Difficult times are when leaders need to rise up. There is no more important or impactful time for you to demonstrate your character and mettle, no time your group needs you more. Leaders cannot shrink from this responsibility, or they should be replaced. It does not take tremendous intelligence to strive in a crisis, but it does require character, fortitude, and courage. This chapter outlines some principles that may be of use in the event of a crisis. It begins with understanding the scope of the problem and how it will affect your group. It goes into how to stay ahead of the curve, predicting the potential outcomes and implications of the crisis before they occur. It talks about the importance of clear, concise, and effective communication to your group. It goes into the importance of aligning your actions with not only your group but the groups above you, such as the hospital and medical school. It covers the concepts of surveying your constituents, learning from them, and adapting your responses based on their needs. We talk about the importance of addressing mental health issues that develop in response to a crisis, not only for your group but also for yourself. It concludes with how to come out on the other side of the crisis as a strong and functional group.

Culture can mean several things when referring to a group: identity, values, goals, principles. Culture can be defined from the inside or outside – how is your group viewed by others, either at your institution or outside? Is your group viewed as “functional,” in which the members get along with each other, work as a team, and accomplish important goals? Or does it carry a reputation of being a “difficult place to work”? Usually a culture is a mix, some elements hardworking and driven, some supportive and nurturing. This chapter talks directly about how to develop a positive culture for your group, and how to be explicit in the process. It starts with recognizing and acknowledging the elements of your core identity as a group – what are your guiding values and behaviors? It dives into the difference between acceptable behaviors that can stimulate the group and be positively provocative, versus those that can be negative, destructive, and unacceptable, and how to deal with them when they occur. It describes the principle of accountability and how all group members are responsible for the overall health of the group. It discusses how to handle difficult interpersonal interactions once they’ve taken place, and how to reset the team after a negative culture event. It reminds the reader of the importance of embracing diversity, that differing opinions are necessary and important, but negativity and destructive behavior is never helpful.

One of your biggest challenges as a leader is having difficult conversations with members of your group. These conversations may be necessary for a variety of reasons: (1) they might be underperforming or out of compliance with documentation or billing; (2) they might have conduct that is detrimental to the team; or (3) they seem to be struggling with the team concept and the overall goals of the group. Your success as a leader will be determined primarily by how well you conduct one-on-one meetings, working with “problematic” group members to help them be successful or to find a different path for them, sometime even “managing them out.” This chapter discusses how to have these difficult conversations, using case examples to illustrate different techniques. It goes into how to set up the meeting in advance, setting clear expectations and the right mindsets. It discusses how to plan in advance for how you’d like the meeting to go, as well as having a plan B and plan C for when things don’t go as intended. It discusses how to conduct the meeting, including who should be in the room when it happens. It also describes necessary documentation and follow-up from these meetings, as well as setting expectations and next steps. It concludes with the particularly difficult situation of removing someone from a leadership position.

All too often, we see the leadership above us as obstructionist, miserly, or otherwise misguided or misaligned. This is usually not the case, but there are often communication issues up and down that create that impression and sometimes lead to an adversarial relationship. Both groups benefit by aligning their goals, and the earlier they do so, the better. This chapter will speak mostly to aligning your goals with that of your hospital, with some time at the end devoted to the medical school. They have many similarities, but some important differences. Understanding their priorities will help you to align yours. We discuss the paramount importance of understanding the finances both of your group and the group above you, hospital or medical school. There are ways to maximize your productivity to a mutually beneficial end, and being overt with leadership about this is always welcome. You should gain an understanding of what a “return on investment” or ROI means to the leadership above you, as this is a central concept to their willingness to invest in you and your group. You will gain an understanding of the downstream effect of your group’s efforts, particularly financial. It emphasizes the importance of understanding the key individuals you communicate with and how to approach situations where you are having communication issues. It concludes with how to align goals with the leadership above your group.

Most meetings are not run efficiently or effectively, and very few leaders put the time and energy into running a meeting well, not only wasting the time of their audience but their own as well. Without question, some meetings, or at least portions of meetings, are necessarily informative and perfunctory, such as updates on the financial situation of a department or the medical center or school. But not all meetings have to be like that, and nor do all portions of a given meeting. This chapter gives some tips for running an effective meeting, getting the most out of your group in the process, and having the group feel not only updated but engaged, respected, and perhaps even inspired. We talk about how to get people engaged from the get-go and the importance of setting the tone and expectations for meetings at the very start. We discuss the importance of setting the agenda and giving people prework so that they come prepared and ready for discussion. We get into the importance of establishing trust in meetings, so that people can speak freely and without fear of recrimination or attack. We talk about how to foster a constructive dialogue, allowing people to spread their wings and explore their creative sides, but also how to deal with a negative team member who makes others uncomfortable. And we talk about how to wrap up a meeting, discuss next steps, and have the group leave excited for the next meeting. We conclude with how to conduct a retreat for your group.

In medicine, the goals are different based on the individual group; thus, establishing the vision and goals for your group is essential, so that they know the scope, steps, and potential obstacles. All too often, teams are left to make assumptions as to what the goals are; this leads to uncertainty, questioning, and a lack of faith or trust in you as a leader. Setting the goals, and reminding people of them periodically, will help keep your group oriented and focused. This chapter focuses on how to assemble a well-running team, whether you need to get to know who is on it already or if you’re assembling it from scratch. It dives into how to gain a better understanding of your team members, what motivates them, and their potential strengths and weaknesses. It also goes into how to identify the personality traits that may make them a more or less effective team member. We describe the great importance of diversity for your team, as it is a key source for innovation, creativity, and perspective. It discusses the importance of midlevel leadership and when it is necessary. Mentorship is discussed in detail, as a key component to the development of your group members. Principles of recruiting and retaining good group members are reviewed, as well as operating principles for your team.

This chapter describes how to continue to develop as a leader. Great leadership is not something you ever really attain, but something you are constantly striving toward. Innovation and creativity help nurture your leadership potential; resting on your laurels leads to complacency and stale leadership. As with all things, this does not come without some work and introspection. Introspection is the work, and most leaders fail to develop because they’re unwilling or unable to take the extra steps to examine themselves and their group deeply, find out what’s working and what’s not, and come up with fixes. We discuss the importance of getting evaluations and feedback on your performance as a leader, and how to incorporate that feedback in a healthy manner. We discuss the importance of availability and accessibility. We talk about the importance of leading by example, “walking the walk.” We go into the importance of clear, concise, and honest messaging, as well as embracing change and learning from your mistakes. We reemphasize the importance of diversity and conclude with some core principles and values.

This chapter will set the table for your personal decisions when considering taking a leadership position and what should go into your thinking as you’re weighing your options. It covers what goes into understanding the position itself and how to find out the crucial details and duties it requires. It then discusses the leadership “phenotype” – what personal skills you bring to the role and whether the role will be a good “fit” for you. It probes what motivates you to be a leader and why, and whether that will give you a durable effect. Finally, it helps you to look at the career move in the context of your overall career, and whether the position will bridge you to something greater in the long run, or whether it’s a dead end. This chapter sets the stage for what comes next, an understanding of your personality as a leader.

Your vision statement for your group, presented both orally and in writing, is one of your most important and memorable acts as a leader. It should be given a great deal of advance thought and planning ahead of time, and you should be sure to vet it with a number of people who will give you good and frank advice. Although they can be intimidating, vision statements are usually full of positivity and forward thinking, are a great source of inspiration to your group, and serve as the ultimate frame of reference. This chapter describes difference between “mission” and “vision,” and how to develop both types of statements. It discusses the three “pillars” of academic medicine – clinical, research, and education – but also additional pillars worth considering as you develop your mission and vision statements. It goes into how to set goals, metrics, and milestones for your vision statement, as well timelines for achieving them. It then describes how to get your group to fully understand your vision and rally behind it, and concludes with a discussion of how to periodically reassess and recalibrate your vision.

Central to running an effective team is knowing your own personality, the good parts and the bad. It is reassuring to know that there are no perfect leaders in medicine, just like in any field, no matter how good some leaders think they are. We all have inherent personality traits that can make us more, or less, effective. This chapter helps you examine your strengths that may lead you to be a good leader, as well as your weaknesses, and how to identify both. It dives into the value of 360 evaluations, and how to procure one that will be most informative and helpful. We discuss the benefit of having a coach to help you process your personality traits to maximize your effectiveness. It goes into the available coursework available in leadership development, including suggested readings. It discusses the importance of assessing and continually reassessing your effectiveness as a leader, and how to recalibrate. It concludes with an explanation of how to find and establish your peer group once you’ve achieved a new leadership position.

The concept of brain death presupposes the viability of the body in the absence of brain and brainstem function. Until the invention of effective positive pressure mechanical ventilation by Bjorn Ibsen in the mid-twentieth century, brain death – as distinguished from mere coma – was not conceivable in broad understanding. Circulatory arrest had long been the sole criterion of death, but medical scientists at the turn of the twentieth century, such as Horsley [1], Duckworth [2], and Cushing [3], observed in cases of severe neurological injury the cessation of respiration prior to circulatory arrest. Apnea in some of these cases was reversible if the brain was decompressed or the offending injury removed. The idea began to form that the brain could die prior to cardiac arrest, but until the advent of mechanical ventilation, death remained defined as the moment the heart permanently stopped functioning [4].