EP. 144: ALL PHYSICIANS ARE LEADERS

WITH PETER ANGOOD

Feb 12

WITH PETER ANGOOD, MD

The President of the American Association for Physician Leadership shares his experiences as a trauma surgeon and why it is essential that all physician learn the habits of leadership.

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Episode Summary

Physicians are trained to diagnose and treat disease, but they're not always taught how to lead. Yet in an era of increasing administrative burdens, evolving healthcare policies, and growing physician burnout, leadership skills have never been more essential. How can physicians reclaim their voices in healthcare decision making? What makes an effective physician leader in today's complex landscape?

Here to answer these questions is Peter Angood, MD, President and CEO of the American Association for Physician Leadership, an organization dedicated to empowering physicians with the tools and strategies to lead successfully. With years of experience as a trauma surgeon and a leader of patient safety at organizations ranging from The Joint Commission to the World Health Organization, Dr. Angood has thought deeply about expanding the role of physicians beyond the bedside.

Over the course of our conversation. Dr. Angood first takes us into the mind of a trauma surgeon dealing with split-second life-or-death decisions, then discusses the evolving role of physician leadership, trends that concern and excite him about modern healthcare, and concrete skills all clinicians can develop to lead meaningful changes.

Peter Angood, MD, is currently CEO and President of the American Association for Physician Leadership (AAPL). Previously, Dr. Angood was the inaugural Chief Patient Safety Officer at The Joint Commission, Patient Safety Adviser to the World Health Organization (WHO), Senior Adviser for Patient Safety at the National Quality Forum, and Chief Medical Officer for the Patient Safety Organization of GE Healthcare. Prior to these roles, he enjoyed 25 years of academic trauma surgery practice ranging from McGill University in Canada to the University of Pennsylvania, Yale University, and Washington University in St. Louis. Dr. Angood completed his academic career as a full professor of surgery, anesthesia, and emergency medicine.
He remains actively involved with a variety of healthcare advisory groups and professional societies, has served as President for the Society of Critical Care Medicine, is on the National Advisory Council of the Agency for Healthcare Research and Quality (AHRQ), and is a well-recognized international speaker and author with 250 publications. His recent books, Inspiring Growth and Leadership in Medical Careers: Transform Healthcare as a Physician Leader (2024) and All Physicians Are Leaders (2020), have been critically well received.
In this episode, you will hear about:
• 2:23 - How Dr. Angood became drawn to a career in medicine
• 5:58 - The day-to-day experience of a trauma surgeon
• 18:39 - How Dr. Angood expanded his role beyond the operating room
• 21:44 - The role of the Joint Commission
• 23:02 - Finding the balance between patient safety, teamwork, and physician autonomy
• 31:37 - Dr. Angood’s leadership philosophy
• 41:40 - Why all physicians should be seen as leaders
• 43:45 - Dr. Angood’s advice for how to be successful in a leadership role
• 53:57 - Dr. Angood’s advice for new clinicians
Henry Bair: [00:00:01] Hi. I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest Questions.
Henry Bair: [00:01:03] Physicians are trained to diagnose and treat disease, but they're not always taught how to lead. Yet in an era of increasing administrative burdens, evolving healthcare policies, and growing physician burnout, leadership skills have never been more essential. How can physicians reclaim their voices in healthcare decision making? What makes an effective physician leader in today's complex landscape? Here to answer these questions is Doctor Peter Angood, president of the American Association for Physician Leadership, an organization dedicated to empowering physicians with the tools and strategies to lead successfully. With years of experience as a trauma surgeon and a leader of patient safety at organizations ranging from the Joint Commission to the World Health Organization. Doctor Angood has thought deeply about expanding the role of physicians beyond the bedside over the course of our conversation. Doctor Angood first takes us into the mind of a trauma surgeon dealing with split second life or death situations, then discusses the evolving role of physician leadership, trends that concern and excite him about modern healthcare and concrete skills all clinicians can develop to lead meaningful changes.
Henry Bair: [00:02:16] Peter, thank you for taking the time to join our program.
Dr. Peter Angood: [00:02:20] Oh, thank you for the opportunity. I look forward to the conversation.
Henry Bair: [00:02:23] To kick us off, can you set the stage for us and tell us how you came to the world of medicine?
Dr. Peter Angood: [00:02:29] Yeah. You know, I was recognized as a young boy teenager, as someone who seemed to care a lot about other people and was always sort of reaching out to others and whatever environment I was in. And so my family and friends sort of nudged, you know, you should probably go into medicine. And that's kind of how it went. I'm also of that generation, you know, where your parents say, you know, you got to get a real job that can pay. So, you know, my son, the doctor kind of philosophy came through. But, you know, that was the driving force, I think, originally. And, um, for me, I think it's worked out okay. I've enjoyed the career, and, uh, it's still a great profession. It's an honorable profession. And I'm happy I'm here.
Tyler Johnson: [00:03:15] And can you walk us through a little bit? So. Okay, so that drives you to go into medicine. Once you were in medicine, what path did your journey take? How did you decide what you wanted to do in terms of your subspecialty?
