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“In the emergency department I treat patients based upon my expert judgment. I can explain to you the sensitivities and specificities of the tests I order, I can detail the physiology and pathology involved in my differential diagnoses, and I can explain the rationale for each part of my treatment plan. But despite my expert analysis, I can still miss important details.

Did I get input from the family or the paramedics? The pharmacist noticed something in the past medical records that might be important, and the nurse thinks something else might be going on. Did I invite their opinions and listen to them?”

Richard Winters is an emergency physician and author of You’re the Leader. Now What?: Leadership Lessons from Mayo Clinic.

He shares his story and discusses his KevinMD article, “How to improve decision-making effectiveness.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Richard Winters. He’s an emergency physician. He’s the author of the book You’re the Leader. Now What?: Leadership Lessons from Mayo Clinic. There’s an excerpt from that book on KevinMD titled “How to improve decision-making effectiveness.” Richard, welcome to the show.

Richard Winters: Hey, thanks for having me, Kevin.

Kevin Pho: So we’ll get into your book and excerpt in a little bit. First off, briefly share your story and journey to where you are today.

Richard Winters: Yeah. I mean, I was born and I knew I was going to be exactly where I am right now. You know, no. So I was like a punk rock kid in high school. I got a C-minus as an average. And then somewhere during those first few years after high school, I decided I wanted to be a doctor. My parents appropriately laughed, because, like, up to this point, how’s it going? And then I ended up going to Mayo Medical School and then going into emergency medicine.

Practicing, I think, like many individuals, I found things that weren’t working and wanted to help improve them, and then found myself in leadership roles, and then realized that I couldn’t necessarily write an order and have things get done, that I had to approach things in different ways. And so as a result of that, I got an MBA and became an executive coach. And now I find myself at Mayo Clinic as an emergency physician. I take care of patients, I’m an executive coach, and I’m also director of leadership development for the Care Network.

Kevin Pho: Talk to me about that transition from clinical medicine into that leadership role. For a lot of physicians who want to make that step, they want to improve the health care that they’re delivering, and they can’t do that unless they step into that leadership role, but not everyone can do that. Tell me about your story. How did you make that transition?

Richard Winters: It is really identifying things that aren’t working so well, and then being uncomfortable, and then stepping into those leadership roles. And I found that as a physician, I could take care of one patient at a time, or I could start working with groups of individuals to take care of lots of people all at once. But there was a huge change, which is really the transition from writing orders to, “OK, geez, there are lots of different perspectives here. There are lots of different layers, some of which I really disagree with, some of which I agree with. And now how do I be most effective in these sorts of situations?”

And so that transition, I think, is a difficult transition, but also a great transition. It’s one of those times of growth where you have done things that I would approach differently now. The MBA, I got that because I found that there was this different language that people were speaking, and it helped me. That being said, I really don’t think you need an MBA to be a great leader. I think you just need to be a student of how to best bring groups of colleagues together, how to communicate one to one, and then proceed from there.

Kevin Pho: What would you have done differently?

Richard Winters: I don’t really look at things that way, honestly. I think that there are lots of things I would do differently every day, and that’s it. I mean, I’m going to give myself a little bit of leeway. And I think right now, given what I know now and my experience, I would approach things differently, but that was all part of the whole kind of growth cycle.

Kevin Pho: Now, for those physicians who are interested in stepping into the leadership role, what’s the single biggest piece of advice you can give them?

Richard Winters: It’s not one of these things where they’re like, “Oh, here’s some protected time, and here’s some money.” It doesn’t tend to be that way. And so this means that you’re finding some space where you’re interested in helping things change, and you start attending some meetings, and you start taking on some projects, taking accountability for them, and getting them done. And then it’s almost like a fellowship or training as you do these sorts of things. The compensation and the time follow the accomplishments. Sometimes there’s kind of a big lag, but the more you do that, the more you get offered opportunities and the better you become.

Kevin Pho: So I’m looking forward to hearing more of your leadership lessons. Your book is titled You’re the Leader. Now What?: Leadership Lessons from Mayo Clinic. Now, how did this book come together?

Richard Winters: Yeah, so it’s based on a lot of mistakes that I’ve made, so that’s number one. And then, as an executive coach meeting with other colleagues, I was just identifying that there’s this common thread here of individuals, physicians who are experts, individuals who are experts, stepping into these leadership roles and finding that it’s just different, that they need to approach things in different ways, that their expertise is actually no longer so helpful. It gets in the way.

Kevin Pho: Tell us a story. Give us an example of that.

Richard Winters: Yeah. I mean, I think any one of us, I bet you, I don’t know if you have any meetings today, Kevin, but I bet if you go to your next meeting, they may bring up a challenge, and in the moment you likely have an exact idea of what’s correct, what’s incorrect, and what should be done. And I mean, I experienced that. And so I’ll enter a meeting, and we’ll be talking about a complex issue, and I have to quiet that. I have to understand that it is one perspective, and that to best move forward, there are structures and formats and things that I can use to try to bring people together to move things forward. So it’s really, how do I get out of my expertise? How do I kind of step outside of myself and get a broader perspective?

