Latest / The Hidden Load: For the educators and leaders in medicine who hold everyone up. / The Courageous Partner: Strategic Followership in Mid-Leadership
Transcript
- Santina Wheat: Welcome to the hidden load for the educators and leaders in medicine who hold everyone up. We will tackle the hard topics and help you conquer your chaos and get to calm all by starting to acknowledge and remove that hidden load. This podcast is a space for us to name the things that are common, but not normal. Each week, we'll look at the invisible weight you're carrying and explore practical coaching-based tools to help you find more calm, better boundaries, and a sense of purpose that doesn't require you to run on empty. I'm so glad that you've carved time out for yourself today. Let's get into the episode. Welcome back to The Hidden Load. I am your host, Dr. Santina or Tina Wheat. Now, today we are tackling a topic that, if I am being completely honest, makes a lot of high achieving physicians, including myself, deeply uncomfortable. Today we are talking about followership. Now, in medicine, every training pathway, every faculty development workshop, and Every leadership title is explicitly engineered to teach us how to lead. We are taught to be the primary decision maker at the bedside. We're taught to be the chair of the committee, the director of the fellowship, and even the head of the division. We are socialized from day one of medical school to take charge, to step forward, and command the room. Because that is what is needed of us in our patient rooms. But almost nobody explicitly teaches us how to be a great follower. Especially when you sit right in the middle of healthcare matrix in a variety of different roles, like associate program director, or vice chair, or site director, or clinic medical director. In these roles that might be considered mid-leadership, you occupy a unique and highly volatile space. You report directly to an executive leader, such as a program director, a department chair, or a health system VP, while simultaneously leading a team of frontline attendings, residents, and clinical staff. It might also be that you have two bosses on paper, or one boss with a dotted line to another boss. In these situations of high stakes clinical or educational systems, passive followership can actually be dangerous. If an associate program director or a vice chair or a medical director simply nods along to every directive that is coming down from above without actually testing the operational reality on the ground, then the organization develops massive catastrophic blind spots. But if that same leader openly criticizes or resists their executive in front of the team, then the psychological safety of the entire department collapses. And so today we are pulling back the curtain on strategic followership, or what organizational psychologists call being a courageous partner. In this, we are going to explore the art of being a fiercely loyal, high-intensity co-pilot. Someone who has the courage to challenge executive leadership behind closed doors, but the ironclad discipline to hold a flawless, unified front the moment that that door opens. Without having these systems in place or without having this experience, it can feel like you're either being dragged along to do things that you don't want to do or constantly butting heads. So to understand why strategic fellowship is so rare and why it represents such a heavy hidden load, I want you to take a moment to step inside the program director or chair or health system leader's office and look at the world through their eyes. An executive leader in healthcare is constantly being squeezed between two radically different and often conflicting organizational horizons. Horizon one may be the internal academic and clinical survival. For someone like me in academic medicine. Educating residents, that is the ACGME accreditation and ACGME surveys, the resident and faculty well-being, the psychological safety, the clinical coverage, and even the duty hours. But then on the other side, there's Horizon Two, the external, institutional, and financial reality. Still beholden to things like C-suite budget cuts and margin pressures and patient access and slot utilization. There's also that hospital throughput and RVU targets, and even those system level system-level strategic initiatives. When an executive leader makes a sudden and disruptive announcement, often mid level leaders will react with this immediate skepticism. They might think, why are they doing this to us? Don't they know how exhausted the team is? I'm sure many of you have had those thoughts run through your head. I know that I certainly have when I've been in different roles. When this happens, what you might be failing to see is that your executive is absorbing the friction of Horizon 2 so that you don't have to. They are being squeezed by the health system VP demands, the operating margin shortfalls, and the institutional politics that they cannot fully disclose in a general meeting. When an operational mandate drops from above, mid-level leaders typically fall into one of three toxic followership styles. There's the sheep or passive compliance. This type of leader just nods and accepts the directive without analyzing the ground truth, and they pass the friction straight down to the frontline staff. But when the plan predictably crashes, they act surprised. The second type of leader here is the yes person, where they have performative alignment. They promise the world to the executive in the meeting room. we'll make sure it happens, boss, no problem. But they make that promise, knowing full well that the team lacks the resources, the bandwidth, and even the morale to execute it. And then let's move on to the third type: the alienated follower, the break room saboteur. They stay silent during the strategic meeting. They offer zero constructive feedback to the executive, and then they walk straight into the resident lounge or faculty break room to complain about leadership's unrealistic demands. None of these styles represent true leadership, and they are all forms of self-protection. And they are all setting that leader up for frustration and more load. And so instead, I want you to think about being the courageous partner. The courageous partner understands that their job is not to passively agree, nor is it to publicly sabotage. Their job is to serve as the operational translator, the person who tests the execution parameters behind closed doors so that the final mission actually will be able to succeed on the ground. I want that to sit with you for a moment. In your role, are you acting as a strategic copilot for your leadership? Or are you letting them fly straight into an operational storm? Because it's uncomfortable to deliver the ground truth. So let's make this real. Let's ground it into a real-world high-friction scenario that happens every single year in academic medical centers across the country. This is the unscheduled expansion crisis. I want you to imagine a scenario. It's a Thursday afternoon in October. The program director calls you into their office. They have just come from an emergency briefing with the hospital VP of ambulatory operations. The VP has laid out two brutal realities. First, clinic third next available appointment metrics are failing system benchmarks. Second, patient access targets must be expanded immediately. And this has to be done without adding any additional physicians. Simultaneously, your recent Clinical Competency Committee review revealed a parallel crisis. Your PGY2 residents are lagging behind on their required volume metrics, and their procedural case volume is too low and the diversity is too narrow. So the program director looks at you and says, starting next block, we're opening our primary continuity clinic on Saturday mornings. We're going to reassign two faculty members and four residents to cover those weekend shifts. Make it happen. Now let me walk you through how the three flawed followership styles handle this moment. The yes person, they smile and they say, Great idea. We need the numbers. I'll send out the schedule changes tonight. But they leave the office knowing that the faculty are already at the brink of burnout. Child care for weekend shifts has not been addressed. And the residents most certainly are going to revolt about giving up another Saturday. But they choose short-term executive approval over long-term operational reality. Now let's look at the alienated follower. They sit quietly, nod stiffly, and leave the PD's office and immediately pull two junior faculty into a callroom. They say, You won't believe what the PD is forcing us to do now. They have completely lost touch with the clinic floor. Good luck to us on Saturdays. In this scenario, they actively destroy trust in the leadership structure to protect their own personal popularity. And then let's not forget the sheep. In the same scenario, they don't really say anything. They just go ahead and make the changes and pass them along to the teams and then are shocked when people are upset. Now let's look at how the courageous partner responds in that exact same room. The courageous partner pauses. They recognize that the PD is trying to solve two real-world problems. Hospital access metrics on Horizon 2 and resident volume requirements on Horizon 1. But they also know the ground truth fiction. So they look the PD in the eye and say, I 100% agree on the core diagnosis. We definitely need to improve our access metrics because we're hurting our relationship with health system leadership. And the PGY2s definitely need that volume to hit their milestone targets. However, if we mandate Saturday mornings without some sort of trade, we are going to trigger a burnout revolt. And also we are probably gonna hit duty hour violations by week three. Give me 48 hours. Let me run the operational numbers and draft an implementation strategy that will help us secure that volume and also not break our team's culture. That right there is the pivot. You don't shoot down the goal, but you offer to engineer the operational pathway that makes the goal survivable. This makes you feel better too, because you're able to advocate for what it is you know is right, and you're able to feel authentic in the decisions that you make. And so this brings us to the fundamental operational algorithm of strategic followership or courageous partnership, and that is the closed door, open door. Inside the closed door, we practice loyal resistance and bring raw, unedited ground truth. We can challenge assumptions, analyze impacts, and debate trade-offs. And we can present completed staff work, the S-BAR, and the execution alternatives. But once that decision is finalized and you're outside the open door, then that is the public execution phase. And there we need to eliminate all hairline fractures and leadership alignment. We need to use the we pronoun framework to take joint ownership of the directive and explain the why behind the operational shift clearly to the front line. So why is that? Well, behind the closed door, that loyal resistance. When that door is shut between you and your executive, your absolute duty is loyal resistance. You don't want to sugarcoat facts to make your leader feel good. You want to make sure that you are both looking at the entire picture. And then when you turn around in 48 hours with A situation background assessment recommendation or SBAR proposal and say, I've analyzed our template math to make Saturday's mornings work long term. We can't just add hours on top of the current workload. We have to trade them. And here is my recommendation of shifting our Saturday resident team to a dedicated Tuesday through Saturday shift model, giving them a different day off, which in this case would be Monday. This will protect their total duty hours, it'll guarantee mandatory rest windows, and even give them a weekday off for their personal lives, which they might really enjoy. We also will need to negotiate a dedicated medical assistance stipend with a hospital VP before we launch. In that private space, you can debate fiercely, you can test every assumption. You can push back on faculty coverage models, and you can advocate relentlessly for your team's well-being and clinical safety. But then outside the open door, the flawless United Front. Here is where the average leader fails. The moment the debate concludes and the final plan is finalized, debate's dead. You unlock the door, walk out into the faculty clinic or the resident lounge, and address the room of grumbling staff. A weak insecure leader shows what I call hairline fractures. They stand at the front of the room and say, Well, team, corporate and the PD decided we have to open on Saturdays. I pushed back and told them it was a bad idea, but my hands are tied. Here's a new schedule. That statement is an act of institutional sabotage. It signals to your team that leadership is fractured, untrustworthy, and adversarial. It destroys psychological safety overnight. Not just for them, but for you too. The courageous partner steps up to the whiteboard, looks the team in the eye, and deploys the United WE Shift. Over the past month, the leadership team has been analyzing our patient access bottlenecks and our PGY2 clinical volume targets. To ensure our residents get the procedural diversity they need to graduate on time and to meet our commitment to community access, we are expanding clinic hours to Saturday mornings. We know that we can coverage impacts your lives. That is why we restructured the operational schedule so that anyone working Saturday gets a dedicated protected weekday off on Monday. We've weighed the trade-offs, we've secured the staffing resources, and this is our path forward. Notice the difference. You don't say they decided, you say we decided. You don't hide behind executive authority, you take joint ownership of the operational reality. You explain the strategic why before you ever detail the administrative how. So, how do you begin practicing strategic followership tomorrow morning? Well, you need to embed three explicit leadership habits into your daily routine. Habit one, master completed staff work. Never walk into an executive leader's office with a raw, unanalyzed problem. If you walk into your chair's or PD's office and say, the clinic staff is furious about the new EMR inbox policy and morale is dropping, you haven't helped them. You've simply transferred your anxiety onto their desk. That is uncompleted staff work. Completed staff work means you never present a problem without an accompanying vetted solution. You walk in and say, the new inbox routing policy is causing an administrative bottleneck for our nursing team. I've surveyed the clinical workflow, and I have two potential adjustments that preserve compliance while cutting triage lag. Here's a one-page summary. Which path would you like me to execute? Here you move from being a source of operational noise to being a high-volume problem solver. And you can be satisfied when one of those choices is implemented and you have supported your team. Habit two is to act as the bidirectional translator. As a leader, especially if you're a mid-level leader, you're the central translation node in the healthcare matrix. When you look downward towards your frontline staff and residents, your job is to translate complex C-suite directives into meaningful clinical purpose. Your job is to help them understand how hospital throughput metrics protect the residency program's long-term funding and faculty lines. But when you look upward towards executive leadership, your job is to translate frontline operational friction into risk metrics. to explain to the VP how understaffing a rooming protocol directly impacts turnover times and revenue capture. And then habit number three is executive protection. If you see your program director, chair, or division chief spiraling under extreme cognitive load, if they are exhausted, overwhelmed, or getting pulled into high-stakes institutional battles, step forward and take the administrative heat off their desk. Offer to lead that complex task force. Draft the initial budget justification, or deliver the difficult briefing in health system leadership. Protecting your executive's bandwidth is the ultimate act of strategic partnership. This may seem like these are all the things that you need to do. And they are. But these things will show you as the great leader that you are and can be. And it'll ingenuine trust in those who you're leading and also those who are supervising you. And they'll be interested in providing you additional opportunities. We have covered a profound dimension of the hidden load today in thinking that we have dismantled the myth that leadership is only about commanding from the front. We have mapped out the cognitive squeeze between Horizon 1 and Horizon 2, and we've established the strict discipline of the closed door open door rule and outlined the daily habits of completed staff work. Strategic followship or Courageous partnership isn't about being quiet, passive, or compliant. It's about having the courage, the confidence, and the integrity to be the co-pilot who ensures that when your leadership team speaks, its voice is a unified and unwavering roar. So your Monday morning challenge, this week, I want you to look at a disruptive institutional directive. Rescheduling shift that your team is currently resisting. First ask yourself, have I had the courage to deliver the unvarnished operational ground truth to my executive behind closed doors? Or have I been silently playing the yes person? Or have I just been going into the other room and venting? Second, I want you to check your public communication for hairline fractures. When you talk to your team, Your residents, your medical assistants, your junior faculty. Are you using they or are you standing firm with we? I want you to lock arms with the rest of your leadership team. I want you to do the hard, quiet work of operational engineering behind closed doors and present an unbroken front to the world. This will allow you to have an environment that feels better. And feel proud of the advocacy that you have done for your team. Thank you for listening to this episode of The Hidden Load. If this episode helps you reframe your role as a strategic partner, I hope you will share it with someone else who could use these strategies, especially an associate program director, a site director, or a clinical colleague who is currently navigating the space between executive demands and frontline reality. Let's lighten the load together, and I will see you next week. Thank you for listening to The Hidden Load. If today's conversation spoke to you, I would love for you to share it with a colleague who might need to hear it too. It's one of the simplest ways we can start shifting the culture of medicine together. And remember, your time spent reflecting here matters. You can earn free CME or CE credits for listening to today's episode through the Pinnacle app. You'll find that link in the show notes. If you are looking for one-on-one coaching support or want to dive deeper into the resources we discussed today, let's connect. You can find information on how to reach me in the show notes. don't forget to hit subscribe so that you never miss an episode ⁓ and leave me a rating so that others can find me too. and take care of yourself because you deserve to be held up too. And I'll see you next time.