Guest Perspective – AM Rounds Beyond the pages of Academic Medicine, journal of the AAMC Tue, 19 Sep 2017 13:54:51 +0000 en-US hourly 1 72453062 Encountering the Other: Providing Excellent Care Despite Differences Between Patients & Physicians Tue, 19 Sep 2017 13:54:51 +0000 A new episode of our podcast is now available through iTunes. Listen today.

Discussing how to provide excellent patient care in spite of differences between patients and physicians are editor-in-chief David Sklar and authors Emily Whitgob, Raya Kheirbek, and Paul Gordon.

This conversation complements articles by the participants in several recent issues, including:

Emily E. Whitgob, MD, MEd, fellow in the Department of Pediatrics at Stanford School of Medicine
The Discriminatory Patient and Family: Strategies to Address Discrimination Towards Trainees

Raya Kheirbek, MD, associate professor of medicine at the George Washington University School of Medicine and geriatrician and palliative care physician at the Washington DC VA Medical Center
Behind the Veil

Paul R. Gordon, MD, MPH, professor in the Department of Family and Community Medicine at the University of Arizona
How Can Physicians Educate Patients About Health Care Policy Issues?
Opposition to Obamacare: A Closer Look

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Deans Need Progressive Responsibility Too Tue, 12 Sep 2017 13:04:27 +0000 post.AHA Gala

Dr. Antman and her family at the 2016 American Heart Association Boston Heart & Stroke Gala

Editor’s Note: This blog post complements the recently published study “The Decanal Divide: Women in Decanal Roles at U.S. Medical Schools.” Read the full study on

By: Karen Antman, MD

Dr. Antman is dean, Boston University School of Medicine, provost, Boston University Medical Campus, and chair, AAMC Council of Deans

Why aren’t more medical school deans women? Medical school faculty don’t normally wake up thinking, “I want to be dean.” How then does one end up there? I was asked to tell my story.

First, my parents didn’t burden me with the standard expectations for girls at the time. My father expected me to be able to change the tire on the car before I was allowed to drive. My mother worked full time and actually returned to school for a masters degree when I was in high school. Thus, I was probably less conflicted about working full time when our children were young than other women whose mothers had not worked outside the home.

During a college study abroad program in Czechoslovakia during the Prague Spring of 1967, I studied politics and economics, contrasting capitalism and communism, and explored Hungary, Romania, and Yugoslavia where half of physicians were women. Clearly women were not fundamentally unsuited for medicine. Also Czech students knew more about American literature and theater than I did. After returning to the US, I took more music, arts, and literature courses, which contributed substantially to a broader education. Playing college basketball taught me not only teamwork but more importantly that losing is not the end of the world. Risks are OK. In my senior year, I was elected the first woman student council president of the college, which had only recently begun accepting women. I learned that politics matter.

I arrived at Columbia College of Physicians and Surgeons in 1970, in a freshman class of 160 students, 16 of whom were women. I met Elliott Antman, a classmate and my husband-to-be, in the lobby of the medical student residence the day before we started classes.

Columbia provided me a great medical education. In a large urban tertiary care hospital, I learned the importance of hands-on clinical experiences and responsibility. Medical students were expected to bring journal articles to rounds and present cases concisely without notes—a priceless skill. I also was introduced to the expectation of “moving the field.” Learning current medicine and being the best possible clinician weren’t enough. We also needed to address gaps in medical knowledge. To this end, many students spent significant elective time doing research, as I did.

Our daughter was born just before Elliott and I moved to Boston to start our fellowships in cardiology at Brigham and Women’s Hospital and oncology at Dana Farber Cancer Institute (DFCI), respectively.

During my fellowship, again the expectation was to move the field. Elliott and I now had two children, and three years of laboratory research provided a break from night and weekend call. I was worried about our kids though, until our son wrote in an essay for his English class that “My mom develops cures for cancer patients.”

I had no plans to be an academic but I did have skilled and, probably more importantly, patient mentors who taught me manuscript and grant writing. Junior faculty at DFCI were hired then as instructors with no office, tech, or secretary. The chair of Biostatistics gave me a cubby in the biostatistics space (and schooled me in biostatistical methods). As an assistant to the chair of a large cooperative cancer research group, I met the best cancer clinical investigators nationwide and learned to design effective clinical trials. I also developed my own research programs; experience on NIH study sections honed these skills. Eventually I organized multiphysician teams with research nurses and administrators with laboratory and clinical collaborations in sarcomas, mesotheliomas, and marrow transplantation research. Each team member was a first author on her or his own project and somewhere in the middle of the author list on other projects, leading to promotions for all.

