reason why culture is in the title of the book. Is what if we created cultures where people actually wanted to come to work? Where they weren't burned out? Those are going to lead to better patient outcomes, the data supports that. It's going to lead to more cost effective care, the data supports that. I think the issue is is getting people to be proactive and not reactive, because a lot of times what we do is after somebody leaves, right, well we just have to hire somebody else. We need to be implementing these things much more frequently. And we need to have intentional ways of addressing, you know, some of these issues in the healthcare system and changing our system. Otherwise we're just going to see more of what we've seen, which is staggering rates of burnout. And we again, we know the data behind that leads to worse outcomes.
Rahul
So I cannot imagine that somebody who's a leader comes and begins their day and has the intention, “I do not want to care.” I would just think they care about other things and not the people. So let's just take that perspective as to what's holding people back from being a caring inspired leader driven by caring? Where is the attention going? Is it going towards getting the task done, no matter what the impact on the people?
Josh
Yeah, it's a great question. I don't know that I know definitively. And I'm only speaking from one person's perspective, although I can add some other things I've heard people say. The one thing, and I would agree with you completely, like every leader shows up every day wanting to do the best for their people and their organization. Like I truly believe that. You know, look, leadership is hard. Leadership in Healthcare is really hard. So, you know, everyone has good intentions. I think it's hard, you get distracted with numbers. People put budget numbers in front of you and, you know, if you're hospital leadership, I know this is as residency program director, every day people are bringing you problems to solve. And your day becomes just enamored with putting out fires and solving these problems. So I think that means as leaders, we have to step back from the fray, and think about, OK I'm dealing with those issues, but how do we step back and actually, again going back to that word “proactively,” proactively address taking care of our people? And this is where I think there is a little bit of a lack of understanding of what it means to take care of your people, and what are the intentional steps that I can actually do. It's interesting to me, I mean I'll meet with people sometimes and and they'll say, you know, I've never really had an effective mentor in my career. I've never really had somebody who invested in my professional development and helped me think about like, what my next career step were, and how I wanted to approach, you know, this position. I've never really had anyone give me feedback that changes my performance. So I think part of it is actually really thinking about OK if we want to take care of the healthcare team, what are those intentional steps? Because if you as a leader, have never seen them or never experienced them, it's hard for you to do that. Because we we are ultimately a product of what we've observed and learned. And one of my hopes of the book would be that we create this cadre of leaders who lead from a place of caring. So that when Amber is going through her residency, she sees them lead in that way, and she feels like taken care of, she feels inspired. And not only that, but they're teaching her how to lead in this manner. So that when she's done with residency, it's just natural for her to do these things in leadership. I think part of it is we just haven't taught people how to do this. So we need to catch up, we need to show people what these skills look like, we need to help people feel what it feels like when you have a leader who is fully invested in your career, who is fully invested in your family. I think when you feel that, when you've experienced that, you wanna give that to somebody else. You want someone else to feel that way because you know how it made you feel.
Rahul
Absolutely. What you're saying makes me think of people who I've met on my journey who have transformed me, not just helped me, you know, do something specific but changed who I am.
Josh
I would also liken it to clinical skills. If you need to learn a new clinical skill, as medicine evolves, which it does, right, you have to figure out a way to learn that. And I think it's it's also incumbent upon us, as leaders, whether we're in a titled position or whether we're leading informally, to dedicate some time to fostering our leadership development. Because when we do that, not only is it an investment in ourselves, but it's an investment in those we lead, and it's an investment in patient care. And I think part of this is getting healthcare organizations to recognize that investing in leadership development is an investment in patient care. If you want to improve access to care, patient satisfaction, you want to improve provider well-being, invest in leadership. That's going to move the needle. There's a great quote by Angela Acosta, she's one of the nurses who I interviewed in the book, and she said, “Do you know what makes happy patients? Happy nurses.” If we take care of nurses, and we treat them well and value and respect them, they will do amazing things with patients.
Maya
I would just add, Josh, what you've observed, you’re talking about nursing sort of interprofessionally, because I'm not sure across other professions in healthcare, and I'm not sure if outside of academic medical settings, that that idea of mentorship is as present for other professions. Like I managed to find myself some mentorship honestly through the physician and the nurse manager that I worked with, not necessarily within my own profession because it's not expected in the same way. And so I wonder like I think we've gotten really good at promoting mentorship as an idea, but I'm wondering how we really broaden it out. And maybe starting with our students, who go out maybe with a higher expectation. Like Amber, I think you're gonna go out in the world, and know, “I wanna find mentors,” right, that's going to be helpful to me. And I I wonder if we, how we sort of set that up more broadly, maybe across our healthcare institutions. I don't know what you've seen in your institutions, Josh, that sort of allow that for everybody, not just the physicians because I often feel that that's where the focus starts.
