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FRANK JAMES LEXA, MD, MBAPROFILES IN LEADERSHIP

© 2009

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leader is best when people barely know hexists, when his work is done, his aim fulfilled,hey will say: we did it ourselves. [1]

—Lao Tzu

NTRODUCTION

rises, whether mild or severe, arehe times that truly test our leaders.or radiologists in the United States,ew would argue that we are not inhe midst of a crisis that is both realnd severe. Our reimbursement haseen cut hard and will likely be cutgain by the new government. Clini-ian self-referral has not only madeeep inroads into the traditional do-ain of radiology, but it is also

hreatening to break the fundamentaltructure of the profession. Denial oftudies by radiology benefit manage-ent companies has also grown sig-

ificantly and now affects the care of5 million Americans [2]. Other formsf rationing and revenue reductioneasures are likely as the health care

verhaul of 2009 progresses.We are not training enough radi-

logists domestically to handle eitherhe aggregate growth in work or thehanging nature of our workflow,ue to factors of call, specialization,igher levels of complexity and inten-ity of diagnostic studies, and so on.his is the time for great leadership,

nd this column is the first install-ent in a discussion of how leaders

hould react in a crisis.

REVENTION TRUMPSEACTION

o the difficult things while they are easy ando the great things while they are small. [3]

—Lao Tzu

The first step toward becoming areat leader in a crisis is, paradoxi-ally, not to have to lead in a crisis.lthough no leader is immune to sur-

rises, the best leaders aggressively l

009 American College of Radiology1-2182/09/$36.00 ● DOI 10.1016/j.jacr.2009.03.012

nticipate and manage to prevent cri-es or at least contain them in ad-ance rather than merely reacting tohem. A savvy leader aims to preventost fires from starting in the first

lace or at least handles them beforehey are out of control, as Lao Tzulegantly put it 2,500 years ago.eaders who are adept at this type oftrategic planning are usually alsoell positioned to deal with the crises

hey can neither anticipate nor pre-ent.

At the other extreme, the weak-st leaders, including some of thearcissists described in an earlierolumn [4], actually welcome crisesr, in extreme cases, even createhem. They do this to be the heroesho intervene to save the day and

ake the glory. This leads to some ofhe most terrible forms of destruc-ive management, in which onlyhe leader benefits and looks good,nd then only to people too foolisho see and understand what has re-lly happened.

HASES OF CRISISANAGEMENT

nalyzing the role of smart guidancen a crisis is facilitated by understand-ng that smart leadership involveseveral phases of tasks and thinking.

reparation

irst, there is the preparation phase.his includes what was discussed

bove in the strategic planninghase. It may also include runningrills for known types of crises,uch as mass casualties, fires, and son. It may include setting aside re-erves or cutting costs before a reve-ue crunch hits. It also encompassesll the elements of smart manage-ent that a good leader should estab-

ish in good times. That foundation m

eaves you better prepared whentorms hit. It also establishes relation-hips and trust within your grouphat will serve you well when the or-anization is stressed.

One test of great leadership is ask-ng the question “What if?” Doesour leader have an answer to ques-ions such as, “What will happen ifhe government cuts our reimburse-ent by 15%? What will happen if

ur payments from the hospital be-ome bundled under a global pay-ent scheme? What can we do if the

ospital administrator threatens noto renew our contract? What if wean’t hire another musculoskeletal ra-iologist by July 1?” A great leadernd a great organization considerhese questions in advance and makeontingency plans for such events.ne of the striking traits of successful

eaders in the corporate, political, andilitary worlds is how much time

hey devote to thinking about thesessues. They are rarely caught un-ware by current events, and theyave plans in place to deal with them.esser leaders act surprised whenvents hit and then scramble to catchp and react.

xecution

lans are nothing, planning is everything. [5]—President Dwight D. Eisenhower

The second of the 3 stages ishen the actual crisis begins. Yourepartment receives notice of areeze on hiring from the dean.

ow do you prepare your facultyembers to handle the implica-

ions of this for their clinical work-oads, their academic time, and son? Do you have a plan for how toedistribute clinical commitmentshile maintaining the academic

ission of your department?

