Act in Service of the Vision

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.

Hello, everyone. Welcome to Beyond Leadership. I am your host, Dr. Brian Bowell, and today I'm joined by Dr. Patrick Byrne, Chairman of Cleveland Clinic's Head and Neck Institute. Patrick, welcome.

Patrick Byrne, MD, MBA: Thanks, Brian, for having me.

Brian Bolwell, MD: Pat, can you tell our listeners a little bit about yourself, your background, and how you came to this role?

Patrick Byrne, MD, MBA: Sure. So, I spent my first 18 years in practice at Johns Hopkins. I moved there from California, where I was born and raised, and my specialty is facial plastic and reconstructive surgery. For my first many years in practice, I was really heavily focused on my clinical practice, and helped build the division there, and focused on reconstruction of cancer defects, and skin cancers, and facial nerve work, and cleft lip and palate, and all that. Super focused on that.

Eventually I had some opportunities to, probably because we built a program there, but had some other opportunities to help be part of leadership teams, and enjoyed it, and never aspired to be a chair or really move up the professional ladder in that way. But I really enjoyed building things with others and had an opportunity to interview for the chair position here, and became super fascinated with Cleveland Clinic, and about two and a half years ago, made the leap and moved my family and myself from Baltimore to Cleveland.

Brian Bolwell, MD: If I remember when you were at Hopkins, you were involved in a lot of different leadership roles, but one of them was surgical operations to some degree. Am I accurate about that?

Patrick Byrne, MD, MBA: Yeah, Hopkins built a really large, beautiful, state-of-the-art ambulatory surgery center, and I was asked to lead the effort to stand it up and develop a strategy to move, it was about 26,000 cases a year, 108 surgeons in 12 different specialties, out of the main campus and into the region. That was super interesting, very humbling, to be honest. I learned a lot, including through taking some lumps, but that was a great experience to dive into that specific domain.

Brian Bolwell, MD: What did you learn?

Patrick Byrne, MD, MBA: Oh, my goodness. People don't get excited and jump out of bed by spreadsheets. I learned that. I can geek out some operations details that I think are really interesting and cool, but not a lot of others share that. That was one thing. The other is it was actually a laboratory to try to create a culture. That I found super fascinating, because the feeling was on the main campus, the operating rooms didn't run very well, and there was a lot of grumbling. That tends to be the true case in main campus academic operating rooms around the country. We just thought, well, what if we could create an amazing place where from the moment you walk in, the surgeons loved it, and also the patients did, and all the nurses, and how the heck do you do that? That was a really fun experiment to try to figure out if you could design for that, essentially.

Brian Bolwell, MD: What did you do?

Patrick Byrne, MD, MBA: In my case, I tried to read a lot, and figure out, how do you do this, and trial and error. I think getting the right people on the bus is super key in leadership positions. People who have, hopefully, an optimistic and growth mindset, and go through life with an internal locus of control. I think in key positions, that's key. I think being super explicit about the vision, you've got to talk about it a lot, helps, because when everybody knows what you're actually trying to accomplish, it's much better than if they don't.

It's amazing how often we all get distracted and busy in our day-to-day lives, and we lose sight of what the big picture is. That's, I think, one of the key jobs of a leader is to keep training people on, well, here's what we're actually trying to do, so let's, at this moment, solve this problem with that in mind. Those are some things. I think how you run meetings, and signal safety to people, and make sure people feel truly safe to express their honest opinions is helpful. I think there's a lot of building blocks to building a high performing culture. I have to be healthy.

Brian Bolwell, MD: For our listeners, there's a lot of fundamentals that Pat's talking about here. So, when you're obviously trying, that's a big change of management job, what you're describing, taking a big chunk of surgical operations from the main campus to an ambulatory center. You always execute through teams, and what you said at the end is, I think, essential. Psychological safety allows people to voice their opinions, and importantly, you want everybody to voice their opinions. You don't want any passengers on these teams. I think that that helped generate some of the culture that you're talking about.