I asked senior leadership how often I should accept invitations for talks and was advised that I “needed a national and international reputation to get promoted” so I should do it until I “couldn’t stand it anymore.” So Elliott and I took the kids to medical and research meetings in Europe, Japan, and China. Both children have subsequently become physicians and married medical school classmates.

Active roles on professional association committees led to expertise in medical and research policy and more management experience, with opportunities to testify before congressional appropriations committees. After service on these boards, I became the president or chair of several societies.

Being able to move was key to accepting new positions. A stint as deputy director for translational science at the National Cancer Institute gave me a close up view not only of the NIH’s grants process but also of their equally important power to convene university and industry researchers to launch new initiatives and develop policy.

When I became dean, an experienced dean emphasized the importance of being, and appearing to be, fair. Faculty will generally accept some decisions they don’t like if leadership listened to their points of view and decisions were fair. From the management school faculty, I learned that execution is as important as vision, maybe more so.

Along the way, was I discriminated against as a woman? Yes, I could tell you some pretty remarkable examples, best handled with clear disbelief and humor. But I also was protected by other leaders who provided opportunities for women to succeed.

Over my career, I had progressive administrative responsibility, sequentially managing larger teams with bigger budgets. (Skipping a step in this progressive process results in critical gaps in management experience.) Given that selection committees for chairs and deans highly value academic excellence and prior supervisory and management experience, women who aspire to leadership positions should be looking for such opportunities.

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The Many Facets of Career Flexibility in Academic Medicine: What Does It Mean to You? Tue, 29 Aug 2017 11:00:42 +0000 work life balance

By: Lydia Pleotis Howell, MD, professor and chair, Department of Pathology and Laboratory Medicine, University of California, Davis Health, Sacramento, California.

What does “career flexibility” and “work-life balance” or “work-life integration” mean to you? When I bring these up to department chairs or academic health leaders at my (or other) school(s), I often get openly unenthusiastic responses such as “Don’t you know that we can’t afford to have faculty working less? We need more productivity than ever before!” This is despite the majority of medical schools—including those ranked in U.S. News and World Report’s top ten—all having adopted career flexibility policies to improve recruitment and retention by helping faculty better meet their work and family/personal responsibilities.1

But career flexibility does not mean working less. Flexibility, as defined by the Sloan Center for Work and Aging at Boston College, involves “making changes to when, where and how a person will work to better meet individual and business needs…. Flexibility should be mutually beneficial to both the employer and employee and result in superior outcomes [italics added].”2 Shared responsibility and accountability are therefore requirements—in other words, no entitlement.

The University of California Davis has had career flexibility policies (such as childbearing and family leaves, active service-modified duties, and “stop the tenure clock”) since 1988, but in our NIH-funded survey, we found only 6.7% of women and 0.0% of men in the School of Medicine officially used these policies.3 Faculty appear to self-censor their use, as one-third under age 50 reported wanting to use the policies but choosing not to make the request.4 Highest among the many reported barriers to use was concern about burdening colleagues and others’ (including department chairs’ or division chiefs’) perceptions that the policy user was not committed to his/her career or team. These barriers are more frequently reported by women, but increased for both genders after an educational intervention, indicating that raising awareness of policies also raises concern about “flexibility stigma.”4,5

The qualitative analysis of written comments from our survey provides unique and valuable insights into institutional culture and norms that depress use of flexibility policies and inhibit growth of a culture of flexibility.6 We identified several themes, including misinformation and myths about using these policies and a perception of an unsupportive local culture, as faculty expressed concern that using the policies could be damaging to their career, despite all faculty generations and genders anticipating the need to use them in the future and considering them to be important for career growth, recruitment, and retention. Another theme we identified was a rigid, inflexible professional/academic culture, as faculty reported an inability to diminish their pace or take family-related leave due to fears of falling behind or limiting future opportunities.5 Many of the concerns identified in these themes reflect “face-time bias” (a form of unconscious bias related to physically seeing/not seeing colleagues in the workplace) and a culture of “over-work” creating conflict between professional and personal identities, which also reflects conflict with gender-specific roles since gender differences in the reported barriers and comments were observed.5,6

Having worked part-time for 16 years of my academic career while raising my children, I can personally confirm these concerns are significant and real. I made every effort to make my 80% faculty appointment “invisible” to others, so I wouldn’t be perceived as being on the “mommy track” and not serious about my career. I took on extra duties, including some considered onerous by others to minimize any bias to having a “part-timer” on the faculty. The upside is I was able to be flexible about my time, create a buffer in my life, and minimize the stress associated with being a working mother, while still rising through the ranks to professor and serving in leadership roles.

Keeping talented faculty in academic medicine and nurturing them so they can succeed and give back is exactly why career flexibility policies exist. How can we help more faculty overcome barriers and conflicts related to accessing career flexibility policies so more can achieve career success in academic medicine? Increasing awareness through published studies3–6 is an important and effective approach to culture change. Identifying and raising the visibility of successful faculty who have used flexibility policies or had alternative work schedules or places is also important to normalize flexible career approaches and paths. Finally, revealing faculty struggles and the consequences of an inflexible culture6 to school leaders is important to change the flexibility stigma and reshape the next generation of physicians and scientists into a happier, healthier, and more resilient workforce.



  1. Bristol MN, Abbuhl S, Cappola AR, Sonnad SS. Work-life policies for faculty at the top ten medical schools. J Womens Health (Larchmt). 2008;17:1311–1320.
  2. Sloan Center for Work and Aging at Boston College. What Is Workplace Flexibility? Accessed July 13, 2017.
  3. Villablanca AC, Beckett L, Nettiksimmons J, Howell LP. Attitudes, awareness and use of family-friendly policies for career flexibility: An NIH-OWHR funded study to enhance women’s careers in biomedical science. J Womens Health (Larchmt). 2011; 20:1485–1496.
  4. Howell LP, Beckett LA, Nettiksimmons J, Villablanca AC. Generational and gender perspectives on career flexibility: Ensuring the faculty workforce of the future. Am J Med. 2012;125:719–728.
  5. Howell LP, Beckett LA, Villablanca AC. Expectations of the ideal worker and its influence on professional identity in academic medicine: Perspectives from a career flexibility educational intervention [published online ahead of print June 15, 2017]. Am J Med. doi:10.1016/j.amjmed.2017.06.002.
  6. Shauman K, Howell LP, Paterniti DA, Beckett LA, Villablanca AC. Barriers to career flexibility in academic medicine: A qualitative analysis of reasons for the underutilization of family-friendly policies, and implications for institutional change and department chair leadership [published online ahead of print August 22, 2017]. Acad Med. doi:10.1097/ACM.0000000000001877.
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Author Reading: Stupid Consult Mon, 14 Aug 2017 19:45:34 +0000 A new episode of our podcast is now available through iTunes. Listen today.

In “Stupid Consult,” Jonathan Kersun remembers a patient who taught him about overcoming intolerance and strong emotions to connect with others. His essay was published in the Teaching and Learning Moments column in the August issue of Academic Medicine.

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 “I Feel that I’m a Human Being There”: A Transgender Older Adult’s Experience With a Family Medicine Clinic Thu, 10 Aug 2017 11:00:24 +0000 doctor holding heart

By: K. Abel Knochel, PhD, University of Minnesota Duluth, Duluth, Minnesota, and Dylan Flunker, MPP, Rainbow Health Initiative, Minneapolis, Minnesota

Melissa is a white, 63-year-old academic. She began identifying to others as female six years ago, although she has self-identified as female throughout her life. Melissa is in the process of transitioning and receives care through Smiley’s Family Medicine Clinic. She discussed her experiences in an interview with the Minnesota Transgender Aging Project (MTAP) in September 2016. MTAP is exploring the care that older transgender adults experience and expect in the Twin Cities Metro and Northland regions of Minnesota. The interview is excerpted below, with Melissa’s permission.

In her interview, Melissa emphasized the difference it makes for a patient to have their legal name accord with their gender by describing two minor experiences with misnaming and misgendering at Smiley’s, both of which occurred before her medical records used her preferred name.

Experience 1: [S]omebody was looking at my chart, and no one had written [my preferred name] on the top of it, which is what they typically do, and so called out my old name … I just sat there … I didn’t even say, “That’s not my name.” … So they gave up and went in and talked to somebody else and then came back out and just said my name. I got up and went, “Eh.”

Experience 2: I was going through some issues of dizziness and fainting that had to do with adjustment of meds related to hormone therapy and my high blood pressure …. It was a Friday late in the afternoon, they were about to close, so [they] said, “Better get in here because we won’t be open until Monday.” …. [T]he nurse that was involved was new to me. He … misgendered me, … but [it] wasn’t malicious, and I corrected him.

These types of experiences underscore the call from Hinrichs et al to ensure that medical staff throughout the clinic are trained to provide competent care to transgender patients.

Despite these experiences, Melissa described an overwhelmingly positive experience with receiving care through Smiley’s. She spoke of the ways the clinic staff has responded to her gender identity, honored her humanity, and partnered with her on medical care.

Smiley’s has been fabulous …. [W]hen you ask for an appointment you have to say why …. I said, “I need someone who’s knowledgeable about—or comfortable about—dealing with midlife or later trans women.” My medical insurance still had my birth name and … so I wrote in my preferred name. Within a few hours, I got a call saying, “May I please speak to [preferred name]?”

[T]he first day I got [to the clinic] … there [were] two people at the desk … I thought, “Oh. How are they going to feel about this?” I [went] up to the first one who was free and… she said, “Could you give me your name and show me your insurance card?” I said, “Well, they won’t be the same because I’m a transgender person.” She said, “Oh, thank you so much for telling me.” She was so … professional about it … pleasant about it … no big deal about it.

The very first day …. I was really prepped to make my case for hormone therapy, because I’d had this resistance, with [a previous doctor] saying no and [previous physician assistants] feeling at sea a little bit …. [My doctor] said something welcoming, and I said, “I guess I’m going to have to persuade—” She stopped me and put her hand on my knee … and said, “You don’t have to persuade me of anything.” I just started weeping …. [She] asked me right away, “Do you need a letter for surgery?” She’d actually read my little note [in the chart] and the whole clinic has clearly been trained. … [M]y current doctor … clearly feels I’m part of my own care team in way that I haven’t experienced …. That is to say … I have a huge role in the decision-making process.

… [T]he overall atmosphere is so positive. I feel that I’m a human being there. I’m not a freak, and that’s huge …. My experience makes me hopeful that I’ll be treated well [by medical providers in the future].

The care demonstrated in these interactions is consistent with the characteristics of trans-competent care that Hinrichs et al identified in their study.

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Author Reading: Whispers Mon, 07 Aug 2017 20:35:26 +0000 A new episode of our podcast is now available through iTunes. Listen today.

In “Whispers,” Raya Kheirbek remembers a patient who taught her to recognize the subtleties and differences in a seemingly shared language and culture. Her essay was published in the Teaching and Learning Moments column in the August issue of Academic Medicine.

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Author Reading: Our First Simulator: A Fond Farewell Thu, 27 Jul 2017 19:05:53 +0000 A new episode of our podcast is now available through iTunes. Listen today.

In this episode, Rami Ahmed reads his essay, “Our First Simulator: A Fond Farewell,” in which he reflects on the role his hospital’s first full-body simulator played in the education of countless physicians, nurses, and medics. His essay was published in the Teaching and Learning Moments column in the July issue of Academic Medicine.

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Tips for Reporting P Values, Confidence Intervals, and Power Analyses in Health Professions Education Research: Just Do It! Tue, 18 Jul 2017 11:00:40 +0000 stethescope and medical chart 2

By: Colin P. West, MD, PhD, Eduardo F. Abbott, MD, and David A. Cook, MD, MHPE

Basic statistical results, including P values, confidence intervals, and power analyses, are variably reported in scientific publications and frequently misunderstood or misapplied. In our current article, Abbott et al, we examined the current prevalence and evolution over time in reporting of P values, confidence intervals, and power analyses in health professions education research (HPER) publications.

We found reporting of P values and confidence intervals in HPER publications increased from the 1970s to 2015, and in 2015, P values were reported in most HPER abstracts and main texts of published research papers. However, reporting of confidence intervals and power analyses remained uncommon and lagged behind reporting in general biomedical research. In addition, most reported P values were statistically significant according to the standard threshold of P ≤ .05, which seems likely to reflect selective (biased) reporting.

Several general recommendations stem from these results. First, more detailed quantitative reporting of key statistical results is needed in both abstracts and main texts of HPER publications. Basic descriptive results (which, depending on the situation, might include group means, proportions, and/or effect size measures, such as differences between means, relative risks, odds ratios, regression parameter estimates, and correlation coefficients) should be reported to allow readers to evaluate educational or clinical significance, which is not automatically conferred by statistical significance. Notably, it remains common for P values to be reported without these basic results, especially in abstracts. In addition, confidence intervals offer far more information to readers than P values alone, and the fact that only a minority of HPER publications report confidence intervals represents a methodological limitation the field must improve. Confidence intervals around effect size measures are particularly important (i.e., more important than confidence intervals around the group means or proportions). As the abstract may be the only part of a publication many readers will review, it is important that these core quantitative results be included there.

Second, selective reporting of (typically) positive results provides a biased view of scientific investigations and their results. We recommend all analyses planned according to the research protocol be reported, ideally in the main text but at least in supplementary files. Of course, this requires that a research protocol exists to guide the study and analyses in the first place. To further reduce this bias, authors, reviewers, and editors should avoid automatically dismissing “negative” studies, and base their appraisal on a study’s scientific relevance and methodological rigor, including reporting of confidence intervals.

Third, sample size and power considerations remain quite uncommon in HPER publications. These should be integral elements of research protocols and reports. The fact that most reported P values are statistically significant, despite low power, for the majority of published HPER further highlights the degree of publication bias likely affecting the field.

Although there is progress to be made in HPER reporting it is notable that the reporting of these basic statistical results has generally improved over the last several decades. With continued attention to these issues, we are optimistic that HPER publications can match or even exceed the reporting quality of other biomedical research. We summarize our key recommendations below.


  1. Report basic descriptive results summarizing study data (e.g., group means, proportions, measures of variability).
  2. Report effect sizes (e.g., differences between means, relative risks, odds ratios, regression parameter estimates, correlation coefficients).
  3. Report confidence intervals, especially around effect sizes.
  4. Thoughtfully plan hypothesis tests, and account for all planned analyses in the final report.
  5. Distinguish statistical from educational significance.


  1. Rely on P values alone to report study results.
  2. “Cherry-pick” statistically significant P values for reporting.
  3. Dismiss statistically nonsignificant P values from methodologically sound and adequately powered studies.
  4. Conduct and report power analyses after data have been collected.
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The Unstoppables: Undocumented Students in Medical Education Tue, 27 Jun 2017 11:00:09 +0000 hands in go team formation

By: Raquel Rodriguez

R. Rodriguez is a first-year family medicine resident, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California.

At eight years old, my first glimpse of the United States was the arid land that separates the U.S.-Mexico border. As I sat in the car waiting to be assessed by the uniformed border patrol guards—marveling at the barren land of opportunity—I could not have imagined how crossing this border would transform my life. My new, secretive existence would make the simplest tasks into unusual challenges. As an undocumented student, turning sixteen came without a driver’s license, turning eighteen came with no reassurance that I would be able to attend college, and my first trip home as an undergraduate was plagued with anxiety as I handed my student ID to airport security. Fearing deportation, I guarded my secret and focused on my education.

In recent years, not unlike me, many undocumented students throughout the country have found themselves without clear hope for the future. Their ineligibility for employment having hindered their efforts to pursue a medical career. Despite their unrelenting persistence, their achievements in the classroom, and the support of entire communities, the dream of attending medical school seemed out of reach. I met many of these hopeful students as I searched for one who had successfully matriculated into a medical training program. I found none. Nonetheless, their stories of resilience amazed me and provided me with the motivation to investigate further.

Counter to the advice of premedical advisers, I applied to medical school. At the time, their concerns were valid and quite serious: How will you pay for medical school when your immigration status makes you ineligible for federal loans? What will you do after graduation without employment eligibility?