Josh
Thank you Maya for that comment. I think part of the reason why I interviewed nurses, and other healthcare providers, physical therapists, for the book was because these lessons are not just for physicians. I do agree with you that I think mentoring is not a common thing among a lot of healthcare professionals. I think this is actually why we see such a robust growth in coaching, paid coaching within healthcare. It's because they're not getting that type of professional development and that type of support where they work, right. So I do some coaching and, you know, it's great for coaching business, but what it means is is that we need to we need to train people within our organizations. And not only within our organizations, but look if I own a private practice, and I have people who work for me, how do I invest in their careers so that they don't want to leave, right? Or how do I invest in their careers, and they do leave, but there are 5 people knocking on the door to come work for me because they know, “boy if I go work for Josh, look what the people who have worked for him have gone on to do,” right. Like they're going to want to work for me because they see opportunity in it. They know they're going to be treated with value and respect and I'm gonna help them further their career. Yeah, I think we we have a lot of work to do, but I am excited. I think these are intentional skills that we can teach people how to do, it’s just going to take some work.
Rahul
OK so I'm going to double click on this culture of caring from a trainee and an early career healthcare professional perspective. So let's talk about trainees, what is the culture of caring look like for a trainee in the health professions when they're looking at a program? You've been a Program Director and certainly explored others as well, what does a great culture of caring look like?
Josh
Yeah. So I think, and I'll just kind of say how we set up our culture I guess as a as an example. I think one, you have to talk to the residents who are there and just ask them, “Do you feel like your program leadership cares about you?” If the answer is yes, then you could ask them, “Why?” So what does that look like for me? I think number one, when I have trainees the way I look at it is as a program we're responsible for your professional development and your personal well-being. Now you might say, “Josh, why are you responsible for your residents personal well-being? Like how can you control their personal well-being?” Well, I can't control it all, but what I can control of it, I know very well having, you know, trained hundreds of residents, that if you're struggling personally, you're not going to show up and do the best work. It's impossible. And it's the same for faculty, right. So we have to have some way of thinking about how are we taking care of people personally? Now that might mean, hey, what do our call schedules look like? Are we like working people into the ground, and not allowing them time to rest? Are we giving them weekends where they can recover? Are we giving them time off during the week sometimes so that they can actually do the things they need to do like change the oil in their vehicle or go to their own physician, right? Are we setting up schedules that allow them to take care of themselves? If one of their family members is sick or ill or dies, how do we treat them in those moments? I can assure you that no matter what else you do, if you treat them well in those moments, and you take care of them and you're like, “Hey, listen, we got you. You go do what you need to do for your mom, dad, spouse, partner, brother, sister.” They will never forget that. They will never forget how you treat them when they're in those moments. And, you know, I had a boss, Bill Schimmel, who used to say life is messy, right. And the fact is if you're a resident in a 3-year program or 4 or 5, something is going to happen in your life. So we have to support people during those times of need. That's sort of the personal side. The professional side is, look, if you're coming to my program, I'm going to have very high standards for you because I want you to leave this program having reached your full potential. If we're not helping you reach your full potential, I am failing you as a Program Director. So that means I'm going to set very high standards for you. We used to say when people would come to Walter Reed, you're not here to be mediocre. Like we're not looking for residents who are just here just to get by, right, like we have a high standard for you. But if I'm going to set that high standard for you, then I have to do things like give you the support you need to be successful. I have to give you the coaching, and the feedback, so that you can learn and grow and evolve. I might have to create opportunities for you to stretch your limits, to create opportunities that will align with your career interests and your career goals. So, you know, what does that look like? Well I've had residents for example who are interested in healthcare policy. I know nothing about healthcare policy, I won't say nothing, but like it's not my expertise, right. So how can I link this resident up with maybe a colleague or someone from a different institution to help them learn about healthcare policy. Maybe Pete. But the goal is set high standards, and then coach, give feedback, create opportunities. So that they know, when they leave, they're going to feel like number one, they're incredibly clinically prepared, that's the foundation, like you have to have the clinical skills. The second part of that is what are the other things you're really interested in? Is that teaching, is it research, is it leadership? How do we help you explore and grow and build in some of those other areas? Again, so that you feel like, man, Walter Reed was really invested in my professional development. And I think you can ask a lot of residents, “Do you feel like that's the case or not?” That will tell you the answer. But I think those are just some of the ways we would set up that culture of caring for a residency program. The feedback piece is is really challenging cause a lot of times people think, “Caring, oh that’s, it's really soft and like mushy.” Like for me to hold you accountable and tell you that you're messing up might actually be the most caring thing I do for you the entire time you're in my residency program, right. Because if I don't fix the fact that you can't interact well with others, that maybe you have some emotional intelligence that needs, you know, coaching and improvement. If I don't fix that, then I've let you down. Not only have I let you down, but I have let every single patient, every other healthcare provider that you're going to interact with over the course of your career. Like that's thousands of people, I've let them down. So if I really care about you, and I care about our healthcare system, then I have to give you that feedback. Now, I need to deliver it in a kind way, but if I care, I have to give it to you.
