Shaping Tomorrow's Medical Leaders: Exploring Leadership Pathways in Graduate Medical Education

Podcast Transcript

Dr. James K. Stoller:

Hello and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello. Welcome to today's episode of MedEd Thread, an Education Institute podcast exploring leadership pathways in graduate medical education. Today I'm very pleased to have Dr. Rendell Ashton, Program Director of Pulmonary and Critical Care, and Dr. Richard Wardrop, Vice Chair of Academic Department of Medicine here to join us. Ren and Dick, welcome to the podcast.

In today's segment we will explore leadership pathways in graduate medical education, how leaders are identified, and how critical leadership skills are developed in trainees. Ren and Dick, to get started, could you please tell us a little bit about yourselves, your educational backgrounds and what brought each of you to Cleveland, and your respective roles here at Cleveland Clinic.

Dr. Rendell Ashton:

Sure, and nice to be here with you, Tony. I've been here at the Cleveland Clinic for 15 years and, uh, I've been the Program Director in Pulmonary and Critical Care for 13. Most of my clinical practice is in the medical ICU, and the thing that brought me here from New York where I was actually quite happy, was the realization of the mentorship that I would find here as a junior faculty, and it has just been amazing.

Dr. Tony Tizzano:

So that was fulfilled. Your expectations have been fulfilled.

Dr. Rendell Ashton:

Continues to be fulfilled, yes.

Dr. Tony Tizzano:

Dick, what about you?

Dr. Richard Wardrop:

Yeah, thanks for having me, Tony. It's really great to be here, especially with Ren, who's a great colleague and friend as well. I came to Cleveland Clinic about two years ago. I was recruited here specifically to be the Program Director for the Internal Medicine Residency. I've spent most of my career post-training in either an academic leadership and/or medical education leadership position. And what brought me here was really, one, the need for a new residency program director, and two, what I foresaw as a truly patient-centric clinical enterprise with excellent medical education opportunities.

Dr. Tony Tizzano:

Fabulous. Well, Ren, you know, to kind of help us frame this topic, you know, what is the importance of leadership development in education, and in medical education and in residency education? Do you have to come with these skills? Or can they be instilled over time?

Dr. Rendell Ashton:

They can certainly be learned. I'm gonna start with just, uh, backing up a little bit. You know, all doctors really are teachers, and, in fact, the word doctor means teacher. And I also want to make the point that all doctors are also leaders, and thinking about the history of the Cleveland Clinic, we had our origins back in World War I with some physician surgeons who served in the war over in France and noticed that teamwork was the name of the game in the army hospital where they served.

And that was in sharp contrast to what would have been going on at home and what really was the normal model here in the States of just really solo practice. And so, from the very beginning in 1921 when the Cleveland Clinic opened its doors, the model of teamwork has really been our brand and a big part of our secret sauce here. And even today, if you look at the way the clinic runs and really throughout health care, the leaders of teams, the leaders of organizations, the leaders of hospitals, by and large are physicians.

And I was thinking about this, and- and the question of leadership in medicine, and, you know, whether you are positioned to be leading a large academic hospital or a medical center, whether you lead a department or a unit or a, uh, or a team of specialists, or even at its most fundamental level, when you sit down with a patient one-on-one as a physician and you have a- a conversation about a diagnosis or about a treatment plan, or the prognosis that a patient is facing, someone needs to lead that conversation. And our patients look to us to lead in unique ways as health care providers. So, I think it's an inherent part of what we do as physicians.

Dr. Tony Tizzano:

So, educator, leader, at many, many levels.

Dr. Rendell Ashton:

Yes.

Dr. Tony Tizzano:

So, Dick, do you think there is a gap in leadership between what is expected of our trainees and what we are actually teaching them?

Dr. Richard Wardrop:

I do, and I think a lot of it plays into what Ren just described as far as what patients expect versus what someone on a nursing unit may expect, versus someone in a clinical setting may expect, whether it's a respiratory therapist or EMT or something like that. There- there are a set of things that are sort of expected of physicians even in training, but we don't necessarily train them in leadership skills themselves. We sort of just expect it to be there in a lot of ways, and then in some settings we actually chide them for not being their present in sufficient quantities.