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522 Profiles in Leadership

In crisis management, begin withhat you already know. If you have ausiness plan or, better yet, have dis-ussed your contingencies and op-ions, this is the moment of truth.ven if your contingency plans aren’tirectly on point for how the crisisnfolds, you are well prepared tohink clearly, avoid panic, and exe-ute your responses in real time. Asormer president Eisenhower, a trulyreat military planner, pointed out,he process of planning is more im-ortant than the details of a plan.

The next step is to put together aore group within your organiza-ion that can carry out your plansnd keep up with the flow of infor-ation in a crisis. This trusted in-

er circle will help you pull throughdifficult time. As discussed in ear-

ier columns, it is also critical toistribute leadership, and you willeed help at this stage.You also need to make sure that

ou disseminate information quicklynd accurately to your entire organi-ation. One of the most commonisconceptions that leaders have is

hat they should hold back bad news.hat is generally a poor leadershipecision. Rumors and misinforma-ion will spread quickly unless youake the initiative to pass along crit-cal data quickly and share your de-isions as soon as appropriate. Ifou stonewall your membership or,orse, lie to hide bad news or deci-

ions, your ability to lead will crum-le quickly.At a personal level, it is impor-

ant that you be engaged with yourrganization and be personally in-olved in the crisis. Leaders who tellhe membership to tighten theirelts and work harder while helpinghemselves to bonuses are not justypocrites, they are incompetent

eaders and should be fired. Leaders i

exa@wharton.upenn.edu.

ho genuinely share the pain ofheir teams are not only better ateading, they are also more moti-ated to truly address a crisis thanhose with little or no skin in theame. If the hospital announceshat the attending radiologists willeed to take extra call duty, doeshe leadership roll up their sleeves?

During the crisis, you need to payuch closer attention to your deci-

ions and the outcomes. Your atten-ion to detail within the inner circleeeds to ratchet up so that you caneact quickly to changing events.his phase is so important that I will

evisit it in a future column.

ecovery and Analysis

ou might think that once a crisisas abated, your role in crisis man-gement is over. However, peopleho deal with life-and-death crises

outinely do postcrisis analyses tonderstand what happened, whatas done correctly, and what to do

o prepare for the next crisis. Thesere known by several names, includ-ng “after-action analyses.” Smart or-anizations learn from crises andnow that they will happen again.ensible leaders know that this won’te the last time budgets threaten orovernments change, any morehan people who live in certainarts of the world would expect toave seen their last earthquake orurricane. Although the specificiming and intensity may not beredictable, the fact is that thesehings will recur, and you had bet-er be ready.

Great leaders sit down after criseso mull over what they did rightnd what went wrong. No teamerforms perfectly, particularly inhe heat of a crisis. One of the rea-ons for great preparation is know-

ng that performance is degraded

y fear, confusion, and other fac-ors in times of crisis. Involve yournner circle to perform an after-ac-ion analysis to examine how thingsent. Listen to everyone and getultiple perspectives on how well

ou reacted. The rationale for this iswofold: 1) it is important to under-tand how your preparation and exe-ution worked and how you can doetter the next time and 2) this ishen you need to rethink who onour staff is leadership material andho didn’t pass muster. The crisis

ested all of you, and now is whenou need to reevaluate your staffingn time to prepare for the next crisis.

UMMARY

. Great leadership in a crisis be-gins with anticipating and pre-venting crises from occurring.Great planning and strategicthinking are hallmarks of suc-cessful leaders.

. Crises have phases, each withdistinct opportunities for suc-cessful leadership.

Leadership doesn’t end when arisis abates or resolves. Great lead-rs learn from high-stress situationsnd use them to prepare for futurehallenges.

EFERENCES

. http://thinkexist.com/quotation/a_leader_is_best_when_people_barely_know_he/214091.html, accessed June 2, 2009.

. Iglehart JK. Health insurers and medical-im-aging policy—a work in progress. N EnglJ Med 2009;360:1030-7.

. http://www.brainyquote.com/quotes/authors/1/lao_tzu.html, accessed 3/11/2009.

. Lexa FJ. Making the grade: levels of leader-ship, part 2. J Am Coll Radiol 2009;6:228-9.

. http://www.brainyquote.com/quotes/quotes/

d/dwightdei149111.html, accessed 3.19/2009.

rank James Lexa, MD, MBA, Wharton School, University of Pennsylvania, GCP, 306 Gypsy, Wynnewood, PA 19096; e-mail: