Abstract
This chapter describes styles for multidisciplinary team leadership that can be learned and practiced. Information is presented using a unique term of whole brain leadership that integrates both the operational and the relational elements necessary to lead highly technical professional teams caring for families with critically ill infants and children with congenital heart disease. The chapter draws heavily on published information from the fields of business, health care, psychology, and interpersonal neurobiology by authors who are well published and well known in this field. The chapter provides numerous examples (some as URL-specific video links) to help illustrate various concepts.
Key Words
Leadership, Teamwork, Work-life balance, Resonance, Excellence, Team leadership, Management, Conflict management
The culture of health care creates important challenges for health care professionals. In particular, we work in a culture that is (1) hierarchical, (2) competitive, and (3) perfectionistic . Unfortunately, the tendency of acquiescing to those demands is contrary to promoting resonant teamwork, and it is important for leaders of multidisciplinary teams to understand how to create environments that flatten the hierarchy (by encouraging all members of the team to contribute and to genuinely seek the wisdom and knowledge of their colleagues); environments that encourage collaboration and cooperation (emphasizing collective “wins” and “losses” both for the immediate team and for all of us, as a profession); and environments that invite excellence (which is a process) versus expectation of perfection (which is an unrealistic outcome).
The concepts described in this brief chapter emanate from our work coaching health care leaders (both authors are certified professional coaches and specialize in leadership coaching); consulting for health care systems and working for a variety of hospitals, academic medical centers, and medical schools; and from our training and experience in medicine (one author is a practicing pediatric cardiac surgeon), business, psychology, and interpersonal neurobiology (the science of relationships). Where appropriate, we provide references. Also, many of these concepts are nicely depicted in videos that accompany our presentations (some of which are linked in this chapter), and we encourage readers to watch them as they read.
Whole Brain Leadership
There is an increasing amount of information linking leadership to a combination of task and relational skills. Information about brain function would attribute task-oriented focus to left-brain function and relationship-oriented focus to right-brain function. Interestingly, this dichotomy has been alluded to in health care as the difference between mechanical (predictable, linear) systems versus complex adaptive (unpredictable, nonlinear) systems. In mechanical systems, behavior (and expected outcomes) conforms to reproducible patterns, and emergent (innovative) behavior is discouraged. For example, a ventilator is a mechanical system, and if it does not perform according to its settings, a repair person is called to interrogate, judge, and fix the system. Complex adaptive systems are unpredictable, and emergent (creative and innovative) behaviors can be welcomed with enthusiasm. In complex adaptive systems, differences are explored to be understood and connected (joined). A growing body of literature on leadership (far too expansive to reference here, but virtually every issue of Harvard Business Review for the past several years has articles on leadership) offers a variety of leadership traits such as many listed in Box 1.1 . These leadership traits can be reorganized ( Table 1.1 ) to better demonstrate the importance of what we refer to as whole brain leadership .
Ability to be logical and realistic
Big picture orientation
Relationship focused
Strategic/past aware
Detailed
Values facts as information
Imaginative/creative
Invites possibilities
Intuitive
Task focused
Good with numbers
Values stories as information
Good with concepts
Analytical
| Left Brain | Right Brain |
|---|---|
| Ability to be logical and realistic | Invites possibilities |
| Detailed | Big picture orientation |
| Task focused | Relationship focused |
| Values facts as information | Values stories as information |
| Analytical | Intuitive |
| Good with numbers | Good with concepts |
| Strategic/Past aware | Imaginative/Creative |
To develop and promote this kind of leadership, this chapter will outline a few areas for leadership development.
Integration
We define integration as the linkage of differentiated parts. That is essentially what great leaders do—they link differentiated parts. Integration is a delicate process. It is a dynamic and ever-changing challenge. Dan Siegel describes an integrated state as FACES (Flexible, Adaptive, Coherent, Energized, and Stable). Coherence is in itself an acronym (Connected, Open, Harmonious, Engaged, Receptive, Emergent [creative], Noetic [inviting spontaneity and newness], Compassionate, Empathic), and all of these are important characteristics for a whole brain leader. Using this concept of integration, it is helpful to think of integration as the flowing of a river. Integrated states (FACES) are found in the middle of the river. On one riverbank is rigidity (linkage without differentiation), and on the other is chaos (differentiation without linkage). In rigid systems there is no allowance or acceptance for individual differences. A mechanical system is rigid. It is predictable and linear. Protocols and checklists can be rigid, and there is a space for them in all health care practices. Protocols and checklists prevent errors of omission, but they will not prevent errors of commission, as well as technical errors or errors of judgment. Protocols and checklists create conformity for tasks that lend themselves to conformity, but they do not necessarily create safety. (For instance, if the system is so rigid that no one is allowed to speak up to challenge a protocol—even when they see something that concerns them or when they have an “emergent” idea that might be better—because it challenges a well-ingrained protocol, then the system becomes less flexible, unadaptive, and unsafe.) The animal school parable at the beginning of this chapter is an example of rigidity—making one size fit all and abolishing the unique and variable experiences and abilities of the differentiated members of a group. In chaotic systems there is no conformity. Differentiation abounds, and there is nothing linking the group—no common purpose or goal, no common beliefs, leaving no one to lead. Chaotic systems can be rich with ideas and energy, but without linkage through integrated leadership, there is no way to harness this “collective wisdom.” The eventual outcome for these teams is dis-integration .