Kevin Pho: Now, that sounds like it’s easier said than done. How can a physician who’s used to giving orders all throughout their training transition to that new mindset?

Richard Winters: Yeah, but I mean, even as I said that, I was kind of reductive, because, right, we write orders, but oftentimes it’s always teamwork. And so as we’re taking care of patients, we’re working alongside nurses and medics and assistants and the patient’s family and the skilled nursing facility. It’s a team, and those skills of bringing people together are very helpful as you’re leading also. But the sense is, “Geez, can we just change this right now? This is all that needs to be done.” Things generally don’t work that way. And so we need to be able to develop kind of a more shared perspective about things before we start to move forward.

Kevin Pho: How long did it take you to kind of adjust to that mentality? Because I could imagine, for a lot of physicians, it would take a little while to adjust to that business mentality.

Richard Winters: Up to right now, still adjusting. I mean, I think one of the things is we’re not really taught how to lead. I think that we understand how to mentor people. We understand, “Given my experiences, what I’ve done, this is what I would suggest you do.” But for me, it was really developing a coaching perspective, which is, instead of me telling you what I think you could do from the perspective of my own eyes and my own experience, it’s like helping try to develop other individuals’ perspectives based on their own experience.

And so it’s doing that either one to one or bringing groups of individuals together, and then seeing that actually I don’t need to know the answer, which is a relief, because oftentimes you’re also in situations where you feel like there’s a lot of pressure to know the answer. But what I can do is I can coach this team of individuals to come together, identify all the fears and worries, identify the things that are disagreeable, and then try to move forward and envision from there. So it’s really a coaching mindset, a facilitative mindset, as opposed to the expert mindset.

Kevin Pho: Now, in general, how accepting are administrative leaders of physician input?

Richard Winters: Yeah, I think that depends, likely, on where you’re at, right? So at Mayo Clinic, this is a physician-run organization. Now, before I came to Mayo Clinic, at the organization I was at before, I didn’t feel like there was as much of a voice, or at least I didn’t feel like I had as much efficacy there. And so I think it depends.

And in my mind, I think for all physicians out there, certainly as we talk about burnout and well-being and things like that, I like to think of the metaphor of a garden. I mean, I have a garden in my backyard. We’re growing things. Some things do not grow in that garden, and so we find a different place, we plant that seed, and it does very well. And so I think if you’re knocking heads, and things aren’t getting done, and you’re feeling like you’re not being heard, I would go to a different garden. Whether that’s in the same organization or whether that may mean leaving the organization and moving somewhere else, find your garden.

Kevin Pho: So your excerpt that you shared with KevinMD is titled “How to improve decision-making effectiveness.” Tell us about that excerpt.

Richard Winters: Yeah, so it’s really about what’s most helpful. Is it process, decision process, or is it analysis? And I can approach any of the issues that come up. We have a physician shortage, or we need to staff differently, or we need to kind of change the FTEs, or we have these revenue shortfalls. I have ideas of what can be done, and I can put together a bunch of PowerPoints, and I can put together Excel spreadsheets, and I have a lot of experience and information, and that data is very helpful. But it’s also behind all my own blind spots. And so as we’re getting individuals together and making decisions, we want to try to get around each other’s blind spots, and that process is what helps us.

And so it’s coming together, developing a shared perspective, a shared reality about what’s going on, which includes all of our analysis. And with all of us physicians and scientists, it’s very common to say, “Well, where’s the data behind that?” You get all that stuff together, and then you start to see the disagreements, and then you can start to move forward. And so really, it’s process. Oftentimes, what happens is you introduce a topic, and one or two loud individuals say something, and you move on, and it’s not the best way of working it out.

Kevin Pho: So tell us about an ideal situation of process. Take us into one of those meetings where the process works the way it’s supposed to.

Richard Winters: Yes. OK, so let’s just say you need to somehow change your staffing to meet the patient demand. And so are we going to expand clinic hours? Are we going to change the way we’re staffing? How are we going to change? What are we going to do? And so you create a question, which is, “How can we best meet the needs of patients? How can we best staff to meet the needs of patients?” So you come up with this question, and then, given that, you start to develop shared reality. And so that means, what do you think? It’s kind of putting this all down in bulleted form, and everyone is writing these things down. What do we think? And then you start to share these. You start to share the perspectives, and oftentimes what happens is we share perspectives and we don’t feel like we’ve been heard, because we haven’t been heard.

And see, part of the thing that’s helpful here is to write things down so people can see it. It’s also grounding. So if I keep saying the same point over again, the person who’s running the meeting could say, “Yeah, we have that here. What else would you like to add?” And in there, you’re hearing what the fears and worries are, you’re seeing the disagreements, and then you’re coming together around vision. And as you establish this vision, which is based on how we move forward in a way that’s going to keep these fears that we have from happening and that is aligned with our values, only then do you start to think about what the options are that we can do to move forward. And you come up with a bunch of options, and then only then do you start to jump to, like, what can we do? What is the way forward?

That’s generally not how we do things, though. We jump to the way forward. We skip the development of shared perspectives, and then we’re making decisions behind our blind spots.

Kevin Pho: Now, this is a story I hear about a lot. I talk to a lot of physicians, and I feel like there’s a disconnect, right, between what we see in the clinical space and what the administrators see. And what you said about shared perspective, I think, resonates with me, because there’s a lack of that step. Physicians want to kind of jump to that solution before getting that shared perspective. Now, short of physicians going into more leadership positions, is there anything else that we can do to be heard and perhaps get administrators to look at what’s going on from the physician’s perspective?

Richard Winters: Yeah. I mean, so I think there are formal leadership roles and there are informal roles. And so, you know, formal is CEO, VP, director, on down. We’re all familiar with that, and we know that isn’t necessarily the best decision-making structure. I mean, you don’t cascade things on down and have things be successful in those circumstances.

And physicians can really leverage the informal network, their informal ability to influence, and whether that means within your group, reaching outside your group, intraspecialty, or working with other specialties. These individuals without titles are oftentimes who people go to during times of struggle, to look for the way forward, to look for how to find things. And they may not have a formal leadership role, but they may be the most influential individuals in those sorts of situations. And so I think the question for each of us is, how do we develop this influence, and how can we best speak for our collective ideals?

Kevin Pho: Now, you’re an executive coach, so I’m sure that you’ve seen a lot of health systems that are rather dysfunctional. What would you say are some of the biggest red flags, the biggest mistakes that you see out there?

Richard Winters: I think one thing right now is, you look at the Triple Aim, where we’re trying to decrease costs, we’re trying to improve the quality of care, and we’re also trying to take care of populations. When we do that at the expense of ourselves, at the expense of the physicians and nurses and PAs and staff, it’s not a long-lasting thing. And so, as an emergency physician, I look at vital signs. I’m not going to make a diagnosis without looking at vital signs. And so a kind of thing that I see is where you have these organizations that are looking at cost and revenue, but they’re not looking at the vital sign of well-being and burnout. There is some danger there. If you’re not taking care of that, things are not going to work.

And the well-being and burnout vital sign really reflects, from my perspective, how groups are getting together and making decisions, what sort of autonomy there is, what sort of resource allocation, like how much command they have over what they’re getting, and whether they feel like they’re aligned with values and purpose. Without that, organizations are in trouble.

Kevin Pho: In general, how commonly do organizations look at things like clinician burnout? How important is that to them?

Richard Winters: Well, so each of us has our own circumstances, but I think in general, let’s say that you’re, like, an evil CEO, and you’re on Skullcrusher Mountain, and the physicians are your minions. Like, who cares? We can just get more physicians. Even then, if you’re not looking at well-being and burnout, we know that burnout directly correlates with a decrease in quality. It decreases patient satisfaction, it increases churn of physicians, and it increases cost. So any organization that is going to function and be profitable, that needs physicians, is going to need to look at that. And so again, as you kind of bring up that metaphor of the garden, if you’re in an organization where your vital signs don’t matter, go somewhere else. And those are going to be the organizations that are going to dominate, I think, in the future.

Kevin Pho: We’re talking to Richard Winters. He’s an emergency physician. He’s the author of the book You’re the Leader. Now What?: Leadership Lessons from Mayo Clinic. Richard, what are some other leadership lessons that you want readers to come away with?

Richard Winters: Yeah, I mean, I think one of the leadership lessons is, first of all, it’s difficult. And oftentimes you’re putting your neck out there, and you’re in groups, in your committees and stuff, and it can be quite a lonely thing. And oftentimes, as you become the leader, all of a sudden you’re the person that people are pointing at as being the problem, and oftentimes you may not have the resources that you need. And so we can kind of go through these levels where, let’s say, the bedside physician is blaming the physician leader, who then becomes the director, who blames the CEO, who then becomes, and like that on down.

And so, as much as possible, understand that this is a collective sort of system issue, in addition to individual issues. I think the best thing is, as much as possible, just to step back from the situation and think about what it’s like at the organizational level, how we’re getting together as colleagues, and then also what it’s like at other organizations outside our organization. I think that’s a healthy way of looking at things. Otherwise, you’re looking at things kind of within your own, again, blind spots and darkness.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Richard Winters: I hope that people step into leadership roles. I mean, you’re asking great questions, which is, we’re at a time where, how do we best care for patients? And you know what? We’re also patients. How do we best care for our families and our friends and our communities? And that takes each of us stepping up and finding ways to become better leaders, which means, how do we best lead in groups? How do we best lead during one-to-one conversations? And that means oftentimes kind of releasing our own expertise and our own decision-making in the moment, and stepping back and figuring out how we can take care of systems as opposed to treating symptoms.

Kevin Pho: Richard, thank you so much for sharing your time and insight. Thanks again for being on the show.

Richard Winters: Thank you, Kevin.