Rahul
That was part of your book that really resonated with me. That yes, it begins with having strong personal relationships and knowing your people. And then it builds on that by setting high expectations, and giving them the support, and the feedback, and the coaching to really meet those expectations. That's truly a part of caring because you're caring for your people and in making them excel, the mission is also getting fulfilled.
Pete
How do you, I'm just curious, because I have high expectations of myself. I'm easier on other people. But how do you hold the bar up really high without crushing their spirit, right? Without really smothering and then making them feel bad and having them cry into the corner, right?
Josh
Yeah, that's a great question as well. I mean there are limits and I think that's where like getting to know people, and understanding them, and like assessing the situation. Trying to figure out like how far you can push people. We obviously, we have this pandemic of burnout. So the the flip side of this actually, to that question I think Pete, one of the things I did a lot of as a resident, and actually do probably 5 times as much when I'm coaching or working with faculty at all stages, is getting them actually to do less. And it's by doing less, that they're actually able to concentrate their energy on some of the areas that they're really they really want to focus on. So I think it is setting high standards, and pushing and pushing knowing when maybe to back off. But also knowing how to prioritize and help people be focused on the things that are really going to be helpful for them. You know, sort of, I'm a big sports fan, and you know, how do you coach people to the edge without sort of pushing them over? Part of that is just feel. I wish I had a a great way to to tell you to do that, but I think it can also be a discussion between you and the person you're leading. Just checking in like, “How are you doing?” And, you know, and if you notice that they're sending you emails every day at 9:00 or 10:00 o'clock at night, well you're pushing too hard, right. Like that's not what we want. So then you maybe got to back off a little bit, and hold them accountable for their wellness. “Hey, look this is not sustainable. I see you're sending me emails at 10:00 o'clock at night. How do we fix this so that you can show up optimally at work?”
Pete
Wow, thank you.
Rahul
One more perspective is a lot of our listeners, trainees, early career professionals, they're leading from where they stand. And, you know, most of the time they're dealing with people who have not read your book. So what are some things they can do that are in their locus of control to contribute to a culture of caring and be a caring inspired leader themselves?
Josh
So they could just buy the book, and like recommend that someone read it. Maybe like, “Hey, this might help you Sir.” No, I wouldn't do that, it's probably not gonna go over well. I think it's a couple things, one is when you can give people feedback, and I would actually say this is an area that I wish we were all better at. Most faculty, not all but most right, like really want to be effective teachers. And they may actually be doing something that they're unaware of. They don't know how much of an impact it's having but no one has given them the feedback. So one of the things students can do is give honest feedback to their faculty about things that they think they could do better or more effective. That's one way to do it. There obviously has to be a sense of safety in that and a feeling that there won't be retribution. But most faculty, if they knew there was something they could do that would help them more effectively teach or lead their students, they would want to know that. So I think one of it is to give feedback. The other is, I think to not internalize those things personally for yourself if you're a student, right. Understand that that person means well, they're just not necessarily leading as effectively as they could, and then it has no reflection on who you are as a student. The other thing I think students can do because, we've all experienced this, is keep track sort of internally for yourself, what is it about really effective teachers that I like and that I want to do when I have that opportunity? And what is it that I've experienced that I don't want another student to ever have to experience this again? To not perpetuate and carry those traits on because I think too often what has happened in medicine is that we've had those experiences, but that's what we've observed and seeing and then we end up doing the same thing when we're in those positions. So I think having this awareness of those things and recognizing that there is a different way. Hopefully that's going to allow us to break some of this cycle of, “Well that's just how I was treated as a student or a resident or junior faculty.” We can lead in different ways when we're in those positions.
