Leading From the Middle Empowers GME Leaders

Graduate medical education (GME) leaders are almost always in the middle—addressing demands and expectations from those above, below, and parallel to their position on the organizational chart. They must be responsive to external bodies (eg, accreditation) and to the internal needs of their sponsoring institution (SI), including learners, faculty, and staff. To be effective and ensure forward progress, GME leaders must embrace their role as leaders in the middle. While daunting, it can be rewarding, influential, and have significant impact.

Every leader is in the middle reporting to someone. Leading up, down, and across the organization is vital for GME leaders. Business celebrates mid-level leaders for their unique value and transformative potential, including their innovative ideas, awareness of needs and emotions of those “on the ground,” and the ability to manage both continuity and change.¹  Mid-level leaders must develop meaningful opportunities for influence through integrity, transparency, dependability, and consistent communication.²  They use formal and informal networks across the organization, serving as a hub of information sharing, partnership, and organizational culture.²  These networks provide a unique opportunity to lead from the middle by aligning learner and faculty needs with the strategic vision of the SI and accreditor(s) requirements. Successful GME leaders stay attuned to the priorities of trainees and faculty, develop and leverage relationships with all GME programs and key partners, champion a positive organizational culture, and shepherd the program through challenging times.

1. Align visions and priorities. Understand and keep current with the visions and strategic priorities of your SI and health system leaders, your direct supervisor, your specialty’s educational associations, and GME governing bodies. Be prepared to reconcile competing or even incongruous expectations. Then revise and align your group’s vision and unique strengths by seeking input from up, down, and across the organization. By finding common ground and vision alignment you can frame future actions and influence forward progress, thereby empowering yourself and your supervisors.

2. Reframe problems as opportunities. First, tackle the important and urgent problems first, per the Covey Time Management Matrix,³  by plotting importance and urgency in a 2x2 matrix. This tactical approach can reduce an overwhelming portfolio of concerns while identifying strategic and growth-related issues (eg, those in the important but not urgent quadrant). Delegate nonimportant quadrant problems to qualified team members to solve. Identify opportunities for your program to add value to your SI’s vision and direction, while meeting external accreditation standards. Creating “win-win-wins” optimizes chances for success. For example, if teaching about climate effects on patients is a program priority, align it with your SI’s commitment to sustainability, equity, and high-quality care. Leadership challenges and risks can’t be avoided; learning how to positively reframe and best manage them will make you a stronger leader.

3. Create a comprehensive action plan. Develop a plan to address all important problems (including the nonurgent ones), by identifying needs, those who have a stake in the decision, partners, and appropriate team members to take the lead. Expect that important but nonurgent problems may be mid-to-long range goals, so include milestone-like deadlines when planning to ensure continuous progress. Devise a process to communicate plans for nonurgent problems to all key constituencies.

4. Lead up, down, and across. Manage up while maintaining connection to your direct reports. To build trust and your ability to influence, establish a regular cadence of check-ins to ensure you are simultaneously meeting the needs of your team and your supervisor(s). Frequently ask your boss, “How can I help?” Maximize opportunities to reach “across” by exchanging ideas, strategies, and concerns with those in parallel positions.

5. Communicate, communicate, communicate. Tailor communications to the audience. Make your SI’s and GME governing bodies’ goals relevant to the daily work of each constituency (eg, senior and peer leaders, trainees, faculty, staff). For example, when implementing new ACGME expectations for core faculty, provide clear operational guidance to faculty, their supervisors, and administrative leaders. Seek feedback to continuously improve communication content, clarity, and format.

1. Invest in your team. Get to know what motivates them and where they want to grow. Delegate the right projects to the right people with clear expectations, knowledge, and appropriate resources to succeed. Leverage accreditation and other requirements when negotiating for resources, training, and support. As you identify barriers to success, implement tactics to address them. Use your strategic network of colleagues, partners, and staff across and outside of the organization.

2. Invest in yourself. Successful and well-respected leaders perform regular self-inventories. Never sacrifice your values but do compromise on logistics to achieve goals if that meets the needs of other key constituencies. Intentionally make time for the most important work and to celebrate achievements. Talk with trusted colleagues when facing challenges. Develop a stretch goal for yourself. Breathe.

3. Invest in your culture. Role model and celebrate open communication, accountability, transparency, psychological safety, and inclusivity. Offer multiple avenues for feedback on individual performance, including your own. Build culture by delegating appropriately, being available for questions or roadblocks, and allowing team members to function without you. Celebrate the wins of others and discuss them with your/their supervisors.

4. Develop long-term strategies to prioritize emerging problems. Continuously use the Covey Matrix or another prioritization model to maintain focus. Create a sustainable, transparent process to triage problems, delegate tasks, and communicate up, down, and across.

5. Make success visible. Continuously amplify individual and team accomplishments—through 1-on-1 meetings with leadership, nominations for awards, and announcements on social media. Add “GME Highlights” into SI-wide and program meeting agendas to describe a recent value-added GME activity. A demonstrated trajectory of achievement builds capital with higher-ups and reinforces the importance of your team within your SI.

The GME Leaders Rip Out Series is co-edited by Deborah Simpson, PhD, and Nancy D. Spector, MD.