And we, we certainly even extend that into the faculty identity too where, if someone is picked to be in a leadership position, say as a program director, for instance, but they don't display good leadership behaviors to go along with their excellence in medical education or in clinical practice, we're like, "Why is this missing? Why is this leadership missing?" And a lot of times it's because there is a deficit in training with some of these skills that are actually aligned with leadership, not just in medicine. And so, if you look at other health care systems and/or education systems, for instance, CanMEDS, which is the equivalent of the ACGME in Canada, actually has leadership as a core competency within their training programs.

We do not yet have anything like that within our own graduate medical education, but in my conversations with folks at GLLI here talking about the medical education of students and re- residents, there- they clearly also see a gap when people leave training and then go off into the workplace. And that's good for their business and the fact that they give leadership training. In our training program, for instance, we have identified leadership as something that we really want to target and improve our education and during training.

Dr. Tony Tizzano:

Yeah. It's an interesting path, and I think back, uh, probably over a decade now, Ren, that, you know, you and I attended the Cleveland Clinic's leadership course, and, you know, that, for me, was probably predicated on having become medical director at a family health center. And I don't know about you, but I mean, that was a tremendous growth experience for me.

Dr. Rendell Ashton:

Yeah, very much so. I loved it.

Dr. Tony Tizzano:

Does something like that exist for residents and our trainees?

Dr. Richard Wardrop:

I think the closest thing that I've seen here is what those in the education institute and Dr. Stoller, they do a leadership academy, if you will, for rising chief residents, and that's something that those that have been selected to be chief residents, and even some of our house staff association officers do get that experience. So that is relatively later in their training, even potentially, at the conclusion of their training.

We are part of a consortium here in Cleveland with university hospitals that's called The Leadership in Clinical Education Consortium, but again, that is of a smaller subset of residents who are in our clinician educator track for instance, and not necessarily the entire residency. So, there are opportunities without them being intentionally put into the main part of a curriculum. They're left to those that have, sort of, been in other leadership tracks.

Dr. Tony Tizzano:

Or developed, perhaps, an interest. So, Ren, what are some of the key components, when you think of professional identity, which we certainly hope the leaders have, and how does that impact their development?

Dr. Rendell Ashton:

So, I love that. I, actually, have gotten really interested in the idea of professional identity among physicians. And what that identity really is, it's sort of the intersection of behaviors that you see, the roles that people play, and the values they hold. And the identity forums gradually, early on, as an early medical student, it probably starts by just mimicking behaviors that you see in leaders and teachers and mentors that you have along the way, and then over time that morphs into more of an internal sense of who you are, and the behaviors flow more or less naturally from that identity that's more of an internal thing.

And for that identity to form really well, there has to be some introspection along the way, some reflection on experiences that we all have as we go through training. And as educational leaders, a big part of what we do is to facilitate not only those experiences but also the reflection around them that leads to the formation of that identity. And you- you talked about the impact that has on leadership. Historically, and Dick was talking about some things that we do for our chief residents and others who we serve in leaders, a lot of times in medicine leadership opportunities come along somewhat haphazardly. You're in the right place at the right time and somebody just sort of taps you and says, you know, "How would you like to run this program, or chair this committee, or- or lead in this way?"

And sometimes that serendipity is great, and it can certainly represent a great opportunity for someone, and you hope that the person who is doing the tapping recognizes some strength or some preparation for that. But I think all of us who have found ourselves thrust into a new leadership role have felt that sort of sense of, "Who, me?" The inadequacy, or the impostor syndrome of, "Ho- how did I come to be a leader in this role?" And so, there is sort of a sense of, you know, are you ever really prepared for when you need to lead? But I think one thing that's coming out of that sense is that more and more people who aspire to lead within medicine are being deliberate about choosing that pathway.