Rahul
Thanks, that last bit is such a great piece of advice. I remember when I was in my surgery rotation in India as a medical student, that's the first thing my surgery chief resident had told me. That in the year ahead, you're going to meet many people, and some are gonna be role models and teach you how you should be. And some are going to be the exact opposite and teach you what you will never do to anybody else in the future. And I think that's an important piece to say it because we don't want to be the person who says, “I had to do that, so you have to now as well.” We certainly want to learn those lessons and then do the best to others where it's in our locus of control.
Josh
Totally agree. And when I was the intern director at Walter Reed, when I met with the interns, I would exactly say that to them. “Watch everybody because in a year you're going to be a resident. What are you learning by watching that you can do or not do, that will help you be a more effective clinician, teacher, leader just simply by watching.” It's like one of the cheapest forms of leadership education we have is observing, reflecting, and being intentional about what we put in our tool belt and what we don't in terms of leadership or teaching for that matter.
Rahul
One other thing I would add is the interprofessional aspect, just from my own experiences. When I was in the US early on as a trainee and had very little social support, sometimes when it's not expected, acts of caring are just the most memorable and will live with you forever. So I will never forget like the nurses at the nursing station who knew that I had not had lunch or dinner that day and would like give me a little bit of whatever they had. And, you know, these are little acts of caring and when they are across professions or across hierarchies I think they stand out even more.
Josh
Yeah, I love that example actually. I remember very distinctly being a resident, you know, and doing like night shifts and when the nurses would invite you to eat with them like that was the best. It really made you feel like you were part of that team, that you were together and that they were, you know, there to help you. And I think we we miss opportunities sometimes just to go up to somebody and say, “Hey, listen, I know you were taking care of Mr. Smith, and Mr. Smith is like a really challenging patient. I know how mad he gets. I saw how he was treating you. I just want to say how impressed I was with how you kept your calm and like you treated him so well and you got him, you know, sort of settled. Like I don't think I would have been able to keep my cool like that. Thank you so much for doing that.”
Rahul
Yeah, and this is after the event feedback. Sometimes I think even making that warm introduction to the patient or to the trainee for another health professional goes a long way because, you know, they may not know the other person, and do not have a relationship, but you do. And if you speak about them in a positive way, that's authentic, then it really goes a long way to build that relationship on a positive note. And what goes around comes around too.
Josh
Yeah. And I think to speaking positively, it reminds me of one time we were getting ready to go have a family meeting with a patient. And it was really related to a swallowing issue and, you know, what foods they can eat or not eat and aspiration. And we were getting ready to go in and fortunately we had the speech language pathologist there who would, who knew the patient. And I really, I sort of looked at team, and I'm like, “We're going to let you know this person lead this discussion because she is the expert. She knows this stuff way better than any of us do. So we want you to lead this discussion, right.” And I think in healthcare this happens all the time. Like I don't know physical therapy as well as our physical therapist does, I don't know whether you're safe to go home or not. I can make a judgement, right, but this is what they do for a living. And I think you're right, like by recognizing that, and showing, and pointing out to the team, pointing out to others, like, “Hey, this is the real expert.” Or “We're going to listen to you.” Again, it just goes back to this simple concept of do you feel valued and respected for the work you do.
Pete
Oh that's great. Hey Josh, I'm curious, I was been reading a little bit, and trying to distill or reflect on like your personal experiences, who you are, your purpose, your values and, you know, differentiating that from the organization's values, societal values, stuff that's all floating around in your head. How do you know what's true? That's really yours compared to everything else. That's like, well, do I really have integrity? Is that a value, is that mine? Or is that really cause Rahul said it and that's what's stuck in my head.
Josh
That to me, goes to us really spending some time thinking about that question. And, you know, I have a chapter on this in the book. But this is one of the exercises I like to do when I'm teaching about leadership is a values exercise, and helping people really spend time and think about, “What are my values?” And not just do it like that day, that one time, and then go about your life. But, you know, write them down, and then ask yourself at the end of each week, “Have I lived out these values?” Right, like, “What is most important to me?” And I my hope would be that if you do that, and you're intentional about it, that you go back to those. Then you are sure what your values are. Why is this important? Well because Pete, when I have to make a decision, if I don't really know what my values are, what do I use to guide me, right? I mean I can use logic, I can use, I mean we make lots of decisions in medicine, right. But some of these decisions come down to internal values that drive us. So I think spending time on those, and really being clear for you, can help you make decisions.