Then, of course, you mentioned communication. There are many different ways to communicate, but how you do it and the tone you set is, I think, very important. Leaders need to have a clear view of the big picture as you just said, but we also need to be optimistic and we need to generate confidence that we'll figure it out, that we're going to actually execute. It sounds like those are all things that you did pretty well.

Patrick Byrne, MD, MBA: Not always. I remember a really good learning experience was, I was pretty new in the job, so this is probably six or so years ago, and I was multitasking on my way into the ORs. I was handling, on my headphones, a difficult conversation, and I had patients in clinic, and a patient waiting in the OR, and I had a very brusque interaction, terse with one of the nurse managers. It really threw her off, and I realized after speaking to her that, particularly if you're the leader and you walk in, and you're super grumpy, and you ignore people who are trying to get your attention and tell you something important, it's a pretty bad signal to send, and it's contagious. Emotions are contagious.

In that moment, that's one of the interesting things about leadership, to me, as I'm trying to learn is, there's the high level, strategic side of leadership, which is important. Then there's the daily interactions, the little details of how you treat people. That really matters, maybe just as much. That was a moment, I won't forget the way she laid into me later and set me straight about it. She was right, she was right. I was not in the right mind frame to lead that morning.

Brian Bolwell, MD: Actually, I think it's those little things that matter more than the knowledge of how to be tactical about leadership. I talk a lot about serving leadership, and living your values, and having the courage to live your values, and I think all that's really important. Anyway, in terms of the story you just described, thank you for that. I think it's important that we all realize that when we communicate, especially from a leadership platform, it's not just the facts behind what we're saying. It's also that these words carry an emotional component to them, and how they're received emotionally is very important. It gets into intention versus impact. The intention of our words is usually pretty noble, but if the way we impact other people is something less than that, then the intention is going to get lost.

Patrick Byrne, MD, MBA: Yeah, so how do you course correct? How do you get feedback to know that it's not landing the way you intend, and how do you adjust your habits?

Brian Bolwell, MD: Well, I think I've messed this up many, many, many times, Pat. I think I'm pretty much an expert at messing this up. A lot of it's been realizing, having people tell me, but also realizing that this was an area of opportunity for me. Over decades, I have tried very hard to improve. Still a work in progress. I remember I was fortunate to meet with you when you first came, and you talked about a book that you had been reading. It was about insight, and a lot of this is that Pat. It's important for us to realize what we don't do particularly well. In my case, the intention versus impact has been a historical opportunity for me. But why don't you share how you came across the importance of insight?

Patrick Byrne, MD, MBA: There's a number of experiences. One that comes to mind was a tough interaction with a chair, my former chair at Hopkins. I don't know that this is all that unusual. I had been so obsessively focused for my first several years in practice, with building my own surgical skills, building a big practice. You know I wanted to do the most difficult interesting things, and then I wanted to recruit a team. Even with the team, we grew an entire division and a research program, but it was focused on us, and our place in this world. I didn't have enough insight at the time to recognize the opportunity to embrace everyone else.

My first hard pivot was really when I had a bit of a dressing down from my former chair. Ironically, it was during a meeting to discuss my promotion to full professor at Johns Hopkins and it was like, oh, this is great. He's going to thank me for my years of service, and he did. But he also gave some honest feedback, and I walked out of there thinking, what the heck? You know, I did all this work and created all this stuff, and he's saying I need to be more attentive in faculty meetings, and show up more, like this, that and the other. But the more I thought about it, it took me a couple days, the more I realized there was tons of good stuff in there for me to just become a better person in the workplace.

I'm fascinated by Adam Grant's Give and Take book as well, and how most of us are givers in our families, but we're matchers, most people are matchers in the workplace. We all know who takers are, and thankfully there aren't, I don't think, too many of those in the workplace, but matching's not as good as giving. Instead of always giving and matching in equal portion, reciprocity, what if we just try to just try to give, try to adopt a mindset where I'm here to add value to other people's lives, and I'm going to try to help them, and I'm not going to worry about what I get in return. To the degree I'm able to do that, life is better, that's for sure. It's more fun, too. That was the first hard experience of realizing I had work to do. I'm sure quite a bit.

Brian Bolwell, MD: For our listeners, Adam Grant is a guru these days on leadership and leadership teaching. One of his wonderful books is called Givers and Takers and it's a great read, but one of the ideas is that altruistic people who are givers can, we were talking about culture earlier, they can elevate the culture of a team and actually convert people from being maybe not so much of a giver into becoming people who are givers. Pretty powerful stuff. Just to wrap up the Hopkins story, how'd it goes? I mean it sounds like it went well. Did it work?

Brian Bolwell, MD: What about the project?

Patrick Byrne, MD, MBA: Oh, the project. It went well. We actually created a wonderful team. It was really one of my great experiences in life, and I love everybody on that team still so much. We're still friends, and I did hear from countless surgeons in that first year we opened like, wow, it's different here. To me, that was more than the numbers and cents, that was the sign of success. Wow, I really like coming here. Everybody's so nice. They seem like they want to help. I think we got the culture piece down, and then we were doing very well on the operations side and meeting targets. All that happened. We opened in about July of 2019, so you can imagine what happened in short order, and then I highlighted it out of here. I actually came to Cleveland in August of 2020, but it was great. Our first year went really well. It was a great experience.

Brian Bolwell, MD: Why did you decide to come here?

Patrick Byrne, MD, MBA: You know, I think we touched on a little bit, Brian, that if I hadn't had that experience in the ASC, actually I don't think I would've responded to the invitation to interview here. I had always thought that I didn't want to be a chair, or a leader of something other than a small subspecialty niche, for a variety of reasons. One, I like being creative. I like building things. It's more interesting, to me, to build something new and innovative than to steer a ship that's going really well. The right opportunity would have to seem like it has a big upside.

Then in the ASC, an aspect of leadership that I didn't know if I would like or not is a lot of the HR stuff, coaching people. And I didn't feel, and now it's probably some lack of insight on my part to say this, but I will say that I didn't feel like I needed a lot of praise or coaching going through my early career. Yet, in a leadership role, often that's what one needs to do. I didn't know if I'd like it. And it turns out, I loved it. I loved helping people solve problems. When we got complaints about someone misbehaving in the OR, instead of it being a challenge, I felt like it was a positive challenge. There's something that's making this person upset, and let's help him or her figure it out. And you know, I felt, gosh, I really like this.

The simple answer is, I felt the timing was good for me to go all in on focusing on others instead of myself. That's honestly probably as much as anything is what it was. When you accept a job, chair for example, you've got to be all in on the team. It's not about you. All those personal professional aspirations have to take a backseat. I felt like I was just jumping into a pool, almost like I just made the leap, and I was ready for a change. Cleveland Clinic explicitly, I do feel, and I still do almost three years in, has a unique capacity for innovation, I think, a comfort with risk and an ability to be nimbler than many academic medical centers. So, I liked the idea of innovation here. That was it. The rest is history. We took the leap, now we're Clevelanders.

Brian Bolwell, MD: Couldn't agree with you more about the concept that one of a high-level leadership position is all about the team and certainly not about you. I think that's totally the right attitude to take. What have you discovered since you've arrived?

Patrick Byrne, MD, MBA: It's hard. It's hard on the high-level strategic decision-making side. It's hard to be consistently effective on the soft skills, small, interpersonal side too. It's incredibly rewarding. The rewards, the tangible progress is often delayed in this role, I find. Very different from training a fellow, where you're right together in the weeds in the OR every day.