Whole brain leaders possess knowledge and awareness of the allure of these two riverbanks and try to keep their teams flowing in the river of integration.
Whole brain leaders can integrate their systems and create resonance in many ways, and some of these are described in the following sections.
Avoid Dissonance
To describe whole brain leadership in practical terms, we like to imagine that whole brain leaders are integrating three primary elements: self, others, and context, and we have described this in previous publications. The challenges faced on teams generally revolve around these three entities.
Self.
What are my needs? What are my opinions? What do I think I know, and what am I very committed to? What are my fears, and do I have enough self-awareness and comfort to be able to acknowledge them? What are my biases? Can I access any potential “unconscious biases” (see Chapter 9 )? There is voluminous literature citing the importance of leaders having impeccable self-awareness and willingness to learn and to grow, and some ways that this can be manifested are described later in this chapter. Self-awareness is the first element for emotional intelligence, and whole brain leaders are emotionally intelligent.
Others.
Whole brain leadership is relational leadership and requires the ability and willingness to value the perspectives of others. Resonant, whole brain leaders understand that just like themselves, all individuals in the system have needs, opinions, knowledge, and commitments. Whole brain leaders create resonance by making it apparent to team members that their individual and collective needs, values, opinions, ideas, and information are also known and considered as important. Leaders can do this by asking questions, being curious, and simply caring about the needs of others. This ability to develop genuine caring for the members of the team is considered by many successful leaders to be the keystone of successful leadership, and it is an essential cultivator for resonance within the system. Whole brain leaders genuinely care, and they also care in general, meaning that they understand the power of story. Everyone in the system has a “story,” and when we can know the story, then the system and how people are behaving or what they are wanting makes more sense. A powerful example of “caring in general” was created by the Cleveland Clinic Foundation in their video on empathy ( https://www.youtube.com/watch?v=cDDWvj_q-o8 ). Valuing and tapping into the needs, knowledge, and experience of others is what makes whole brain leaders powerful and resonant. Whole brain leaders genuinely care, and they do this by exhibiting four major qualities that drive connection: (1) perspective taking (inquiring with curiosity to try and understand the experiences of others); (2) avoiding judgment regarding someone else’s “truth”; (3) recognizing emotion in other people (which requires being “present” to the felt experience of others—having a sense for what might be happening for them “below the surface” that might not be expressed by their words); and (4) communicating and validating the importance of those emotions. These traits can be both learned and developed and are essential for whole brain leadership. The difference between empathy and sympathy is also beautifully described by Brené Brown ( https://www.youtube.com/watch?v=1Evwgu369Jw ) as the difference between driving disconnection versus driving connection. Creating connection is an essential component of resonant teamwork. In resonant teams all members are important and valuable; the team is a single organism, and when one part is affected, the entire organism is affected. Whole brain leaders understand this and cultivate that oneness through genuine caring.
Context.
Context is the elephant in the room for health care. Context is the patient, the situation, the reason for us working together, the ever-present “need” that drives our health care world. Context is huge and just like each of us, has needs that must be acknowledged and valued. Teamwork would be difficult enough if it simply required us to “get along” with each other; it becomes daunting when we have to do this in the shadow of urgent, life-threatening, win-or-lose situations that challenge all that we might know and be capable of doing. Add to that challenge the perceived need for perfection, and we have the perfect storm. It is no wonder that many health care teams dis-integrate into rigidity (there is a single answer, and, by the way, it is the one espoused by the leader) or chaos (there is no way we can work together because we all have different opinions about how to get better results). Resonant teams understand that outcomes are an indicator of process drivers . Paul Baltaldan states that “every system is perfectly designed to give you the results you get,” and some systems fall into chaos when the individuals disconnect from process and begin to focus solely on outcome. Outcomes derive from structure and process (well described by the Donabedian model for health care quality or the Balanced Scorecard approach to best outcomes) (see Chapter 2 ).
In their book Primal Leadership, Daniel Goleman, Richard Boyatzis, and Annie McKee describe the concept of resonant leadership and provide a few examples of both resonant and dissonant leadership styles. Boyatzis and McKee went on to write an entire book on resonant leadership, and their work is incorporated in our concept of whole brain leadership for creating resonant teamwork. (Our work is also based on contributions from many others we have studied [and in some cases worked with] over the course of almost two decades, including Dan Siegel, Virginia Satir, Jean McLendon, Sidney Dekker, Don Beck, John Gottman, Doug Silsbee, Brené Brown, and Richard Strozzi-Heckler to name just a few).
Whole brain leaders create resonance by understanding that rigid adherence to certain styles might fail to integrate the competing needs of self, others, and context, and over time this will lead to dissonance within a system. When there is dissonance, there is lack of positive energy, and members of these teams describe their working environment as follows: “sucking the energy from me,” “oppressive,” “it feels unsafe,” “there is no point to my being here because no one cares what I think,” “I just show up and do what I’m told” (which is symptomatic of a system that has disregarded someone’s potential for unique contribution), “I’m looking for another job somewhere” (I’m checking out), or “I just come to work to make money so I can have a life outside of here” (I’ve checked out). Any of these, and other comments that we have collected and reported, are indicative that the system (team) is dissonant. We have now “collected” seven behaviors that we have observed in health care leaders that are dissonant leadership styles when used exclusively and exhaustively over time. We have also observed these behaviors in health care professionals. They are human behaviors inherent not just to leaders (who are every bit as human as the people they lead). Each of these behaviors shares lack of integration of self, other, and context. They are briefly described in the following sections.
Dissonant Styles in Which the Leader Fails to Integrate Others as Valuable Contributors to the Team
Commanding.
These leaders are typically always “in charge” and lack curiosity to explore the stories of others. They commonly blame others or circumstances when things go wrong, have difficulty accepting any accountability, and exhibit little capacity for listening, asking, inquiring. They already know. Commanding leaders simply say, “Do it because I say so.” The Federal Aviation Administration created cockpit resource management to counteract the potential damage that can be done by a commanding leader who is unable or unwilling to access ideas, opinions, or information from others. Likewise, Karl Weick has written about how High Consequence Organizations can become High Reliability Organizations by “flattening the hierarchy” to protect against commanding leaders when there are unexpected and potentially catastrophic events. In Weick’s model the most important person on a team, at any moment in time, is the person with the most important and relevant information. It is the role of the leader to access that information, wherever and in whomever it resides. An example of a commanding leader is nicely demonstrated in this video ( https://www.youtube.com/watch?v=sYsdUgEgJrY ).
Pacesetting.
This term was suggested in Primal Leadership, and we have found it to be especially prevalent in cardiac teams, where perfection is often the goal. Pacesetting can be extremely dangerous because it always seems to be motivated by a “noble” need to do things right. Ironically, many people who have trained in medicine have been taught that “if you want a job done right, do it yourself.” That is pacesetting. (Actually, if you want a job done your way, do it yourself; if you want it done “right,” then it can be done by many people as long as you can accept that the “right” way will look different, and often unique and innovative, when you can let go of only one way being “right.”) Pacesetters discourage emergent behaviors because their way is the right way, and this ultimately creates an environment of mistrust (a general sense of unease with someone or something) or distrust (lack of trust based on experience with someone or something). Pacesetters demand perfection (meaning the outcome must be precisely their way), and it is often simply not possible to satisfy them, so team members simply stop trying (and this leads to the experience of being no longer valuable to the team because one’s opinions, knowledge, experience, and ideas are simply not welcomed). Pacesetters see themselves as being indispensable leaders because without their expertise, everything would fall apart. Ironically, pacesetters often become blamers when things do fall apart, despite their best intentions. Pacesetting can be insidious. Although pacesetting might be manifested by open disregard for the ideas of others, it can also be conveyed by the leader who simply comes along and does everything their way, even after the team has already agreed on a different plan. See if you can recognize the pacesetting in this video ( https://www.youtube.com/watch?v=ZZv1vki4ou4 ).
Manipulating.
Manipulation is the ultimate creator of mistrust. Leaders who manipulate are typically dishonest and unable or unwilling to communicate their needs. They typically abuse their position of authority to simply “trick” people into giving in to what they, the leader, wants. Leaders can gain insight that they are possibly being motivated to manipulate when they approach a dialogue, conflict, or problem with a predetermined conclusion regarding what they want and they begin thinking of strategies to get their needs met without wanting to directly express those needs. Manipulators are master strategists, and they are often fairly remorseless about the impact of their strategies on others. Their end justifies their means. They are driven solely by making sure they get their needs met, and they are never transparent.
Dissonant Styles in Which the Leader Fails to Integrate Self as a Valuable Contributor to the Team
Placating.
Placaters are driven by the need to be liked and to also make people on the team happy. Ironically, they generally fail at both. They become nontrusted because they do not express genuinely consistent values that team members know the leader is committed to. Instead, they seem to be constantly influenced by the last person who has talked with them. They can be paralyzed from making critical decisions because they are constantly worried about how they might be perceived or judged by others, particularly if they fail (and failure is common because little that these leaders do is an expression of their authentic skill set). Placaters invite chaos because rather than knowing how to “link,” they give in to the constant demands of unending differentiation in the system. In trying to keep everyone happy, they become exhausted and frustrated; a sign of placating is occasional emotional explosion as the exhausted placater erupts against the disorganized demands coming at the leader from every insatiable source. Unfortunately, our health care culture risks the development of placating as a cultural norm as we are constantly reminded “to put the needs of others before our own.” In fact, the Accreditation Council for Graduate Medical Education (ACGME) definition of professionalism uses those precise words as an example of what professionalism requires. The conundrum is that we are all human and we have needs, and sometimes those needs, when they are not appropriately acknowledged and valued, continue to express themselves “below the surface” until they simply come out sideways or explode out the top. The antidote for placating is unflinching self-awareness to know what is important to us; self-compassion for ourselves as learners and as valuable members of the team; and to constantly develop mindfulness around our evolving selves. Whereas commanding, pacesetting, and manipulating eradicate others, placating eradicates the self; it creates a form of relational suicide, and it is simply nonsustainable. In our work with (and in our own development as) leaders, this insatiable need to please others has created a common challenge, and the solution is simply to gently reacquaint ourselves with our humanness, the validity of our needs (values, opinions, knowledge, and skills), and some tools for integrating ourselves into a culture that has normalized disregard of the self. The patient (our context) always comes first. And so do you. And so do others. Whole brain leaders recognize the challenge of linking those differentiated parts without excluding the part that is themselves. It is a constant challenge to hang on to the self, and it is necessary to simply know that, because your team needs YOU and all the unique and extraordinary features that an authentic YOU can bring to the team.
Dissonant Styles in Which the Leader Fails to Integrate Context as a Valuable Component of the Team
Super Reasonable.
We have seen this dissonant style most frequently when we have measured dissonant styles in medical systems. It seems to be the most convenient style that satisfies the need for our systems to be predictable and reproducible. It is a mechanical style because it disregards our human needs and variables. Mechanical focus works for mechanical systems (ventilators, heart lung machines, elevators, airplanes) that can be interrogated (inspected) and fixed. Human systems are complex adaptive systems, and the beauty of complex adaptive systems is that they express emergent (innovative) and unique behaviors that are not always predictable. None of us wants to be “fixed.” We would rather be “explored and understood.” Super reasonable dissonance treats people like robots ( https://www.youtube.com/watch?v=753eH92u2B0 ), and a machine cannot give you what a person can. When leaders treat people like machines, they essentially are devaluing and dismissing the importance of our human factor. The only thing that is important is the context. Context is ubiquitous. There is always a sick patient, a chapter that needs to be written, a lecture to prepare, teaching rounds to attend, a meeting for making an important decision … always something to occupy us and distract us from our humanness. (Ironically, in recent years, “human factor” has become a phrase that connects our human capacity for making mistakes to the risk of error in medical systems. However, it is also our human capability for innovating, observing, and preventing mistakes that can lead to extraordinary advances and safety in medical systems. We have found ways to measure the lives lost through “human error,” but how do we measure the lives saved because of our incredible human contributions?)
The insidious impact of denying our humanness is commonplace in medicine when super reasonable becomes the driving force. This is beautifully and poignantly portrayed in the movie The Doctor with William Hurt. In this movie William Hurt is a heart surgeon (how ironic) who develops cancer, and when his physician is informing him that he can begin radiation therapy on Thursday, he states that he cannot do that because he “has a heart surgery scheduled for Thursday.” It takes his wife, sitting next to him, to overrule that objection and state, “No, Thursday is fine.” He has cancer. He is human. He is attentive to context. That is super reasonable. (A bit later in this movie, he comes home early from work, and his wife calls their son, Nick, to come down and say hi to his father. Nick runs downstairs and picks up the phone and says, “Hi Dad” without even noticing his father standing there in the room. Of course, there is no one on the phone, and Nick says, “Mom, we got disconnected.” Then Nick looks up and is totally surprised to see his father, in the flesh.) Super reasonable is a sure way to disconnection.
In Chapter 9 the syndrome of physician burnout is described, and one of the factors associated with burnout is depersonalization , which is a measured consequence of our medical education process. We have recorded a progressive increase in depersonalization across 4 years of medical school education for one group of students at a nationally recognized medical school. The class cohort shows an increase of depersonalization from approximately 10% of students at the beginning of medical school—during orientation—to approximately 45% of students at the completion of 4 years of medical school. Most disturbingly, depersonalization, unlike feelings of depression, anxiety, and other factors linked to burnout (which exhibit phasic increases and decreases throughout medical education), progressively increases and does not regress once it occurs. From this one medical school, almost half the graduating physicians are depersonalized at the time they begin their medical residency training. Depersonalized physicians have just as many needs as they had before they became depersonalized; they are simply less aware of and less compassionate toward them. Ultimately, they begin to treat all people in the system (including their patients) as they have learned to treat themselves. Depersonalized (super reasonable) systems are subject to an 11-fold increase in medical errors, as well as to unprofessional and immoral acts, in addition to ultimate dis-integration from people who want more for their lives than burnout. Systems with depersonalized leaders feel oppressive and dehumanized. It is not possible to exist in them over the long haul, and they exhibit frequent turnover. Team members find ways to “check out,” and there have also been reported examples of some leaders who have committed suicide because they cannot be perfect.
Dissonant Styles in Which the Leader Fails to Integrate Self, Others, and Context—A Totally Chaotic and Differentiated Team That Has No Linkage
Irrelevant.
Irrelevance occurs when people become overwhelmed and are no longer capable of accessing their own needs or being available to the needs of others or the context. Irrelevance is nonattuned leadership; it is not focused, and it fails to connect. These are simply leaders who have “checked out” and who are no longer available. Unlike invisible leaders (described in the next paragraph), these leaders are often distracting with their presence. An example might be the leader who continually cracks jokes even when things are falling apart and need their attention. Irrelevant leaders tend to try to “minimize” problems and are not available to hear the very real concerns of their team members. Likewise, they tend to minimize important context issues and might not respond appropriately. Charles Bosk termed the kind of errors these leaders make as “normative errors,” meaning they fail to perform the normal duties and responsibilities of their leadership role. Irrelevance creates dissonance because the members of the team become discouraged that their leader is not “available” to connect with them around their concerns and instead is a distracting presence when they need to have focus. At an extreme the irrelevant leader has given in to substance abuse as a form of escape from the demands of the job. Irrelevance might seem funny and creative to the leader, but the leader is not attuned to the needs of the team.
Invisible.
Invisible leaders are not present for their “leadership moments.” This is nicely described by Sidney Dekker in his work on “Just Culture.” The members of the team become secondary victims of an unexpected or untoward event. There are times when the team needs a leader to “step up” and take accountability for the team or to make a critical decision or to simply be “the leader.” Invisible leaders tend to hide at these times in the hope that the moment will pass (unnoticed) or that they might escape unscathed. Many years ago the national media covered an “error” at a major medical center. The hospital leader was not visible on the newscasts. Ultimately, an individual on the team got the majority of the blame. How different it might have been had the leader been immediately present and made a statement such as “This was a terrible tragedy for this patient; AND (we find it is always useful to insert “and” in place of “but,” so as not to diminish the value of the immediately preceding statement; try it sometime) this was also a terrible tragedy for our extraordinary health care team—some of the best doctors and nurses in the world; AND this was a terrible tragedy for our hospital that this happened, and we commit to trying to understand how these things happen so that we can, as a health care system—as a really exceptional health care system experiencing a terrible tragedy—help prevent this from happening again—here or elsewhere.” But the leader was not visible. He was nowhere to be found, and the events unfolded differently. Some of the members of that team are still affected by that lack of leadership.
All of these styles become dissonant when they are used exclusively, over time, as the most predictable response by the leader to a problem. The dissonance is created by the lack of FACES that resonant, whole brain leaders require in order to navigate the river of integration. Ironically, leaders (all of us) have access to each of these styles and, when integrated into a complete repertoire of response, can create a more vibrant ability to adapt and perform effectively. Each of these styles actually exists on a continuum or spectrum of strengths. When the strengths are overdone, they can lead to dissonance, but a strength used appropriately can be a powerful tool or style. In Table 1.2 we demonstrate how the style might look along this spectrum, with the “strength overdone” being represented as the dissonant style and the strength being used when needed and at appropriate times representing the more resonant version.