Dr. Peter Angood: [00:03:28] You know, it's interesting when you go into medical school, you're most folks are undifferentiated. And I was kind of undifferentiated as well. And I was also encouraged. Just keep an open mind, Peter. Just keep an open mind. And so I knew upfront fairly quickly. Well, obstetrics gynecology pediatrics was not going to be my deal. That was pretty fast. It was a little bit interested uh, In internal medicine, not so much. Psychiatry a little bit. And then out of the blue, surgery jumped out at me where I went to medical school in Midwest Canada. I had the opportunity to go out to a rural environment, and I hung out for about a month, six weeks, with a rural general surgeon. And for some reason, that just clicked for me. You know, it was tangible thought processes. You could do something to the patient to help them get better real fast. And so all of a sudden, everything else just disappeared. So that was kind of the thought processes in there. And then similarly, as I went into this general surgery training, at least in the Canadian system where I grew up in, the approach for surgery training at that time was in your first couple of years, you rotated through all the different subspecialties.
Dr. Peter Angood: [00:04:47] Therefore, I again kept an open mind and thought, well, you know, this general surgery is surgery is okay. At one time, I thought maybe I'll be a neurosurgeon. Hey, plastics is pretty cool. You know how it goes. You go rotation by rotation. And there was an arrangement at the time between McGill University, where I was doing my training in the University of Miami Jackson Memorial, and I was able to, in my fourth year, go down to Miami before I finished my residency and got exposed to the whole trauma surgery and surgical critical care environment. Now this is early mid 80s, right? So the cocaine wars were going on in Miami. I was a young guy. I was in surgery. So there were days when we were processing 25, 30 cases a day and operating on half of them. So I thought this was really cool. So, so from there, it kind of became, all right, I'm going to do the trauma surgery and surgical critical care routine, then went back up to the McGill system and closed out my residency and took it from there. So that was the the spontaneity of it all.
Tyler Johnson: [00:05:58] So I'm a medical oncologist and so I work hand in hand with surgeons. Right. I am a GI oncologist, so I work mostly with colorectal surgeons and hepatobiliary surgeons. And obviously, I don't mean to imply that those kinds of surgeons can know every detail about how a case is going to go. Of course they can't before they go in, but it is the case if I have a patient that I'm sharing, let's say a patient with pancreas cancer, and I share that patient with a surgical oncologist, and we give them some chemotherapy, and then it looks like the tumor is resectable. The surgical oncology team will sometimes do two or 3 or 4 different scans of the same organ over the course of weeks or even months to do this as minute and detailed of surgical planning as possible. Right? To the degree that it's possible to have 3D vision or x ray vision, they're trying to have that so that they can prepare for every anatomical detail of the surgery as much as possible. And so with that sort of as background, I have to say that one of the things that is just I mean, that kind of surgery sounds scary enough to me, right? Like the idea that you do all that planning and then have to go in and encounter whatever surprises may come up when you're in the O.R.
Tyler Johnson: [00:07:13] and the patient is open on the table. But from my little understanding, which is very little of trauma surgery, but often, you know, you have an emergent case and you just have to go in and figure it out when you're there, right? Maybe you have a very brief CT scan or x ray or something that's come while the person is coming in the door, but if they're crashing, you may just have to effectively go in blind and try to find and fix it while you're in there. Tell us a little bit about, first of all, why would anyone want to do that? Because that sounds terrifying to me. And secondly, what is it like to be in there and doing that when you have patients whose lives are literally depending on both your ability to figure out what's going wrong and then how to fix it in real time.
Dr. Peter Angood: [00:07:58] Well, just in your commentary there, you've demonstrated a deeper knowledge of surgery than you care to admit. So thank you for that. But part of general general surgery is elective. And so it's very often like what you describe. You know you know you're going to go in you know you're treating this problem. And this is kind of the the process of which you go through. And yeah, each case is unique and all those sorts of things. But what I found about the trauma surgery to be highly appealing, one, you never knew what was coming in each day. So there's that piece and I enjoyed that variability. And then when the cases did come in, there was the rapid thought processes. And it challenges you in terms of going through the rapid thought processes of trying to make the Diagnosis in, you know, 15% of the cases or thereabouts, they're actively trying to die on you. You've got to work fast. And so the challenge of getting them into the trauma bay out of the trauma bay up to the Or is stimulating enough. The whole team's got to work together. You've got to be coordinated. Sometimes you wind up doing procedures in the emergency department just because you know someone's that actively trying to die, especially with some of the penetrating injuries, etc.. But then when you're up in the Or and again, it's team based care, you've got to have an anesthesia team, a nursing team that are all highly coordinated with you. It's not only that rapid decision making, but then you've got to go find the body parts that are giving you all the issues. And so you are in all of the anatomic areas, but not in planned, plan coordinated elective surgery types of ways.
Dr. Peter Angood: [00:09:50] And so that part is also exciting in terms of trying to make your diagnosis figure out where the problem is. Try to get through the anatomy in such a way that you've got it figured out, and then you can decide, okay, now what are we going to do with this problem? And sometimes you're in multiple body parts and body regions in the same or case you might be in the chest, you might be in the abdomen. You got to do some stuff down in the pelvis. And all of that is intellectually challenging but technically challenging. And then coordinating the team to try and get that patient off of the table and then out into the recovery room, or more typically in that setting into the ICU and then continuing on with that. So that uncertainty, what's coming in each day, that rapidity of decision making, and then that rapidity of technical challenges in non-elective surgical planes or surgical fields, that can be very satisfying in terms of, hey, we did this. We did it well. Patients survived and get a good outcome out of it. Sometimes, though, patients come in that far advanced in their demise that no matter what you do, they wind up dying on the O.R. table, and that's deflating for everybody in the room. You know, we tried, but it just didn't get there. And, you know, as a medical oncologist, you know that feeling, right? You've tried everything for some patient with a bad oncologic disease, and you don't get them out in a way that they can have a better life. So there's pros and cons to that whole scenario. It's very satisfying in some ways, and it can be very deflating in others.
Tyler Johnson: [00:11:31] So I have to ask though about the and this might sound like some sort of a backhanded, I don't know, question of surgical trauma or trauma surgeons character or something. And I don't mean it that way at all. But I genuinely like I remember when I when I first became an attending. Right. So we have to remember that I've done three years of general internal medicine training and then another three years of oncology training, right? So I had been around chemo orders for a long time and diagnoses and regimens and whatever. But when I first became an attending, I became almost obsessed with the NCCN guidelines. Every time I would see a new patient, and if I was going to start them on chemo, I would like make sure that I had double checked their staging. And then I would make sure that I, you know, had like the chapter and verse from the right page of the NCCN guidelines to make sure that I knew what the chemo regimen was. And largely this was like a psychological safety mechanism because I was so worried, like my worst nightmare was that I'd give chemo to someone, it would go terribly wrong for whatever reason. And then I would look back and realize they didn't need chemo or they needed some other chemo or they, you know, whatever.
Tyler Johnson: [00:12:34] But all of that is to say that, I mean, as you sort of alluded to, there is no question that as a medical oncologist, my patients get incredibly sick sometimes because of the underlying cancer, but sometimes because of the chemotherapy we give them, right? They have terrible side effects and it can even be life threatening. But for my psychology, the saving grace is that I always have time and I always have a little bit of a remove. Right? I can sort of take a couple of days. Almost always. There are exceptions, but almost always I can take a couple days. Think about it, double check, discuss with colleagues, whatever. But if you're the trauma surgeon and as you put it, there's a person who comes in the door, the door and they are dying on the table, and you're either going to save them right now as the person on call or you're not. How do you develop the kind of confidence that is needed to just plunge in to an exsanguinating abdomen, or a tension pneumothorax or like whatever the thing is, and just do that. It makes my palms sweat to think about it.
Dr. Peter Angood: [00:13:41] Well, you're very kind. Um, you know, I was tempted to say, well, you make a really damn good internist the way you described yourself, but, you know, but part of it is, is the personality differences in your way. You're highly detail oriented. You're very patient, focused, and you have a way and a process that you go through in a different sort of way. The trauma surgery and other types of surgery, too. You know, you've got to get your your content knowledge and you've got to certainly know what your options are depending on what the situation is. And then you've got to have a certain amount of technical skills that you can implement given whatever that situation is. And so for many of us who get better at it, you've kind of pre-thought some of these scenarios. Okay. You know, stab wound to the front of the of the chest. It's probably in the heart. You've already thought that through. What you're going to do, you know. Penetrating injury that's gone through both the abdomen and the chest. You know you're going to start in the chest, then go to the abdomen, those kinds of things. So you've got that in the back of your mind. But then yeah there is a certain skill set of rapidity of thought process, rapidity of decision making and then implementing the technical approaches and all of that. And, you know, part of it is, is, I think, just personality traits that go into that, that like that challenge, part of it is just having the confidence that you evolve through your training program and your exposure. But then it's also what you've prepared yourself for through your reading, through your learning, attending conferences, hearing others stories. So, you know, it's it's the uncommon time that you truly are totally out of your depth and never seen this, or you don't know what you're going to do. You may not ever have seen it, but you probably know what you're going to do.
Henry Bair: [00:15:47] It's interesting because Tyler is an internist by training initially and then in medical oncology. I'm in ophthalmology, so I am primarily it's ophthalmology is sort of half surgical, half medical. Yeah. Yeah. But I would say 60, 70% of what we do is probably surgical intervention. And it's so different. Like hearing how you talk about opening up the body in the emergency room, going in blind, operating on multiple multiple organ systems at a time. You know, compared to, you know, the eyeball when you do intraocular surgery, you're operating inside a grape that's measuring about 23 by 25mm, right. And it's very different. And then just the difference in real estate that you're covering compared to what we do is so different. And there are relatively much, much fewer true ophthalmic emergencies where you need to take them to the operating room right now. You know, even with like a retinal detachment, which we consider an ophthalmic emergency, it's still you can see them tomorrow morning. You can still do that tomorrow morning. It's very rare. It's like now, you know, they're going to go blind. It happens, but to a much lesser degree than in your profession. So it's very different to just just conceptualize, even within surgical disciplines, how different we approach and think about the kinds of procedures we do. Okay. So you discover joy and fulfillment in trauma surgery. And then how does your career develop subsequently? Like do you like what kind of setting do you then practice in?
Dr. Peter Angood: [00:17:21] Yeah, I'm going to go off tangent for just a moment because you brought up ophthalmology and I'm going to make a comment about training programs because I am a patient of a retinal detachment. And so I know what you were talking about. And, uh, it was a Saturday evening, I self-diagnosed. I took myself to the. I drove myself still to the local emergency department. Ophthalmology junior resident just happened to be in the emergency department, so I got fast processed. The fellow wasn't too, too far away. And the chair of ophthalmology happened to be a retina specialist, so all the things fell into place nicely. There I am at midnight on this Saturday evening, and the needle is just about ready to go into my eye. And what is the junior ophthalmology resident do? She leaves because she has. She was at her 80 hour workweek and I'm thinking, what the heck just happened here? She's missing the best part of the whole damn thing. So and I bring that up because it comes into this whole thread of conversation. How do you get your experience? How do you get enough confidence, and how do you get so that technically you're good as well, so that when you're out there in the real world all by your lonesome, you can feel good, right? It's all about those, uh, untrustable professional activities these days.
Dr. Peter Angood: [00:18:39] So, anyways, sorry for that digression, but, yeah, you know, as I got into mid-career, both the surgical ICU environment and the trauma center environments are very systems oriented. Icus can choke a hospital if you haven't got good throughput or you're getting blocked up, the emergency goes down, the ORS go down. Et cetera. Et cetera. So I found myself thinking about how do we get better systems and processes and then a truly well-functioning trauma center, or if there's multiple centers in a city, it's systems oriented from pre-hospital care, communication coordination. Where do the patients go? Then there's that whole arrival Ed or ICU floor piece. And then there's the post-discharge care, which often includes rehab, long term care, etc.. And I found myself thinking through, gosh, if we're really going to make this work, you really need to have a better sense of systems and processes. And then my aptitude was then as well. How do you create large scale change? So as I got into mid-career, I was feeling very satisfied that I had seen pretty much all of the great trauma cases I'd operated on, most all of the great trauma cases. I didn't need more of those, and I didn't want to get worn out on that discipline clinically. And the ICU environment is, you know, it's fascinating the progress of medical science for ICU care, very slow moving, very slow moving. And so I found myself kind of stalling out on the clinical side of it from an interest point of view.
Dr. Peter Angood: [00:20:18] And so I was very fortunate I did academia. So as you know, as part of that, you do your educational stuff, you do your clinical stuff, you do some research, and then you get involved with other professional societies. I was fortunate I got I got involved with a variety of societies, but one in particular, the Society of Critical Care Medicine. I wound up being president of that for a period, and that coincided nicely with this focus on systems and processes that I was having. And so I was able to make a nice switch, and I became the first chief patient safety officer at the Joint Commission. And that was one of those enlightening moments in a career. I learned that there's a variety of significant levers and pulleys in health care that we all react to. Finance is obviously one of them. Accreditation is another one. And some of these entities are creating significant change in health care and not necessarily fully understanding health care. So that was very insightful for me. But at the Joint Commission, it was it was a fascinating time because safety was just really becoming very much on the scene in the mid 2000 there. So we did a lot of domestic stuff. We did a lot of international stuff. I got involved with the World Health Organization helping set up their safety stuff.
Henry Bair: [00:21:44] Sorry to interrupt you. Yeah, I would imagine that some of our listeners might not know what the Joint Commission is. Do you mind expounding upon that?
Dr. Peter Angood: [00:21:52] Happy to explain a bit more about the Joint Commission. So accreditation is a process by which health care delivery systems need to meet accreditation in order for them to get paid or reimbursed by Medicare or Medicaid. And it's also a way of ensuring good quality of care in the processes of care for patient outcomes. So the Joint Commission is the United States dominant accreditation agency. There's a few others out there, but it's the dominant one. And the Joint Commission has Commission has been around since the early 1940s, and so it's got a strong presence in the industry. And as well it had expanded into the international arena because comparing to the United States internationally, there aren't or weren't that many accreditation systems. So Joint Commission International is very well regarded out there as well. And so accreditation is an important influencer on how systems and processes must behave in order to meet standards.
Tyler Johnson: [00:23:02] So one thing that I think is an interesting frame through which to view part of the role that the Joint Commission plays, although I know, as you said, the Joint Commission has been around a lot longer than this, but I still think it's an interesting cultural shift, at least in the United States. So, you know, probably now maybe 20 years ago, 15 years ago, Atul Gawande gave a medical school commencement address at Stanford that then was sort of, I think, kind of more or less turned into an Atlantic article or New Yorker article, I don't remember. Later on, but it was called something like The Cowboy and the Pit Crew. And in effect, what he talks about in that address then article is that many people at, at least at the time that he was training in medicine, had come up with this notion that the idealized version of a doctor was like a then largely cowboys. Or you could now say more also cowgirls. But the idea was that it was this sort of independent, lone presence who was supposed to be able to sort of do everything and fix every problem. And that, in fact, the sort of the coin of the realm in terms of a really great doctor was precisely that they didn't have to rely on anybody else for anything, and they could just kind of do it. All right. And then he talked about in that talk that even during the time that he was training, and I think that the same is true, but even more so over the last 15 years or whatever since, is that there has been an evolution to an understanding where now the point of the invocation of pit crew in the title is that doctors and every other kind of health care practitioner function like the member of a pit crew, where the idea is not what can this one person do, but rather what can the the team, the pit crew do together? And how can you make it more efficient and safer and more reliable and reproducible and all the rest? Having said that, though, I will also say that as a doctor who has been in practice for a while and been in some hospital leadership positions and whatever, it is still the case that in my experience, even on a relatively micro level within, you know, one group or one hospital or whatever, trying to get doctors to do anything is like herding unruly and very intelligent cats, right? And in fact, many doctors bristle at the very notion that anyone should need to tell them anything about what they should do because, you know, doggone it, they're doctors.
Tyler Johnson: [00:25:27] And they trained for 15 years. And. Et cetera, et cetera, et cetera. So all that is to say that as a person who had this position of leadership at the Joint Commission and then has had other, you know, similar leadership positions in other organizations thereafter, how do you think about that push and pull between trying to institute a culture and an infrastructure that protects patient safety and encourages doctors to practice in a way that ensures quality and safety, while at the same time working with people who, almost by their very nature, in many cases, desire very deeply to be independent and not told what to do.
Dr. Peter Angood: [00:26:08] Well, you know, if we could solve all of that, we'd have it. We'd have it. It's fascinating. You know, I always say that healthcare is an incredibly complex industry. And arguably, in my mind, it's it's the most complex industry that's out there. And if you think about it, in this country alone, we're currently on a $4.8 trillion expense in terms of healthcare. About 25% of every dollar is just to manage the overhead of running the finances of it. We know we've got about a 30% waste and inefficiency. We've got about a 10 to 15% major error rate, and we've got arguably a 15% misdiagnosis rate. What other industry would tolerate that? There is no other industry that would tolerate that, right? And yet here we are. Arguably, the current era of safety and quality happened from the Institute of Medicine reports in 99 and 2000. But now we are 25 years later and we still have the same sets of issues. Yeah, we're more aware of it. Et cetera. And so a lot of that to say, it's the inherent complexity of this Of this industry. Now, the other piece in there is as you intimate, the Multi-professional team based care is evolving. It's there. Physicians need to be part of Multi-professional team based care, or interprofessional nursing, is continuing to try and elevate its training, its expertise, and its responsibilities through licensure.
Dr. Peter Angood: [00:27:45] Licensure. Pharmacists are doing the same. Obviously, the app community is doing the same. And others, you know, if you counted up how many different clinically oriented disciplines there are in healthcare, it's around 50. That includes the Venipuncture people and all those sorts of things, but they're all trying to elevate their level of training, their level of responsibility. So this multi-professional team based care is there. The clinical delivery system moves fast. We really move fast. Innovation comes at us from pharma comes from us from devices. It that comes from us, from entrepreneurs, etc.. Well, where is the medical education piece? It's not keeping pace. And so it's gradually changing. But when you look at the curricula of medical schools, by and large it's the same setup. Right. Those first two years book knowledge. Second two years. Some introduction to clinical settings is their knowledge about management. Is their knowledge about health services delivery, is their knowledge about leadership all those other kinds of things? No, it's clinically oriented. And it's fascinating as well. When you look at the list of what drives kids to go into medical school.
Dr. Peter Angood: [00:29:06] It's still I want to help people. I'm interested in the science. I want to make a change. Those kinds of things, so that altruism is still in place, but our education system still helps to drive that autonomous thinking, independent minded physician who comes out into practice. And so you're absolutely right. You get into practice, you think you're the boss and you great. When other people are trying to tell you you're not the boss, you're going to go work with this team. And so medical school and residency programs, we've got to start shifting further and a bit more assertively. But we also have to recognize all those other disciplines. They've got value, they've got validity, they've got contributions. But my last point is that at this period, that patient physician relationship is still the dominant driver in healthcare. Patient physician relationship is the dominant driver. And so yeah, the physicians should be still the most influential piece of the health care delivery system. We just have to have to shift in terms of how we fit in there, and we don't get to be the boss all the time, but we are the dominant driver in the decision making and how things evolve.
Henry Bair: [00:30:26] So this gets closer to your, you know, you've dedicated a significant component of your career to physician leadership. I think I want to explore a little bit of that because I do think, well, at least when I was in medical school and then business school at Stanford University, I think I heard that term used a lot to the point where it's not even clear to me that a lot of people who use that term know what it means, because you have like lectures, you have classes, you have books written about physician leadership, and then, you know, you listen to it and it just sounds like they're just talking about physicians doing the job of a physician. Like, are we talking about taking physicians out of the clinical context and putting them in an administrative role? Like, is that what we're talking about, or are we talking about taking leadership principles and effective communication and effective leadership approaches into the clinical setting, like which which direction is or is or is it both, or is it something else entirely? Right. So I think I do want to spend a bit of time exploring what that means to you. Sure. But, you know, first of all, you talked a lot just now from like, a more systems approach, the ways that clinicians need to perhaps rethink reconceptualize or alter the way that they think their role is in the healthcare system.
Henry Bair: [00:31:37] I'd love to hear a little bit about your own personal approach, however, in the sense of, you know, you started off as a clinician, as a surgeon, and then found yourself as you recognize these issues, taking on more and more positions. I'd love to hear. In what ways has your own leadership philosophy change evolved along the way? Like, how did you learn what it means to be a good leader? And what are some of the influential inputs that have shaped that understanding?
Dr. Peter Angood: [00:32:09] It's a great question. I'm of a generation where certainly in the trauma surgery world, it was very much a command and control type of an environment, right? As the trauma surgeon, whenever there was a resuscitation going on, you were the boss of the team. And what you said was what was going to happen. And that was the same in the O.R.. That was the same in the ICU. Yeah, there were teams around you, etc., but that was all oriented to what does the trauma chief say or do? And that even occurs in in the training environments. Right. And so again, coming through my own training, yeah, I strong ego was trained to become even more autonomous thinking, independent minded. Oh, and then I got to do this clinical setting where everybody thought I was the boss. So command and control comes pretty easy. And as you move along, though, there are certain situations that pop up where you realize, gosh, I'm getting a lot of resistance here. I'm getting some pushback. And why is that? And a big part of what I think each of us need to consider is a component of self-awareness, that when you are getting some a sense of your own frustration or people aren't quite believing what you say should be done, then you shouldn't necessarily just be bearing down harder on them.
Dr. Peter Angood: [00:33:40] Think and reflect. What is it that's going on that I might be doing that's not quite right? And so for me, as I gained more self-awareness and quite honestly, it it started to happen just as I was tailoring off my clinical arena. But then as I shifted into the non-clinical side of things and appreciated that, you know, the decision making in these other environments is much more collegial, much more collaborative takes in opinions from a variety of variety of different personalities and different job responsibilities. I had to go into and I'm still doing it, quite honestly, active unlearning of all those traits. What it represented to be a successful trauma surgeon. So the command and control piece. Yeah, it has its moments, but by and large it's few and far between. And if you follow the business literature and if you follow kind of the evolving leadership literature, that command and control, highly charismatic leadership style doesn't work anymore. It's kind of a passive strategy. So as physicians, even though we still are coming up through this autonomous thinking, independent minded training, we have to be aware that that's not necessarily going to be the environment we're working in. So we have to unlearn a little bit and start to take on some other kind of habits and traits.
Tyler Johnson: [00:35:08] So I'm so interested to hear you talking about unlearning there. And I don't mean to keep quoting Atul Gawande, but there's another article that he wrote that has always stuck with me as being so interesting, partly because I read it at exactly the right time. I think I read it like my first or second year as an attending. But he talks about how so he is a cancer surgeon, right? I think he specifically specializes in thyroid surgery. So one of the things he talks about is that anybody who has been through medical training knows this, right from about the third year of medical school. Until you finish your training, you are never not under a microscope, right? If you are on sort of an internal medicine ish path, then you have people peppering you, your superiors peppering you with questions all the time, often in front of a big group of your peers in a setting that is very high pressure and feels very high stakes. And then if you are a person who is a proceduralist, whether a surgeon or ophthalmologist or what have you, then in addition to getting peppered with questions, you actually literally have someone looking at you, sometimes literally with microscopic lenses on their glasses, watching the way that you're suturing or whatever, and critiquing you on whether your bites are too big or too small or what have you.
Tyler Johnson: [00:36:20] But then what's so bizarre is that that happens and happens and happens. It's relentless, never ending constant. And then all of a sudden you become an attending and it's like, poof, it all goes away and nobody watches you do anything and nobody gives you. I mean, occasionally, you know, maybe if you're in a trauma surgery with other surgeons or whatever, but at least as a medical oncologist, I can say that from the day I graduated from my fellowship with some very rare and frankly, sort of, you know, cursory counterexamples, you are just on your own. Yeah. And I would argue that the implicit message inside of all of that, you were talking about the command and control. I mean, you know, medical oncologists are probably not, let's say, known for being command and control type folks as much as maybe trauma surgeons, because the setting doesn't call for it in the same sort of dramatic way.
Dr. Peter Angood: [00:37:15] But you're the boss of the team.
Tyler Johnson: [00:37:17] Yeah, but the message is not just that you're the boss, but that you don't need to be questioned anymore. You don't like you have graduated to a place where it's like you are beyond questioning because, you know, people talk about doctors with a God complex. You can sort of understand, like there seems to be an implicit message that you have arrived and are educated and know what you're doing. So all of that is by way of asking what may be a funny question. You talked about having to unlearn those implicit messages, and you talked about having to be numb or re become open to seeing your own blind spots. But when I would argue that the implicit message is so powerful, like when there's such a almost a gravitational pull toward becoming kind of an arrogant jerk in some ways, who feels like, oh yes, I know everything and everyone should do what I tell them. Like, how do you cultivate not being a jerk, not assuming that you just know everything and that your decisions are beyond question?
Dr. Peter Angood: [00:38:21] It's interesting because we we see that phenomena. And, you know, I walk around saying at some level, all physicians are leaders. Partly why I say that is because our medical profession as a whole is still very much viewed as a lead profession in society. We're highly trusted. We are looked at with respect all those types of things. And so even though we don't get any leadership or management exposure in our training, society expects that leadership behavior of us. So that's one piece. But then think of just your own social settings and you're not out with your other medical buddies. You're at the kid's soccer field or you're meeting new people at a party somewhere and somebody finds out you're a doctor. The conversation changes, doesn't it? And that's that subtlety that reinforces what you're getting to is we are still at a period where when we're put on these pedestals a lot of the time. So yeah, it's appealing. If you got the right personality to kind of keep believing yourself that you should be on that pedestal. But, you know, in terms of clinical competence, fortunately, with maintenance of certification and all those trends that are out there, those are meant to be put in place to protect the public so that you're maintaining clinical expertise, clinically competent in your procedures, etc.. But what you're getting at here is the psychological side of that. And how is it that we can actually grow in new and new and different directions as physicians, because it's one of the hardest things in life to say. You know, I'm being a bit of an ass here. Your spouse may tell you you're being a bit of an ass, but they tell you that once a week anyway, so you don't believe them.