And we see people even in medical school or and certainly during training saying, "You know, I think I want a job like yours one day. I would like to be an educational leader. I would like to train people coming along after me. And what do I need to do to do that?" And so, they're being a lot more deliberate about mapping out that course. They're talking to people who are doing what they want to do one day and figuring it out from where they are with that eventual goal in mind. The last thing I'll say about this is, you can't talk about this without emphasizing mentorship and the importance of good mentors and role models for these young professionals that are beginning to aspire to lead. They need to see what that looks like, and they need to be guided by people who understand that landscape and can help them navigate it.

Dr. Tony Tizzano:

Well, Ren, I couldn't agree more. I am even looking for mentorship now. And I've been around for a while. In fact, you know, the wisdom that comes from that, if there were a wisdom tree, I'd be under it shaking it, you know, as we speak. So, it sounds like we're actually, you know, the saying that, you know, "Failing to prepare is preparing to fail." So, for- with this idea of leadership, that preparation can really make a difference. So, Dick, we talk about professionalism, we say, "Gee, is it innate, or can it be developed?" You know, when you see on the horizon that you think you've got this chief resident, what was it that you saw in this individual that brought, uh, he or she, to your doorstep and that you decided to nurture. What is it?

Dr. Richard Wardrop:

Well, there probably is an invisible professionalism standard that many of us would say, "That person has it." But we, when asked, it's a series of behaviors, it's a series of characteristics, the way they talk to patients, for instance, the way they talk about colleagues, or don't talk about colleagues. The way that they do their daily tasks of citizenry in- in the residency, for instance, or the way that they present themselves in a public venue, it creates this snapshot that quite honestly is maybe a little bit unfair to apply without there being clear, you know, behavior elements.

But luckily, we have the ACGME who's helped us define at least some of the milestones with behavioral anchors around professionalism, and that has made it, from a program standpoint, easier to help define, especially if there's a lack of professionalism. We can point to specific areas and say, "We need you to work on this part of your professionalism, or this part of your professionalism." So, I do think that it can be developed, however. I'm reading a book right now called The Book of Joy. It's about the Dalai Lama and Archbishop Desmond Tutu, and these dialogues that they're having about finding joy. And they talked about a person's happiness and their ability to be happy is probably about 60 to 80 percent, it's genetic, and the rest is malleable.

And I've also heard in my own personality inventory here at GLLI that about 70 to 80 percent of my personality traits and probably how I see the world are also pretty defined, hardwired, and only about 20 to 30 percent malleable. So, I also feel that professionalism and that some of those behaviors are tied to those, and I don't know what percent is malleable or not. But we definitely, as educators, do feel comfortable in remediating those that are having difficulty meeting professionalism standards.

I oftentimes go back to, uh, this idea of etiquette-based medicine, that if it just doesn't come innately, then just do these six things every time and you're gonna be just fine. Almost behavioral engineering around professionalism. But I definitely think it's something that can be nurtured, role modeling, mentoring, spending time in reflection. I couldn't agree more with what Ren said about that reflection. In fact, our residents are asking, literally, for more time for reflection, and we're trying to build that into reflective practice in our curriculum.

Dr. Tony Tizzano:

That's great. You know, that's a word that I didn't even really understand or even know about until I began doing some work with CCLCM, the Cleveland Clinic Lerner College of Medicine, and where reflection is a huge part. And I've really come to value that. You know, in our APM3 class at Art and Practice of Medicine, we have the students write a reflection on that day's discourse. And I take those very seriously. And my responses to them, I spend time with it. Uh, I never had anything like that in medicine, and part of what you're talking about seems like we're talking about character and building character.

And I hope that students who come into health care at every level look at it as a profession and not just a job. And as a profession, you require professional behavior. You know, for either of you, we talked a little bit about it, but I want to go over it again. What are the leadership paths that, someone who comes here and says, "You know? Not only do I want to be an excellent physician, I also want to lead in my area, lead a hospital or a clinic or an area of specialty." You know, where can you start to build on that?