So, I think my first year, it was incredibly interesting, I didn't regret the decision for a moment. I don't know that I would use the word fun to describe what I was doing, But I was into it. We have a job to do. We're going to become the best place, and we set aside time. We created a vision statement and a set of values. We put a lot of time and attention into it, and it's an amazing one. It's, we aspire to be the best place on planet Earth to receive or provide care for conditions related to the head and neck. We're going to treasure our caregivers, innovate, and demand unprecedented excellence. We have five pillars there.

It's really fun to develop a clear and compelling vision, but more fun to just try to take daily action in service of it. Once you see a little progress here and there, you know, it's so energizing, and if you keep your eyes open, you see progress all around. I think people get excited, and it's been really fun. Very hard, but also super rewarding. I feel very blessed.

Brian Bolwell, MD: From a leadership philosophy, what do you think are the keys? What do you think are the keys to doing what you're doing, which is having a compelling vision, rallying your team, executing, leading through change? How do effective leaders do it, and what do you try to do?

Patrick Byrne, MD, MBA: I assume I'll answer in a better way five years from now, 10 years from now, 15 years from now. So far, I'm a big believer in the culture, like we mentioned. I think having a vision is incredibly helpful. I don't know if it's necessary. For me, I think it is. The vision has to be pretty specific. You have to be able to feel it. When people know what you're actually trying to, I think of it in terms of, at the very top are the objectives, and once you know what the big objective is, what are we actually trying to accomplish?, is another way of saying that, then creating a strategy and then letting the tactics fill the strategy is sort of the sequence that makes sense to me. The vision is super key. I think creating the conditions for a healthy culture, which we mentioned, is incredibly important.

In the end though, a lot of the getting stuff done, you can't do yourself. Pretty quickly, you know, realize you need teams, and you need good leaders of each team. And then, you can't micromanage each team. People hate it, and it's stupid, because if I start telling the front desk people how to do their job, I'm dumber than I look, right? They know their job better. They're the ones with the patient every single day. Listen to them. I think what we try to create is a bunch of signposts towards, we want you to lead in your own area. We want you to let us know how best to do that, but none of us matter in comparison to the vision. The vision is what matters. That's been interesting.

Then I think you do have to manage as well as lead. All the vision talk in the world is, I think necessary, but it's not sufficient. That's building in management practices with clear expectations, objective measures, holding each other accountable. I find that side of leadership interesting as well, actually. But those are the building blocks, I guess, which is where I would start to answer your question.

Brian Bolwell, MD: A few topics to briefly expand on. Obviously, what you're describing when you say that you've got to rely on your teams to execute is the concept of trust. If you're going to effectively delegate and empower people, you've got to trust them too, in fact, as you said, they know what the job is and you're trusting them to in fact execute.

Patrick Byrne, MD, MBA: Totally. That begs the question perhaps, do you earn trust, or do you just grant it? I think it's a little bit of both, for me. I think for key leadership positions, it takes some time to know who's capable, but I think starting with the baseline respect of every single person, that I want to hear your views, I want you to be honest with me because I don't have all the answers. That's pretty key. I can see how easy it would be as a leader to live in a bubble where everybody laughs at your jokes, and they all tell you you're great, and then you're not making great decisions because you're not getting good information.

I often think of every single lecture I ever gave in an academic setting my entire career; I always hear the exact same thing. Great talk, great talk. I know they weren't all great talks, but everybody always says, great talk. Somehow, we have to solicit unvarnished, true opinions, and prove to people that it's okay for you to do that. With that, I think you can trust virtually everybody. If they prove they're not capable of filling a certain role, then you've got to make a change. But I think you're right, trust is so key to health, because otherwise nobody talks, people harbor grudges. They're not going to align with your vision if they don't believe in it, and don't feel comfortable expressing alternative points of view. There are so many things that are based on trust. It's a great point.

Brian Bolwell, MD: You're touching on some other themes as well. You just said I don't have all the answers. I think when leaders show humility, it elevates culture. I think it's a great way for leaders to connect with members of the team, because they'll want to help. They'll want to contribute. Then you talked about treating people with respect, and this tends to come up repeatedly. There's a study that Steve Covey quotes in The Speed of Trust. What separates high performing organizations from those who aren't as high performing, and it's how you treat your fellow human beings. If you treat the people around you with respect, and dignity, and curiosity about what they're thinking, again, that elevates culture, and it just is a winning formula, and you're just describing it, so congratulations.

Patrick Byrne, MD, MBA: Well, what jumps out to me is, I remember in, I'm sure it's true as an oncologist as well, in facial plastic surgery practice, you've got a lot of different types of patients. Occasionally, you'll have someone who you know is just going to be challenging. Maybe you met them before and you just, oh, man. You see the name on the schedule, and you, early on, it took me a few years to figure out how best to manage difficult people in my practice. It actually might have been another Adam Grant thing that got me to thinking about it, but somebody I heard once talk about how instead of being your true self, because maybe your true self that day is a grumpy person, be your best self and inhabit that space.

I started experimenting with talking to myself as I entered the room and reminding myself, I'm going to love this person no matter what they say. I use the word love, and I'm open about it. I realize that I can immediately express my own concerns, because it's always our reaction to the other person that causes distrust and lack of respect. It's not the other person. By inhabiting that space of, I'm going to be there to show compassion. I'm going to let them know it, and it just makes life better. I find that it's like a switch that I think we can turn on with others, and remind ourselves that it's not about me, it's about them. How can I support and love this person? Hopefully, that's a little contagious. That gets around.

Brian Bolwell, MD: That is a great story. I really, really like that. Actually, there's a book called Love 2.0, which in fact talks about the fact that we can create loving encounters with anybody in 30 to 40 seconds if we actually make the attempt. I believe that. I think that's a great way to put it, to always try to be your best selves.

Earlier, you also talked about how you liked another part of leadership, which includes objectives and key results. You mentioned at the beginning that you were learning, or you learned how to run a meeting. Can you tell us a little bit about your thoughts on this part of leadership?

Patrick Byrne, MD, MBA: So, I find business interesting. I have a pretty varied background in the private sector and academic sector. I think what I've found is there's abundant opportunity to innovate and improve practices within healthcare, within large centers, within individual practices. What I've tried to do is a combination of creating a structured process, focused on clear accountability, but also infusing it with coaching and learning.

Amongst the tactics that we've employed is, I don't think any are particularly novel, a monthly business review with individual division or section leaders, in which we try to focus on data that actually matters. There is so much data that we are exposed to, Cleveland Clinic's amazing at creating data, but the effect tends to be mesmerizing the observers, where we all sit around and look at the data. We just admire the data. That doesn't help anyone.

I'm often reminded of one of my favorite business phrases being, never underestimate the complete unimportance of almost everything. I think part of art is trying to home in on what matters. That's a leadership skill. So much noise, but what's the signal? I think we owe it to our leaders that report up to us, and our colleagues, and our staff to help them see what actually matters. So, in those business reviews, we try to limit the data to what matters, and then take action on those. Simple tactics, like a fill rate by clinic visit type can be looked at frequently because it can be adjusted. You're continually optimizing, and you don't do the same thing for every single specialty. You adjust it for that specialty.

Rebalancing clinic versus OR. We don't put nearly enough thought into this, we just assign clinics and assign ORs. In reality, there's probably an optimal balance in how many days per month should be in clinic versus OR for every surgeon, and it's different for each practice. Why not design for that? We can look at wait times for one, wait times for the other, and on a quarterly basis, just like rebalancing your stock and bonds portfolio, you rebalance. This is how you optimize.

I think focusing on operational leverage and productivity ratios is, productivity ratios are interesting because in healthcare, by and large, unless you create alternative payment models and all that, which is coming as well of course, but it really comes down to volumes, yield and cost. We can bucket the various options into these different categories, and realize they're multiplicative, and small changes make a big difference. I do find the coaching of business principles really interesting and fun to unlock value.