So I usually think of values as like my compass. They're going to keep me on the path I need to be on in terms of where I need to go. The other thing I guess I would say about that is we can also do that with our organization. So as a residency program, we spent time talking about what our values were and what is important to us. Shockingly, like right, “caring” was one of those values. So how do we as a residency live out that value of caring so that people know about it. And do we talk about it? Because, you know, we talk a lot about culture, and how do you build a culture, but this really has to be an intentional process. If well-being is important to you and your culture, anytime you see somebody doing an act that is supporting well-being, you should try to highlight that. And remind people, “Wow hey, Rahul, listen, yesterday I saw you walk by and you saw Pete at his desk at like 6:00 o'clock.” Number one, neither one of you should have been there, but you saw Pete, you're like, “Hey, why are you still here? I know that you need to be home for something. You need to get out of here, go home.” And if I know that, then I go to you and like, “Hey, Rahul thanks for sending Pete home. Like that's a great example of upholding our value of well-being.” We need to talk about these things and make them intentional and not just like some Internet slogan, or something you see when you walk in the elevator and you're like, “Oh, those are our values? Well you wouldn't know it by the way people treat each other.” But you need to live them out and make them real. But I think as an individual leader, to get to your initial question, we need to spend some time thinking about this and, you know, writing them out and then holding ourselves accountable for living those values.
Pete
Great, thank you.
Rahul
Yeah, and the hardest part is when some of our core values clash with each other. You know, when like number one is family, and number three is service, and when they clash with each other, that's really really hard. And as Pete brought up, when your personal values might clash, or you know, get repeatedly violated in an organization, that can really weigh on you. So it is something worth reflecting on and in the long run, on the converse, if you can match your personal values, or a lot of them with the environment you work in, or the teams you create, then that can be an area of flourishing. Especially a team where people know each other's core values and are honoring, them can really make a team flourish.
Josh
The one point maybe to both what you said Rahul, and what Pete said, is you know, we are often in very large organizations. And sometimes our values, I mean in an ideal world yes, they align with the organizational values. Sometimes they don't line as much as we would like. One of the things I like to get people to think about though is, how can you at your level, right, which is way removed, potentially, from the senior level leadership, how can you on your particular floor in a hospital, or you in your clinic, or you know, your small space, whatever that is. How can you live out your values there and create a culture that you want and that the people around you want. It may not align completely with the organizational values, but how can you at least get those within your sphere of influence as close to living out the values that you all agree on or that you individually want to see within your workplace.
Rahul
Big lesson, bring it back to what's in your locus of control. What can you control? Excellent. So one of the biggest things I'm taking away from this conversation is that being a leader who's driven by caring can really make you more effective, as well as more connected. And that caring is not just about personal relationships but it's really about setting high expectations, and then supporting the heck out of your people to help them meet those high expectations and excel. Josh before we close if there's one message you hope listeners take away about leading with care what would that be.
Josh
It would just be what you just said. Which is that when we lead with caring, and people feel cared for, they will show up and do amazing work. So if we can intentionally lead, in the book you know that's the whole purpose of the book, is to give prescriptions or ideas about what does this actually look like? What can I do? If you show up that way, it can ignite our cultures to be more effective. There's really no greater return on investment than investing in your people and investing in them with a way that shows you care for them. These are proven strategies that are going to help people be more effective. Not only professionally, but the the better we feel at work, that leads over to how people feel at home. So you know I think these are strategies that are going to help people personally and professionally.
Rahul
Love that Josh. Josh, what a great conversation. It's been fantastic having you on our show and I've learned a lot from this conversation about leading with care and I hope that our listeners have as well. I'm sure they will. For anyone who wants to keep learning from Josh, his book A Prescription for Caring in Healthcare Leadership is available on Amazon, Barnes and Noble, and wherever books are sold. If people want to keep up with you and what you're putting out Josh, what are the best ways they can keep in touch?
Josh
LinkedIn is definitely my primary venue at this point.
Rahul
Thanks for that. Well, thank you again, it's been a joy. And to all our listeners, thanks for tuning in until next time take care and keep leading with care.
Brooke
Thank you for listening to our show. Learning to Lead is a production of the Quinnipiac University podcast studio, in partnership with the Schools of Medicine, Nursing and Health Sciences.
Creators of this show are Rahul Anand, Maya Doyle, Peter Longley, Amber Vargas and Brooklynn Weber.
The student producer is Brooklynn Weber, and the executive producer is David DesRoches.
Connect with us on social media @LearningToLeadPod or email us at LearningToLeadPod@quinnipiac.edu.