Dr. Rendell Ashton:

Well, I have a few thoughts. There isn't just one path to Rome, and that's something that may change over time, but I suspect not. You know, the concept of the road to success is a straight freeway that gets you from point A to point B quickly is dispelled for all of us somewhere along the road early on because it's just not like that. The road takes twists and turns and hairpins and double backs and, you know, you find yourself sometimes going around the block a few times before you figure out which way, you're gonna head eventually, you know. So, I- I think as people find their way toward their niche in medicine, in leadership, in education, a lot of it is the experiences that come along the way. But that being said, I think it- there's more to it than just, you know, jumping in and letting the current take you wherever it's going. You have a lot of control over how you interact with that current as you go down the sort of the stream of life.

And I'll give an example. So, you know, my fellows will sometimes come in and talk to me and say, "You know, I want a job like this or that, and I think I need a master's degree." And I say, "Okay. That sounds interesting. Let's talk about it." And sometimes they'll say, "Do you think I should get a master's degree?" And I say, "Well, let's back up here a little bit, and talk about, well, what kind of master's degree, and what do you want to do with it? Like, what do you want to do with your life?" And sometimes it becomes clear that what they really want is some extra initials after their name and haven't really thought about how they're gonna use that experience to help them reach their goals.

But sometimes after we talk it out it becomes clear that they have very definite ideas about what they want to do with their professional time and their life work. And those skills that they would pick up through a master's program would be essential to them doing what they want to do. And sometimes they're not so sure, and I'm not sure either. And so, I say, "You know what you need to do? You need to go talk to my colleague down the hallway here who does what you're talking about and see if they would get a master's degree, if they were sitting where you are right now and planning to do their job." And those who pursue that and put in the leg work and figure that out for themselves end up doing the things that really serve as valuable steppingstones toward their goals.

And so, a lot of it is pretty iterative as you sort of maintain your view of the future and you pick up wisdom and input from others along the way, and this is again where the input of the mentor comes in so strongly, who can say, you know, "Let's think about that. Do you really need a degree, or do you just need a statistics course? Or maybe you need this kind of experience. Maybe you need an international experience for what you want to do. Maybe you need a different kind of leadership role that we could give you within the program." And that little bit of extra wisdom that comes from years of experience sometimes puts that younger trainee on the right course toward what they eventually want.

Dr. Tony Tizzano:

Yeah. That's a great point. You know, we're always told, "Look ahead. Look ahead. What are you gonna do down the road?" But with a good mentor they have the benefit of hindsight, which we don't have yet, as a trainee. And so, they can bring a lot to the table that just wouldn't be there otherwise. So, Dick, along the same lines, tell us a little bit about the clinical educator track at Cleveland Clinic.

Dr. Richard Wardrop:

Absolutely. So, within the medicine residency we have a subset of our residents who match directly into our program, our three-year program, into what we call our Clinician Educator Track. And that is a small subset of residents of the 55, it's only three per year, but that group has a specialized set of didactics and they have prearranged specific contact with the medical schools, and they also are charged with having a project, a mentored clinical education project, usually the development of some sort of curriculum plus assessment.

And so those residents then leave our residency not only as clinically trained as everyone else is, but with this other specific set of skills that they wouldn't necessarily have. That oftentimes leads to a career in medical education as far as their next steps, whether that's fellowship or directly into employment. We have had a program, I think, for about five or six years now, so we don't have a lot of long-term outcomes, but there is a collection of clinician educator tracks, and even post-residency fellowships that are now emerging to really build upon this, you know, very intentional pathway.

I will say, to be fair, that many that are not in the clinician educator track actually end up going on to jobs in medical education as well, sometimes unexpectedly, in their first job. One of our recent graduates was asked if he wanted to be, you know, part of a leadership of a residency. This was not on his radar. He just happened to be at the right place at the right time, and he was talking to me about it. And I said, "That sounds maybe a g- like a good opportunity for you." So, it's an intentional and very specific approach to giving skills, but it's also in line with that, you know, very intentional creating future clinician educators.

Dr. Tony Tizzano:

You know, it's excellent, because what has certainly come for me to understand is there is a science of education. There is a science behind curriculum design and assessment that we're beginning to question in many, many ways how we've done it in the past. So, you know, I think there's a lot on the horizon. So, Ren, when we look at these, I always think of the chief resident, a- and I look back at my experience in medical school and our internal medicine chief resident and the respect everyone had for that individual. We're talking about additional time. What is the time commitment? What is the scope of what they will do?