A medical program took a chance on my application, and I began my studies in the fall of 2011. As expected, financial challenges persisted, but a significant reprieve arrived shortly before my third-year clerkships. The Deferred Action for Childhood Arrivals (DACA) program was implemented. Via this federal memorandum, I was finally allowed to obtain employment authorization, a driver’s license, and an identity of belonging in the United States—benefits that had eluded me since my arrival in this country almost twenty years ago.

Since the DACA program was established, many medical schools have officially opened their doors to DACA recipients. While these talented students currently make up a small percentage of medical students, their stories have impressed me with their resilience, creativity, and humility—traits that everyone would value in their own physician. As described in the article, “Considerations for Residency Programs Regarding Accepting Undocumented Students Who Are DACA Recipients,” the next step is to facilitate their continued medical training.

On the days when my commute to the hospital provides me with time for reflection, I think about the undocumented students I have met and how my achievements are inspired by their stories. These students have given me hope. Now, I can only dream that the communities they call home will give them the precious opportunity to see an America that is not arid, but one that has tall buildings, resplendent streets, and where their dreams will know no boundaries.

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How Prepared Are You to Lead? Tue, 13 Jun 2017 13:21:17 +0000 EKG rhythm with light bulb

By: Peter Pronovost, MD, PhD, and Christopher Myers, PhD, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine

Physicians increasingly are being asked to lead health systems and improvement efforts, so it is important that they have the necessary skills to do so. To see why and how these leadership skills matter, we propose a quick test. Below, we present three scenarios that a health leader might need to navigate. As you read these scenarios, we encourage you to reflect on whether you have a framework you could use to address the issues described, whether you have all of the necessary skills to address these issues, and whether you have a commitment and mechanism to grow and develop these skills.

Case 1: You were just hired as a new attending in a surgical division. A nurse comes to you confidentially to raise concerns about the quality of care provided in the division. The nurse does not want you to discuss the issue with others, because she fears she will suffer retaliation. She states that there is a strong culture of fear and distrust. What do you do?

Case 2: You are leading a project to introduce a new pathway for managing heart failure patients. You bring together the academic and community cardiologists and the primary care physicians. The main academic cardiologist says he wants to make the pathway as he is the world expert. He drafts a pathway and hands it out at the first meeting. The other physicians feel disrespected and do not want to participate. You are under pressure from your hospital leadership to implement the pathway and reduce practice variation. Yet the physicians do not want to join. What could you have done differently and how might you recover?

Case 3: You recently have been made the chief quality officer of a hospital. The boarding time for patients admitted through the emergency department is very high, and your Board and leadership want you to reduce it. You understand that it is a complex problem involving multiple departments. You also know that the interventional cardiologists and surgeons do not want emergency department patients to take their beds–they want to be able to accept transfers from outside hospitals. You call a meeting to work on the problem. How would you motivate the different departments and lead the change effort? The lead medicine physician and surgeon say you do not even need a meeting because the emergency medicine patients are a low priority. How do you approach the problem and get them on board?

All three of these cases illustrate issues of trust, teamwork, power, and change in organizations. These are issues that all leaders face every day, yet they are not the issues that physicians are trained to address. In all three cases, an understanding of leadership and organizational dynamics could provide the frameworks and tools to successfully navigate these challenges.

How did you do on the test? Did you feel prepared to handle the situations? If you need more training, where will you get it?

While we believe these topics need to be incorporated into the medical school curriculum, for physicians who are already in practice, we suggest looking for opportunities at business schools (particularly for those physicians at AMCs affiliated with large universities). Increasingly, business schools are offering specialized courses and opportunities for developing the leadership skills needed in health care. For instance, at Johns Hopkins, we offer a specialized five-day Executive Certificate in Health Care Leadership and Management, which is open to health professionals from any institution and offered for continuing education credit. This program brings together health leaders and management experts to develop the kinds of foundational skills and abilities described in our Academic Medicine article.

In addition to formal training, ongoing skills development through peer or formal coaching is also important. This training can be practical. For example, ask a trusted colleague to provide feedback on your performance in a high stakes meeting. Did you listen to others’ concerns? Did you align around a common interest? Did you reduce resistance? Whatever the source, though, it is never too late to develop these critical leadership competencies, and, by doing so, we can improve the quality of care we provide.

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