Brian Bolwell, MD: Well, they are. They're actually fascinating. I really like what you said a minute ago, which is, we are inundated with a lot of data. We measure a lot of things, and we track a lot of things. But I do think that one of the leader's important roles is to let the group know what's really important, what our primary priorities are. Because if we don't, we've got literally hundreds of priorities. What do we really need to focus on? Arguably, if you get three or four of them, probably most of the rest of the stuff will go okay too, because you've got really good people. Then of course, as you said earlier, some of the things aren't that important, but simply being able to articulate that is, I think, a really important leadership skill.

Patrick Byrne, MD, MBA: One of the famous examples of course is your emphasis on time to treat. To me, that's beautifully reductive. I was fascinated by it, because it's clearly the right thing for a patient with a cancer diagnosis, and that's where every effort should start. But, although I don't recall you saying this when I learned about this, what followed for me was a lot of other important financial metrics would follow from that. It's not the primary reason to do it, but it's an elegantly reductive thing to focus on, and when that's possible, it's very helpful.

Brian Bolwell, MD: Well, thank you for saying that. That's very kind of you. For our listeners, when I was running the cancer center, the interval between a new diagnosis of cancer and the first treatment, called time to treat, was very important to us because when I started to look at it, it turns out, in an academic healthcare center, the average time to treat is over six weeks, which seems to be an unusually long time for a newly diagnosed cancer patient.

We're in tough times right now, Pat. We're coming out of Covid. We've got financial challenges. You always express a degree that's refreshing of optimism, and a confidence that it'll be okay. How do you do that, and how do you see the next couple years playing out?

Patrick Byrne, MD, MBA: Well, I think one of the biggest risks is that we will beat our caregivers too much over time. I often reflect on my experience, about 20 years now in academic medicine, that the refrain each year is payments are going down, care is getting more complex, we have an aging population, and the net result is we have to do more with less. The pandemic has dramatically exaggerated this, obviously, because of workforce shortages and inflation and what have you. But it's the same theme really. It's the same theme. You think of those three levers. We can increase volumes in response, we can try to drive a higher yield, or we can cut costs. We tend to focus on the first one in healthcare, because it makes sense. But if that's our only answer, year in year out, this story isn't going to end well.

I really worry about our caregivers, of all types. I'm optimistic, because I do think there's significant slack in each system that I've been involved with, where these small, incremental tweaks can create some space. I also have great confidence, and this is probably a stronger reason why I'm super optimistic, that we can innovate our way through. I think that's where the greatest hope lies. We clearly need to evolve how we deliver care in this country. We need to do a better job at true preventive health, for example. We need to deliver care more efficiently, with probably fewer caregivers in aggregate, but target them to the highest capacity, and we need to leverage technology more. But I believe we can do it, and I think it's a great challenge because our patients and our caregivers need us to.

Brian Bolwell, MD: That was very eloquent, and I agree with all. As we're wrapping up, Pat, any last-minute thoughts about your leadership philosophy that you'd like to share?

Patrick Byrne, MD, MBA: The only other element is humor. I do think we should have fun. You know, we spend a lot of time at work, and I notice that if I go for a few days and no one's laughing, then I'm doing something wrong for sure. It's just an element of leadership I don't hear discussed as often as I think I'm realizing allowing all of us to actually have fun, and find moments of levity, it quickly changes the mindset in the room, one from burden to opportunity, and I think there's something there as well.

Brian Bolwell, MD: It's also authenticity, which I think is a bonding thing. Actually, in one of our earlier podcasts, we talked a fair amount about humor. Obviously, it's got to be the right forum. There are certain forums where it's not going to play very well, obviously. But yes, I think that your work teams are your work family, and all the things that are wonderful about that are part of it. This was absolutely fabulous. Thank you so much Dr. Byrne, for joining us for Beyond Leadership. To our listeners, thank you for listening. We'll join you again soon and I wish everybody a wonderful day.

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