Dr. Rendell Ashton:

Well, that's a great question, and I guess the concept of a chief resident is a highly variable role. But I was a chief resident once upon a time. I now have chief fellows in my fellowship program, and I can't imagine how a program would run without them, honestly. And in fact, what we're seeing now is some specialization within chiefs. A lot of programs will have curricular chiefs and scheduling chiefs, education chiefs, that, different roles that the chiefs take on as educational leaders.

And it's a fantastic experience for these young people who may be aspiring to be program leaders or other leaders in medicine one day, and it's really a chance for them to see what goes on, sort of, backstage, so to speak, in GME and in other aspects of education and of medicine, really. It's a great mentoring experience. These chiefs are mentored closely by program directors and associate program directors, and chiefs also find themselves functioning as mentors for their younger colleagues, and that can be a very enjoyable and enriching experience for them.

They'll have experiences with skills that they may not have used much, like conflict resolution, and I've had people say, you know, "Since when did I become a marriage counselor anyway?" And just things that they never expected to have as part of their job description, but they just, they come up. And people have trust in them and in their skills to communicate and to guide. Another thing that is very valuable and a great learning point for chiefs is to learn when it's time to kick it up to the program director. If one of their younger colleagues needs some disciplinary action, for example, that may be something that it would be best for that chief not to try to handle on their own.

It's just so important in their role as the chief to maintain the trust and respect of their colleagues, of the residents and fellows in the program. So, there's a lot that goes into this role, and it's a tricky role because they have to face both ways. They kind of represent the leadership to the residents or the fellows, and they represent the residents and fellows to the program leadership a lot of time. And they have to do that with integrity on both sides. So, I have a lot of respect for people in that chief role, and I see them as extremely valuable to our educational system.

Dr. Tony Tizzano:

Oh, I couldn't agree more. So, Dick, you know, I listened to what Ren just had to say, and I think about, you know, leaders and education in health care, and I think about the autonomy that I had when I was in residency, where we did not have in-house attendings until the second half of my last year. I look back and say that with some embarrassment, but that's just the way it goes. You know, how do you begin to balance that autonomy that you want to build, and the oversight that you need to give, and what organizations play a role in all of that?

Dr. Richard Wardrop:

That's extremely relevant when it comes to professional identity formation, too. You know, medical students graduate from medical school with a set of expectations that in residency they will get X, Y and Z skills, learning how to admit a patient, discharge a patient, maybe doing procedures. We then have to align their expectations with what we are actually obligated to do versus what we're able to do within the health care setting. So, we align, as medical education leaders, that expectation that the residents have, balance that with what is possible from the health care system versus what, like, the, i- in our case, the American Board of Internal Medicine and the ACGME would say that we have to provide.

It can be challenging in our residency and in the residencies which I've been associated with. We almost always go towards resident agency and autonomy as something that we want to promote. We assess the residents' feedback on the presence of other learners in the environment, they may be impinging upon their autonomy, though this balance between work and, you know, education that work versus service-type autonomy as well. You know, we don't necessarily want our residents to be in patient transport for instance. We want them to be, you know, delivering patient care. So, there's a lot that factors into that as far as the oversight and balancing autonomy and, you know, their professional identity formation as physicians, and what we're able to do because of the health care system.

Dr. Tony Tizzano:

So, a constant work in progress. You know, Ren, we talk about inclusivity, diversity, equity, inclusion. How do you build that into training programs?

Dr. Rendell Ashton:

You know, that's such an important topic when we start talking about modern medical education. We've really learned a lot about how to make a good learning environment. And for a young professional to learn, and especially to form that identity that's so important that's gonna drive their behavior, their professional behavior, there has to be a sense of safety and also of equity on this team that, we believe medicine is a team sport. You have got to understand that you are there with everyone else on the team.

And so, we've become aware of the sort of symptoms of a lack of that safety and equity. So, for example, if you have a health care team where there are necessarily differences amongst the different providers, but if those lead to a sense of treating each other differently because of those differences in detrimental ways, you know, we- we talk about micro-inequities that may or may not even be intentional, or even aware of. But when those take on a negative aspect and start to interfere with people's performing their duties or having, you know, healthy interactions with each other, we call them microaggressions.

And when they become, you know, more intentional and derogatory and really damaging to the overall work or performance, you know, then they call them micro assaults. And these can be so toxic to that learning environment that we have to recognize them and know what to do. But if we want to get rid of these things in our learning environment, what we really have to do is back-up to what led to these problems in the first place. And it's a sense of differentness in a negative sense, like, when we look at each other and compare each other and look for superiority and inferiority, that's when these things start to show up in our behaviors, even subconsciously.

And so, again, one of the skills that maybe wasn't in the initial job description when you said, "Yeah, I wanna be a educational leader in medicine," that you find is so important, is learning to iron those things out and helping people to have respect for each other, in spite of differences, to value diversity and even, you know, and embrace it, and say, "This is actually gonna make us all better." And, you know, quick, and- and maybe obvious example as we train our fellows in critical care, we found that the experience and the learning is richer for everyone if we have trainees that come from different backgrounds, from different cultures, from different subspecialties even.

And all of this just enriches the overall experience for everyone, not just the fellows, but for, you know, those of us on the faculty as well. And if we can learn to embrace that in more and more ways, then these problems would disappear. But it's the consciousness of those issues and the approach to fixing what's broken that is becoming more of a theme in education now.

Dr. Tony Tizzano:

Yeah. And I think this is a tough one for students, I think it's a tough one for trainees because they want the approval, they want the great letter, they're afraid to even bring these things up and that idea of psychological safety is a real issue. And I think that a lot of microaggression, if not most of it, is predicated on implicit bias. You don't even realize it.

And so, I think it's incumbent upon us as leaders to have an awareness and to say to our trainees, "Look, this is something I'm learning about. I'm interested in it. I want you to come forward. It will never be looked at like a weakness." But that's a step that I think leadership in any organization has to take. So, considering all of these things, what do you see on the horizon? Is there something coming that you're looking forward to in the idea of leadership development and health care education and graduate medical education?

Dr. Rendell Ashton:

I can see a couple of thoughts. I think, one thing that we're gonna see is more and more of these sorts of tracks toward more formal leadership roles in education. And I think that's a good thing as long as, you know, the landscape remains fluid enough for people to find their way and- and they don't feel like, "Okay, if I, you know, start down this path, it's a life sentence, so I'm gonna end up doing this one thing for the rest of whatever."

You know, we need to be able to explore who we are and where we're gonna find the most joy and meaning in the work we do. But I think having these tracks defined in ways that allows people to do that exploration early on is gonna be very helpful. And I think it's gonna go along with this increased awareness of that professional identity that we keep talking about, that people are gonna be able to envision, how that identity is gonna look for me down the road?

Dr. Tony Tizzano:

Well said.

Dr. Rendell Ashton:

And plan for it.

Dr. Tony Tizzano:

Dick, do you have anything to add to that?

Dr. Richard Wardrop:

As we get more specialized in some of the opportunities that we provide in residency training or in medical school with leadership, I think we then need to answer that with positions and opportunities for those that finish training and then go on and have these experiences that are formatives for that next step. And so, finding ways within departments, within divisions, within institutes to create leadership bandwidth, there's plenty of leadership tasks to go around, is to really match that with the professional identity formation of faculty and/or staff, too.

'Cause I think that if you do it in training but yet there's no ability to practice, it's almost like point-of-care ultrasound, you don't get a chance to master your skills or grow. So, I think that's an important endpoint too, is when people make that transition from trainee to early career physician to mid-career physician that we still continue to have the leadership pipeline in mind.

Dr. Tony Tizzano:

Well, this was a fabulous discussion and I want to thank both of you for joining us. I think this has been an enlightening episode of MedEd Thread. To our listeners, thank you very much for joining, and we look forward to seeing you in our next podcast. Have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread, and please join us again soon.