Have the Courage to be Vulnerable

Podcast Transcript

Brian Bolwell, MD: Beyond Leadership, a Cleveland Clinic podcast at the intersection of leadership and everything else. In this podcast, we will co-mingle with extraordinary thinkers and explore the impact of their ideas and experiences on leadership and management.

Welcome, everybody, to today's episode of Beyond Leadership and I'm delighted to be joined by Dr. Lars Svensson who's the Chairman of the Heart and Vascular and Thoracic Institute here at the Cleveland Clinic which, you probably all know, has been ranked number one by US News and World Report for many, many years. Lars, welcome.

Lars Svensson, MD, PhD: Thank you very much. Delighted to join you, Brian.

Brian Bolwell, MD: So, Lars, tell us a little bit about your career, where you started, how you became a cardiac surgeon and, ultimately, how you got to this role.

Lars Svensson, MD, PhD: So, it's sort of a mixture. I'd like to say I'm Swedish by blood, I'm African by birth, I am American by mind and training, and British by marriage, so it's a bit of everything. So, Swedish, African American, if you like.

Brian Bolwell, MD: Oh, fair enough.

Lars Svensson, MD, PhD: So, it is a bit of a mixture. I was in Sweden when I was accepted to medical school in South Africa, and I actually had tried to get into medical school in Sweden, but they wanted me to spend one and a half years studying Swedish and that didn't suit me to spend [time] doing that. But I had spent some time at the Karolinska in Stockholm, and I went to medical school in Johannesburg at University of Witwatersrand and did a MSC and a PhD also there.

And I was going to do engineering, that was my passion but my father, when we were on vacation said, you need to listen to the news. And I said, "Dad, why do I need to listen to the news?" and he said, "Yeah, you need to listen to the news after lunch." So, it was at 1:15 and that's when they repeated the news from the morning, that Chris Barnard had done the first heart transplant and he said, "You know, you might be interested in this."

I put it in the back of my mind but, eventually, when I was in my last year in college, I decided I'd go to medical school. I never did any zoology or botany at Treverton College and went into medical school, steep learning curve but I loved it. And then, when I was finishing medical school, I decided to do cardiology, but a fairly well-known cardiologist John Barlow, Barlow's valve is quite well known to people, I talked to him about when they did the first PTCA in Gruentzig in Switzerland and he said, "If you're interested in this, why don't you go into cardiac surgery and it will take 20 years to perfect it." In fact, it took about 25 years to perfect.

So, I contacted Chris Barnard, got a job with him on provision that I did what's called the primaries in surgery. I did those but then he stopped operating so I decided to finish vascular surgery, general surgery in South Africa and then came to the Cleveland Clinic in the mid-'80s and with a job in Houston with DeBakey. And so, I went down there, and I was offered a position there and, if I ran the VA, I would be able to get a green card. So, I ran cardiovascular at the VA and then spent nine years in Boston and Toby Cosgrove and Bruce Lytle invited me to come back. Toby made me an offer I couldn't refuse to come back and so that's how I came back to the Cleveland Clinic.

Brian Bolwell, MD: Well, that's a very fascinating story, we probably could talk a lot about that stuff right there. But when were you named Chairman of the department and how did that occur?

Lars Svensson, MD, PhD: So, that's occurred eight years ago, beginning of 2015, I was made Chairman and it was a tremendous privilege to get that position. I'd obviously benefited from having great mentors in Fred Loop and Toby Cosgrove and Bruce Lytle who I knew from my training here initially and then Stanley Crawford and Michael DeBakey in Houston. So, I had wonderful role models and people who were encouraging and helped me on my journey.

Brian Bolwell, MD: So, you go from being a world-renowned heart surgeon which is a leadership job in terms of the team, folks in the operating room, et cetera. But it's a pretty big leap then to running this institute or was it the department first, Lars, and then the institute?

Lars Svensson, MD, PhD: Yeah, it is, but I think the principles still apply and I would say that I learned a lot on the sports field when it came to rugby and cricket and athletics. And at Treverton College I was sort of in an unusual position where I did well academically, but also in sports and you were involved in putting together teams like a national science conference, but also putting together sports teams like rugby. I think rugby and American football and a lot of team sports are a great place to learn a lot of skills and learning what you have to deal with, finding both the right capabilities of people, the cognitive abilities, people who get on well together, communicate well together and giving them guidance and then coaching them.

And I think coaching's very different to mentoring. And so, building teams and, early on, taking over as chairman, I started putting together teams in what we now call centers. So, we have 54 centers under 13 umbrellas of excellence. So, we've put together both a surgeon and a physician to co-lead these areas around a disease entity and then market the groups under that. So, I think some of the principles from team sports are very important and I find it interesting that a lot of the very powerful New York banking and financial institutions like choosing people who have been in American football teams.

And I think one of the strengths of the American education system is that, generally, students do participate in team sports, and you learned to win but you also learned to lose, and you learn more from losing than from winning. And even if you lose, you've learned something, and so you, hopefully, are in better shape for the next time.

Brian Bolwell, MD: Well, I wasn't a very good football player so I learned a lot of humility when I played football, Lars, I will say that. But I think the points are valid, I think that you do learn a lot in team sports and sacrificing for the good of the team and a lot of principles that I think do apply to leadership.

So, tell us a little bit more about the 54 centers. So, you've got a very large institute, obviously very, really, as good as any place in the world in terms of your excellence and your expertise. How did you go about that and how does that look today, and how has that fed into your leadership philosophy that you now have?

Lars Svensson, MD, PhD: Philosophy has certainly evolved over time. When I was asked to come back to the Clinic, I was particularly tasked with building an aorta center and I'd done that in Boston and it had become successful in New England and getting patients from all over New England. And we were doing about 190 thoracic aortas a year here at the Cleveland Clinic but, clearly, there was a great opportunity to build an aorta center and, what I said to Toby, I'll include Marfan and connective tissue disorders in that.

So, we started getting the right players together, the team together and built it up, marketed it, put together some CME conferences. In 2021, we were up to 1,431 aorta patients, so grew tremendously so we built that up. And so, on the basis of that, I thought we should try and do that for other disease or valve entities or coronary artery disease and then also put together people, typically a physician and a surgeon, who had an interest in a niche disease and then promote that, for example, Marfan's connective tissue disorders but we've done that in multiple areas. And that's why we have these multiple centers and then we market them, we encourage people to write research papers together and then, when they have a great paper or presentation, we market that, given that out in, for example, Cardiac Consult and we also use it for recruiting and for philanthropy to grow those entities.

Brian Bolwell, MD: Lars, one of the things that you do which I think is very, very effective is you try very hard to communicate in different ways. And certainly, one fundamental principle of leadership is the ability to communicate and, frequently, on this podcast, we talk about the fact that it's very difficult to over-communicate. But one of the things you do is you spend a great deal of time with your newsletter that you send to the entire institute weekly or every other week, I forget how frequent it is. How did that evolve and what do you think the benefits of that are?

Lars Svensson, MD, PhD: That's a very good, important point you're making, Brian. And before Fred Loop retired as CEO, I asked if I could have half an hour in his office just to chat to him and it ended up being one and a half hours. And he said, "One of the things you need to do as," in this case, it was a department leader, he said, "Identify the challengers, the problems and then make suggestions, poll your people and then come up with how you want to change things,"and change management in itself is a big discussion. "And then communicate clearly to them why you have to change, why you have to do things. And if they understand your vision and your message, then you hold them accountable for the outcomes and you coach them but let them get on with it." And as you know, physicians are very good and very self-motivated. As leaders for physicians, we are very fortunate to have people who, on the whole, are very motivated and work very hard.

And so, when I came into the role, I felt that I needed to be transparent with everybody about what I knew so they knew and that would minimize rumors. I was in the military as a conscript, and I knew all too well how rumors would fly around if there wasn't good communication from leadership. And so, that's why I put together that newsletter, the update that we put out about every two weeks or so. Initially, I did it more frequently while we were communicating what we were doing, what we were changing but now it's about every two weeks. And I try and put there everything that I think people should know within our institute, about what's happening, what new news there is, what breakthroughs there are.

And it's an opportunity also to highlight and cheer for people to do great work. If somebody gets media, we put it in there. If they have a great publication, we put it in. And so, it's a way to appreciate the great work that the team's doing.

Brian Bolwell, MD: I think it was also very effective during COVID.

Lars Svensson, MD, PhD: Yeah, it's an interesting thing. Up until COVID, I had not written the update and introductions and overview from a personal point of view. But when COVID struck, I decided to do a deep dive to understand what I could of COVID, and my wife has a background in genetics and viruses and so on, so she also gave me insights. And I had done my masters on infectious diseases after surgery and I decided then I would try and both present what I thought the reality may be, what the possible consequences would be. I'd seen a bit of that related to HIV in South Africa and, obviously, here in the United States too, and then reassure people that we are going to go through this. We may have a few waves, that's to be expected just like the Spanish flu, as it was called in 1917 and that period, but we'll get through it and we need to stick together.

And so, during the worst of the dark days, we shut down from March the 13th and then I got permission from our senior counsel to restart on the 23rd of April. So, what we did that then during that period when we didn't have as many people needing our help from a point of view of surgery care, we still started up cardiac surgery, PCI and so on. But for that period of the lull, I divided people into teams of six. And so, two would be at home, two would be doing virtual visits and two would be actually working. In effect, it usually was three people who would then rotate in those roles. So, during about a six-week period of the lull, that's how we did it.

Brian Bolwell, MD: Well, a lot of positive feedback about it, I think, was very effective. You mentioned change management a couple minutes ago and, certainly, that's a big part of what we do as leaders and there's a lot going on in healthcare right now that requires change management and one of the things you quoted Dr. Loop as saying is explaining the why. So, I always think that if you want to get people on board with a new initiative, the why becomes very important. Tell me a little bit about your thoughts on that. And then, if you get people to buy into the why, how do you proceed with executing a change.

Lars Svensson, MD, PhD: So, I have not read extensively on change management, I'm sure there's lots of books on that. I've taken more of the practical approach based on the advice of Fred Loop and that is to identify the problems and then move forward. The first time we had a strategy retreat, what I asked everybody is I want to hear from the front lines, I wanted for everybody in the institute to tell me what are your challenges, what are the opportunities you see, what actions would you like, who's going to be responsible in a timeline and what's going to be the goals and measured metrics. Now, of course, it's OKRs or KPIs and what are your structural and support needs, and we'll try and meet those.

So, we did that and those that I just mentioned spell our COAGS that was purely by chance, serendipitous. It's COAGS and, obviously, in HVTI, we deal with blood clotting and coags. So, we summarized all of that, broke it into big subject categories like marketing process, operations, et cetera, and we came up with 221 initiatives. So, there's a famous scroll in my office here that we kicked off with and we worked through that, and we eventually took us about a year and a half to, in a sense, have ticked off that Excel spreadsheet on everything we did and then we focused on different areas.

So, that was how we put together our strategy. And I know, when people talk about strategy, you should limit it to three or five or, most CEOs of a big company, they can usually just carry one strategy. But there were a lot of things we felt we needed to address to make our institute better so that's how we undertook it.

Brian Bolwell, MD: So, you said a few things there which I think are really important. Number one includes the frontline and, boy, I think that's a big deal. I think that, too often, you see certain individuals and leadership positions who seem to have a reluctance to talk to people in the frontline and tend to make decisions in a fairly cloistered space. But I agree with you wholeheartedly, Lars, I think talking to the folks who are actually doing the work is essential. And then it sounds pretty intuitive but it's not always easy in healthcare to actually have goals that you can measure. But it's really important to try to define how to measure goals and, in fact, what defines success, otherwise, the path forward is a little less clear.

And then having a timeline, I think sometimes people run meetings and good ideas are raised and it's the meeting then ends. Well, you've got to figure out how to take the next step. Okay, what are we going to do next, who's going to do it, when are we going to do it, how are we going to measure it, et cetera, et cetera. All these things sound pretty fundamental but they're very important.

Lars Svensson, MD, PhD: True. Yeah, I agree with you. Having every person on board, often, what you need or what you think needs to be done, the frontline also knows that. But the fact that they've been asked to be involved in the process means that the changing of the culture is going to be a bit easier. And I think the other factor that is very important, and I learned this on a course I was at the Columbia Business School, is that, when you change things, you have to give people security. Because when you're changing things, people, they may not always voice it and they might be enthusiastic, they're thinking internally what this means for me, am I going to be okay, am I still going to have my job and so you have to provide that security now. Obviously, if you are not going to keep everybody, well, then you need to make that cut pretty early, otherwise, you're not going to have everybody on board.

And so, that's the challenge on the change execution. And then, as we have said, you need to communicate to everybody what you're planning to do. Leadership can be tough, as you know all too well, and, unfortunately, we as humans don't have the DNA for leadership. We have the DNA for strategy because all our lives, 3.2 million years ago, were bipeds and started hunting, we would observe that the animals, whether that was the predators or the food we wanted or the trees we were going to gather nuts from, we observed, assessed, we put the tools together that we needed to, let's say, knock the nuts down. We needed some long sticks, maybe we will take some spears to dig out tubers, but we better have a spear in case the lion comes for us. And then you gather all your food together, maybe you take a bow and arrow, trap some hares, and then you sit down around the fire at the end of the day and commiserate on what worked, what didn't, where we're going to go next day.

And if you think about it, this is exactly what we as physicians do for abstracts. Background, overview, methods, results and then discussion, et cetera, et cetera. So, strategy comes naturally, but leadership doesn't because, as Stone Age neolithic people, it's only in the last 7,000, maybe 10,000 that we started organizing into communities. And that's why, if you look up on Amazon.com or Google, there's something like 75,000 titles on leading and leadership and so on.

So, we clearly don't have a document for leadership and the path forward. So, my thinking about leadership is my own theorem and I invite people to develop their own axioms around this, but it has a lot of steps to it. And my sort of, summary, of great leadership is the ability to create a vision and the courage to develop it, taking into account opportunities and challenges, pervasive culture and then through trust, integrity, influence, initiatives, motivation, lead people to a measured goal that has higher moral value and purpose.

Brian Bolwell, MD: So, that's a great way to frame it in terms of moral values. And the other thing you mentioned, which I talk about a lot, is courage. A lot of times these things aren't easy and sometimes you have to do things that may not be popular. That requires courage and it requires courage sometimes to be vulnerable. Tell us a little bit more about your thoughts on courage.

Lars Svensson, MD, PhD: I was just going to touch on what you said, vulnerability. Nowadays, of course, people talk about vulnerability. Well, the vulnerability from my point of view follows courage and initiative. You have to have the courage to start initiatives and that makes you vulnerable. And you may fall in the process but, if you really believe in what you're doing, you have to take initiative. And sometimes one makes mistakes, and you get into trouble but, hopefully, you learn from those mistakes. But I think the great danger is that one becomes comfortable and doesn't have the courage to start new initiatives. And one's always going to get back to what we were saying, you got to look for what is hurting your team, what are the problems and then try and address that.

I think it's dangerous to say, "Oh, well, we don't need initiative to deal with this and that problem." Eventually, it will become corrosive and then you have the risk of your whole leadership falling apart and also the team that you're leading falling apart and then, basically, the work you're trying to do. And getting back to, also, the discussion about purpose and moral value, for business schools, for many, many years, they always taught maximizing shareholder return is all you’re responsible for. Now, of course, businesses have taken on more of the moral aspects of management but, for us in the nonprofits and taking care of patients, it's about the moral value, as you rightly said, what I call the lodestone which is, Vikings used the lodestones, they didn't use the North Star, it was too overcast to use.

If you saw the northern sky when you're sailing between Norway and Iceland, Greenland and North America, you were lucky but, most of the time, you had to use your lodestone during the day.

Brian Bolwell, MD: So, another thing you mentioned, Lars, which I thought was very interesting was when you said it's important that people feel a sense of security when you're trying to change, when you're talking about change management. And I think that that's an underappreciated aspect of leadership. One of the things that I talk about when I talk about communication is remembering that objective data and facts, depending on how they're presented, can connotate a bunch of different emotional reactions in the people hearing the message.

Lars Svensson, MD, PhD: Yeah.

Brian Bolwell, MD: And frequently, if you're talking about change, those emotional reactions are about anxiety and sometimes fear. And one thing that I think effective leaders do is make sure that they're aware that their words can impact people emotionally and they're proactive about that and I think that's part of the whole security stuff.

Lars Svensson, MD, PhD: Yeah, it's a delicate balance. Going back to our neolithic model of leadership and in the cave, if the nut trees are full of nuts and there's lots of animals to eat and lots of tubers to eat, yeah, you might talk about it. But if there's a lion in the neighborhood, that's what the whole cave hears about and everybody's alert. We're wired to hear the bad news and newspapers have realized that, especially the throwaway magazines and so on, they promote the bad news because, well, they know that we will follow that.

But if you look at it as a percentage of experience, it's very rare, a bad news event. If you like business, the black swans. As a leader, I think one needs to communicate these are the facts, this is what we know but there's great hope for us in the future and these are our strengths. In our cave, as it is now at the Cleveland Clinic, we have got incredible financial backing of what we do, we've got an incredibly good model for taking care of patients and the team model, we continue to look after each other as a physician run organization. I think those are things that we need to keep in mind as strengths and then realize that, yes, there are institutions that are struggling but we're in good shape and we are a great place, great people, we work well together, and patients still want to pour in.

I find it amazing; we've hired 40 cardiologists over the last three years for the region. Within a month, their schedules are filled and they're still running 98 percent full rates of the metric of fourth available so still very busy. So, we now have over 200 cardiologists. So, within HVTI now, with the expansion as an enterprise, we've got 427 physicians so, cardiologists, vascular surgeons, cardiothoracic surgeons. So, I think, yes, there'll be challenges but patients want to come here and, ultimately, we are here to help patients and that's what keeps us going.

Brian Bolwell, MD: As we're wrapping up, one of the things you do is you actually conduct a leadership course for members of your institute. You mentioned a lot of really interesting themes that you believe are important as a good leader, anything that we haven't mentioned so far or that I haven't asked that you think are important and that our audience should be aware of?

Lars Svensson, MD, PhD: Yeah, that's a good question. I've tried to make my theorem all-inclusive which means there are a lot of words and phrases in there. We're talking about the importance of culture, courage, initiatives, motivation can be challenging. What I would say when it comes to motivation and physicians, because they're, as I said, self-starters, it's much more important to show them respect and give them the resources and they are self-starters, and they'll mostly do the right job. It's not like you have to use much in the way of the carrot and the stick that that doesn't work. But I think you also need to understand personalities. Some people want to be flamboyant, and lead and they want to be upfront and other people want to be the ones who meticulously take care of the details and so on and so understand the personalities you work with.

The one thing that I would say that I didn't do initially which I found very helpful from an operations point of view is we have a meeting at the beginning of the week, every Monday morning, and I have this with my leaders and I go around and I tell them any updates I have, and then I go around and everybody presents what they have been doing or challenges they have and it often starts some great conversation between the team leaders. It helps us all, sort of, stay on the same page. I think, certainly, it's better to have your team help you in the decision making and I think all of us understand, if you've got a good functioning team that's giving you input, then you as a group are much stronger than an individual person solely trying to have all the insights.

Brian Bolwell, MD: Virtually every, I think, leadership textbook talks about that as well as the importance, not just of including your team, but making sure that everybody's voice is heard and actively inviting that. Lars, this has been absolutely fantastic, thank you so much for your insights. This has been one of our best podcasts and, obviously, you're at the pinnacle of your career. We're very proud of the institute that you're in charge of and your continued success. For our listeners, thank you so much for listening to this episode of Beyond Leadership and we look forward to connecting with you all again in the near future. Have a wonderful day.

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