Dr. Peter Angood: [00:40:15] If you can have a good friend or a peer or part of your group, and you can have those kinds of conversations in the group, or say, hey, am I being a normal, healthy, happy person here or am I becoming an ass? That's clues that, you know, maybe I should have a little bit more self-awareness. And then for a lot of folks, you can self-adjust what's becoming, however more common is mentorship, which I sort of just mentioned. And and you don't want to mentor. That's just going to tell you, hey, you're doing a really good job, Peter. Keep up. It's the kind of mentor that's going to challenge you in your thought process. And then the next step, depending on what kind of environment you're in or what support is, is actual coaching. And the coaches aren't there to, you know, tell you what to do. It's to provide you with those challenging types of questions. You know, what are you doing in that environment? Or what are you doing with that decision making and why? It's not therapy. It's just kind of leadership and management. And so, you know, for a lot of us as physicians, as we get through training spend, that first five, ten years in practice, we've consolidated that. We're good. It's a hard shift to then back out of your behavior. Many people can do it on their own. Sometimes your spouse and family will tell you, but mentors and coaches can help you if you think you're struggling.
Henry Bair: [00:41:40] So, Peter, you sort of alluded to this, but I guess I just wanted to make it clear. Is it your belief that all physicians are leaders should be leaders?
Dr. Peter Angood: [00:41:51] So this is a definitional piece then. And when we say leaders, we tend to think of folks in formal title roles who are doing administrative work. And if that's the case, no, not every physician could should be in those type of roles. Most of us need to be trained and need to learn what leadership is and even what management is. There's very few of us that are just natural, natural leaders. But when I say all physicians are leaders, it's kind of goes back to what I was referring to earlier. We don't get trained or exposed to it. Society expects it of our profession. And so we as representatives of that profession, we are leaders. And so even if we're not in a formal title role in our practice, in our hospital, in whatever place we're working, we're still expected to be leaders. People look up to us. They respect our opinion, they want our opinion and they want our decisions. And so that's a responsibility that's new and different. The other thing in this is and it's related, believe it or it or not, only about 20 to 25% of physicians are non-clinical. So 80% of docs are out there doing clinical, 20 or so are non-clinical, and therefore they are in other elements of society. Most of them are still in healthcare in some fashion, but they are influencing the industry. They are influencing society, their leaders to whether they're in formal title roles. Excuse me, have I talked to my buddies who are in federal or state governmental agencies? Absolutely. The staff in those agencies look to the physicians to be leaders. So there's a nuance, as I say, but at some level, I strongly believe all physicians are leaders. We have the responsibility to uplift that.
Tyler Johnson: [00:43:45] So, I mean, I think that two things are true. So on the one hand, I think it's true that, as you said, you know, some portion of the of physicians do become titled leaders where they can't help but recognize that they have, you know, they're the chief or the chair or the dean or the, you know, CEO of the hospital, whatever it is. And then there are a lot of people who don't recognize themselves that way, but who, as you say, almost, you know, most physicians, especially now because almost all health care is carried forward in teams. Most physicians function in a team and are seen, at least to some degree in that team, to have some kind of leadership decision making role. So I guess my question then, is one theme that you have talked about repeatedly already is this idea of unlearning the idea that you can have a command and control. I'm in charge. Whatever I say is right. Arrogant attitude. So okay, we recognize that. Beyond that though. So one of the things you have also mentioned is that this is something that we get virtually no training in, right? Like I don't I don't think most doctors to be have a class in medical school called physician leadership or what have you.
Tyler Johnson: [00:44:54] So as someone who has studied and thought a lot about physician leadership. If you are going to try to distill down to a person who like, let's say that they finished all their training a few years ago, they're solidly on their feet in practice, and maybe now they have been given a formal administrative role, or they just feel like they're they've got their arms around the clinical part of what they do, enough that they can start to focus a little bit on other parts of their professional identity as well. And they say, well, gosh, okay, I feel like I do have a leadership role. I have something that I really need to live up to here. And then they kind of say, okay, so you as someone who has studied and observed and written about this, what would be some of the most important lessons or truths or pearls that you would distill down for what people who now newly recognize themselves as having leadership roles need to be or need to do to be successful.
Dr. Peter Angood: [00:45:50] Let me take it this way. And if you believe my premise at some level, all physicians are leaders in the medical profession is viewed as such. As we get through training in our early career stage, we resonate very highly with what we've trained as. So, you know, you're a medical oncologist, you're an ophthalmologist, etc. and that's how you would tend to identify yourself as you then move along. Inevitably, you're getting some type of managerial responsibility. And if you have the aptitude, you may wind up taking on some leadership responsibilities. Again, whether it's in your group, whether it's in your ancillary work in the community, whether it's in your hospital, etc.. And as you take on those responsibilities, the people you're working with, whether they are clinicians or non clinicians, are now judging you on your management of people and your leadership and being influential. Those skills, and they pay less attention to the fact that your medical oncologist or an ophthalmologist. So you have to recognize that shift is occurring. Hey, I need to pay attention to my interpersonal skills. I need to pay attention to systems and processes and how to influence others so we can get things done around here. So there's that one piece. The other is that self-awareness that we were alluding to earlier is recognizing, what do I need to do for myself in order to gain some better skills, whether it's the so-called softer skills of being a leader or whether it's the hard managerial skills of, hey, I got to learn accounting, I got to learn some finance here.
Dr. Peter Angood: [00:47:44] What goes on over there in HR and, you know, get familiar with all of that stuff. Do you have to be a CFO? Quality accounting guy? No. Should you be able to talk to the CFO about finance and understand? Yeah. So there's different languages that are going on out there in the management and leadership. And you need to have an awareness of what those languages are and get a somewhat conversant in them. The opposite of that is you have to recognize you've got a unique language with the clinical information. So how do you provide that information in a way that people can understand what the heck you're saying? And so it all becomes part of that relationship building communication, collegiality and respect. Big part. What I haven't mentioned yet is, and it's a hard one for physicians, humility. It's okay to be a little bit humble, but you got to respect, you know, you do have a skill set. You do have a knowledge base. They're looking at you to provide knowledge and decisions. But be humble.
Henry Bair: [00:48:51] You know, when I was in, uh, so I mentioned earlier already during this conversation, but I did the MD and the MBA at the same time. When I was in the business school, it was required of us at my business school to for all of us to take classes in accounting and finance and human resources and operations. And I remember going through initially going through those classes, and I really did not like those classes. I mean, like, I went into medical school because I didn't want to deal with numbers and math, you know, like, I like science, but not math, therefore medical school.
Dr. Peter Angood: [00:49:22] Yeah, yeah, yeah.
Henry Bair: [00:49:24] I think the pivoting point for me was for one of the final projects of my accounting class, I got to do like an analysis of the balance sheet of the Stanford Hospital. And because I was a student, I got access to some pretty interesting information. And it was just like you said, it's learning a different language. And I recognized that if I ever need actual accounting work to be done, I will hire an accountant or find an accountant. If I were ever in a practice setting, I probably have someone involved doing full time doing the finances, for example. I'd have an HR manager. I wouldn't be doing all those things, but the value that I gained from taking those classes was just some kind of rudimentary literacy. In making sense of how do you read a balance sheet? What does the financial model look like even? Or things like with operations analysis, like, how do you conceptualize, you know, how a patient comes into the hospital, gets processed, gets seen, and then leaves. Like, what is the entire process? Where are the bottlenecks? This is very basic things that once I understood conceptually what I could gain from these classes, I started seeing real world applications just even through my clinical rotations on the wards. So I absolutely agree with with what you were saying there.
Tyler Johnson: [00:50:41] And I would just observe that I think it is really difficult because it's very clear if you go to hospital leadership meetings. It's just clear that there are absolutely times when the physicians and the people on the business side are talking past each other because they speak different languages and they have very different sort of prime directives, right. So that for the physicians, it's all about what can we do for patients. And it's not to say that the business folks don't care about that, but the physicians are are almost sort of morally obligated not to care, or at least initially, to try to not care, or at least not to make decisions based on financial implications or the bottom line or the profit margin or the whatever. But the people who are running the business, if they want to, you know, keep the lights on and keep the CT scanners running and whatever else, somebody has to care about that stuff, right? And I think it does make those sorts of high level conversations sometimes very difficult, because both groups, I'm sure, sometimes feel like the other group is group is either not hearing or understanding them, or is failing to take into account everything they need to take into account. But as you said, they largely it's like almost like they come from different planets, right? They have different customs, speak different languages, different goals. And it makes for a very fraught situation in some cases.
Dr. Peter Angood: [00:52:02] Right? No, absolutely. And I would posit that it is easier for the physicians. And as long as they've got some background, education, experience and knowledge, it's easier for the physicians to make the shift to talk to the non-clinical administrators than it is for the non-clinical folks to shift and talk to the clinicians. So as a clinician, as a physician own that don't sit there and bitch at the administrators because they don't get what you're saying or they don't understand it, just assume they don't know. And you take on the responsibility of trying to help them understand the importance of this or that. But as you do that, make sure you're trying to respect their knowledge and try to make sure that you're understanding. Why are they saying what they're saying? And then the physician leaders can drive the decision making in a much more smoother, collegial way by taking the higher road. Yeah. Let's bring patient centered care in here. Let's do what's best for the patients, etc.. But it really is, I think, a better responsibility of the physicians to bridge that gap. Now there is data out there that when you've got physicians in the CEO role or you've got physicians that are running places, those places do better. And that's because they've got this experiential leadership approach. They they know health care, they know medicine, they know leadership, and they know how to make systems run. So surprise, surprise, those places outperform peer organizations that are run by non-clinical administrators.
Tyler Johnson: [00:53:57] Yeah. Well, we in the last minute or so, we hope that you'll wrap up by telling our listeners. So we gather that a lot of people, not everyone, but a lot of people who listen to us tend to be on the sort of the younger trainee side. If you were sitting next to a doctor who's just coming up through medical school, or maybe their postgraduate training or whatever, or getting ready to set up a practice as an attending, and you could give them a line or two of what you wish you had known or think is most important for them to know. What might you tell them?
Dr. Peter Angood: [00:54:29] Yeah, you know, that's always a tough type of question to answer, isn't it? Because there's just so much in all of this. I think as a physician, and that's who I'm going to talk to, given your question is Be proud of the heritage that you now represent. The medical profession is an incredibly privileged profession to be in. Historically, over centuries, we've been the natural stewards of health care. And I think with the patient physician relationship still being the dominant driver and a well educated, well experienced physician in leadership roles, physicians are the natural stewards of the health care industry. So if you're interested as a young evolving physician, get your added experience in management, in leadership. And look for ways to create the change that so very much needed in the industry, because it's a great profession and it's a great industry. Where else can you impact people's lives as much as what we do in health care? It's a privilege.
Henry Bair: [00:55:42] Well, with that encouraging, rousing note, we want to thank you again, Peter, for taking the time to join us in conversation, for sharing your life stories and your insights.
Dr. Peter Angood: [00:55:51] Well, thank you guys.
Henry Bair: [00:55:54] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show. Available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:56:13] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:56:27] I'm Henry Bair.
Tyler Johnson: [00:56:28] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.