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• W2904107222 abstract "In this final 2018 issue of Advances in Chronic Kidney Disease, our Guest Editor Rebecca Schmidt takes the lead on leadership. She has compiled a series of articles that compress 2 important and sometimes nebulous concepts into digestible format with the assistance of her contributing authors. Each article adds to the others to provide a roadmap to establishing a successful career in medicine and specifically nephrology. Two decades ago, I was interviewed by a high-ranking member of our medical group about my leadership style. I think he anticipated that I would deliver a classical monologue of top-down, hierarchical, authoritative, and, possibly, authoritarian leadership. He said that he wanted everyone to be like me. I stopped and said nothing for about 10 seconds. Having been steeped in leadership at very high levels in the US Army, I was no stranger to taking and delivering orders. That style of leadership was intrinsic to one's life in the military. Early on, I realized the importance of taking and delivering orders because multiple people would be depending on me as I depended on my own superiors. I surprised my interviewer declaring that I would not so much lead or dictate but be a reflector of ideas, a rotating mirror within a circle of peer-colleagues, absorbing the useful and, in a consensus-based fashion, rejecting the nonuseful. I also told my interviewer that all divisional members would be leaders, just at different times. I informed him that I had very high standards and desired highest quality and rapid and consistent results delivery from my group after deliberate and prolonged discussion, and results would be expected to continually improve. I said that I would have an “open door” policy and, if required, unhesitatingly do anything that was asked of anyone else. Finally, I was not interested in them becoming me, but each one becoming more of himself/herself. This is the way that leaders of American Indian tribes led their autonomous nations, advising more than commanding to achieve consensus.1Becker T for the American Indian Research and Policy InstituteTraditional American Indian leadership: a comparison with U.S. governance.http://www.navajocourts.org/Harmonization/Traditional%20American%20Indian%20Leadership.pdfDate accessed: September 16, 2018Google Scholar The Tribal Leader may or may not have been the smartest or wisest individual and likely was no longer the most powerful battlefield warrior, yet he made his council work together by cajoling thought, collecting ideas, collating proposals, collimating goals, and cohering them for consensus-based decision-making. In brief, the Tribal Leader was doing less and leading more. The work was not in delivering oratory, but in maintaining a highly engaged group for the betterment of the tribe, that is, working for a higher cause than oneself was what the Tribal Leader achieved. Note, this method does not mean that compromise was always necessary, only that agreement on decisions was made by the majority, without prejudice or pejorative toward dissent. Nonetheless, there is no definitive path to successful leadership. However, I will attempt in the musings to follow to provide points to ponder in one's journey to becoming a successful leader, not necessarily only in nephrology. Many of these points you may have heard or seen on the big screen. I received a book by Buckingham and Marcus when I was serving as an interim division head of nephrology.2Buckingham Marcus Coffman Curt First, Break All The Rules Paperback. Simon & Schuster, New York, NY1999: 271Google Scholar The book is based on differentiating features of leaders and managers who are more effective than others. However, the book is based on robust data from employees and managers, not theory. Essentially, one precept was that the best managers do not follow the status quo. Exhibit boldness, not brashness, and be unafraid to try new things and to challenge the existing state of affairs. When rejecting the conventional wisdom, provide proof that you are right. Really, “talk is cheap.” Also, one must think of employees as individuals within the corporation, not as a singular entity of the corporation. Early in the martial arts masterpiece, Enter the Dragon (1973), sifu Bruce Lee instructs his pupil: “Don't concentrate on the finger or you will miss all that heavenly glory.” Academic nephrologists are always told to become really great at one thing, but achieving singular expertise is often not enough to lead. With the digital informational explosion and its transformation of medicine, the bar is higher for all, and the tools to reach the bar are more accessible than ever. Certainly, and especially in academic medical environments, one desires expertise like the Federer Forehand in tennis, but to become expert one must explore greater horizons and read and think broadly. Discussions with mentors may provide insights as additional areas to explore. One need not become a polymath, but an element of horizontal integration to supplement one's vertically integrated knowledge, and expertise will strengthen one's leadership skills. More importantly, that the leader is not so hyperfocused and predisposed to his or his own personal “thing” will be welcomed by those so led. In a terrifying scene from The Godfather (1972), a “rat” is executed for treacherous behavior by one of Luca Brasi's henchman. Afterward, the most-feared Luca Brasi commands his devoted follower, “Leave the gun. Take the cannoli.” Brasi had promised his wife that he would bring home dessert, and keeping family promises was paramount. Leaders must be judicious in what they promise, but must keep promises when made. The business sales pitch of “overpromise and underdeliver” should not be adopted by any medical leader. As medicine is increasingly corporatized, this theme has become increasingly prevalent. It is far better to underpromise and overdeliver. When a promise is over-ruled by a hierarchical, superior leader, the promise is still broken and the leader must take responsibility for the failure and learn the lesson to avoid this in the future. Unkept promises fester in those so promised, and typically have adverse consequences for both parties involved. In Gladiator (2000), the enslaved Russell Crowe as Maximus desires his freedom. To do so, he must “win the crowd,” not by defeating his Roman combatants but by promising “I will win the crowd. I will give them something they've never seen before.” For a medical leader, the constituency is “the crowd,” which will become “the mob” when the goal of its leader is merely to satisfy the status quo. Winning the crowd entails sufficient depth of knowledge of “what must be done” and prioritization of “what” thereafter.3Carnegie D. The big secret of dealing with people.in: How to Win Friends and Influence People. Simon & Schuster, New York, NY1939: 17-29Google Scholar Moreover, the prioritization must be achieved with the consensus of the crowd. In terms of a leader's crowd, accountability, timeliness, reliability, leading-by-example on a consistent basis as well as consistency in thought, judgment, and action, and maintaining a servant-leader mentality will “win the day” and every day. Effective leadership is not divinely conferred but achieved through planning, patience, and practice. No gladiator succeeded without hours of toil in the ludus. In Raiders of the Lost Ark (1981), the final scene shows the hero, Harrison Ford as Indiana Jones, battered and bruised on a steamer ship heading for home. The fierce heroine, Karen Allen as Marion Ravenwood, happily exclaims that it is Indy's birthday, and he says to her, “It's not the years, honey. It's the mileage.” When my housestaff note that my experience counts for so much, I always am reminded of this quotation before reuttering it as a life instruction. For Dr Jones, this meant doing all that had to be done, not the minimum. True work is a cumulative event of decisive effort. For us, true work in patient care can never be achieved by the minimum standard. This choice is neither the path to delivery of high-quality medicine nor acceptable for medical leadership. One must predetermine a strategy of medical care that inculcates the best evidence (easy part), and incorporates the socioeconomic stratum of each patient (hard part). Today, a patient must feel that his/her provider has his/her best interests at heart and will do more than just what is necessary. Convincing one's followers to adopt this mantra as the leader constantly exemplifies it himself/herself is key. When the leader cannot follow his or her self-proclaimed advice, the result is entropy. Meryl Streep as the iconic Miranda Priestly from The Devil Wears Prada (2006) exclaims, “By all means move at a glacial pace. You know how that thrills me.” For Miranda, there was no substitute for excellence; it was ground zero. Excellence has to be pursued continually and with pace. There is an element of patience in attaining high performance, but not slothfulness.4Young N.S. 5 Qualities of a High Performance Organization. Optimal Solutions Consulting, 2005http://opti-solutions.com/pdfs/5%20Qualities%20of%20a%20High%20Performance%20Organization.pdfDate accessed: September 24, 2018Google Scholar Attaining sufficient pace to produce rhythm is required to define organizational culture. Leaders must push and pull their groups at various times to greater heights The best way is to convince a group is to instill a sense of achieving a greater goal that requires collective effort. To get the best out of a group, the leader must be explicit in goal-setting and anticipated results, and committed to a culture (and environment) of continual learning and evaluation. The leader must over-communicate clearly and concisely, develop and implement effective change management messaging and processes (the backup plan), and always promote excellence. To do the last, one must understand one's organization via internal and external opinion; quantitate its weaknesses and strengths; develop plans for upscaling the group, which includes the use of external help. However, the drive for productivity alone is destructive, and equipoise between high performance and burnout from overwork must be monitored. The leader must be able to discern when imbalances occur. Unfortunately, Miranda never appreciated this concept and ran her people into the ground, simply replacing them with the next-in-line. However, for high performance organizations, high turnover rates are a death knell to sustainability. Every leader is replaced, one hopes after establishing a fine legacy. To accomplish this requires mentoring of colleagues led, and not just in knowledge-based techniques. In essence, do not confuse teaching for mentoring. There is overlap but not as much as one may think. American Indian tribes developed their tribal Elders from within. Those chosen to become Elders began their training at a young age, having demonstrated certain types of aptitudes and attitudes. These adolescent trainees attended “night” schools and winter sessions. They received lessons to learn social and cultural mores intrinsic to the tribe by their thoughtful and generous Elders. Generosity, especially of time, is crucial to mentorship. Giving time to the mentored when there is no time to give is elemental. Goal setting for the mentee and goal achievements are equally important. Otherwise, the relationship is apprenticeship, not mentorship. Bidirectionality of thought and knowledge is the goal of an aspirational mentor-mentee relationship. In the end, the mentor ought to learn from the mentee—the truest measure of a successful relationship. Stepping aside for the right successor, perhaps a mentee, is the ultimate goal. This stream-of-consciousness editorial was meant to illuminate what a modern leader in medicine or nephrology must be, particularly when “business time” erodes into our true work time. There are so many things followers want their leaders to be. So much so that if one aspired to become each adjective that describes leadership, there would be no time left to lead. In When Harry Met Sally (1989), Billy Crystal as Harry proclaims his love to Meg Ryan as Sally, “I came here tonight because when you realize you want to spend the rest of your life with somebody, you want the rest of your life to start as soon as possible.” The same love for the leadership of one's group is vital, and, hopefully, enthusiastically contagious. Become a leader that your group wants to follow. Do not be a “nice” leader or aim for leadership because it is another “step up the ladder.” For me, the leadership model that promotes a group's best interests is one that has been practiced for hundreds of years by Tribal Leaders. All of us must lead at some time. During those times, we should lead as they have, holistically, transparently, and interconnectedly with a strong spiritual core of doing for the group the “right thing,” the “right way,” and at the “right time,” which is always. It can be exhausting, but as Rocky Balboa said in Rocky IV, “Going in one more round when you don't think you can—that's what makes all the difference in your life.” And by the way, my interviewer begrudgingly said, “Good answer.” He and I became great friends over the next 2 decades. Just keep swimming, swimming, swimming.—Dory (Finding Nemo, 2003) Erratum to “Leadership as Tribal Leader”Advances in Chronic Kidney DiseaseVol. 26Issue 1PreviewIn the article “Leadership as Tribal Leader,” which appeared in the November 2018 issue of Advances in Chronic Kidney Disease (2018;25(6):469-471), there is an error on page 470, column 1, second sentence in the “Keep Promises” section: “Afterward, the most-feared Luca Brasi…” should read “Afterward, the most-feared Clemenza…”. The author regrets the error. Full-Text PDF" @default.
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