FRANK JAMES LEXA, MD, MBAPROFILES IN LEADERSHIP

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Strategic Leadership: Setting Priorities

Strategy without tactics is the slowestroute to victory. Tactics without strat-egy is the noise before defeat.

—Sun Tzu [1]

INTRODUCTIONIn other installments in this series, Ihave explored the nature of leader-ship in radiology. In this column, Iexamine one of the key challengesto great leadership: your ability (orlack thereof) to focus on the thingsthat matter most. Although this is achallenge for any leader, it seems tobe a particular issue for some radi-ologists in leadership roles. Part ofthis may come from our perfection-ist nature. We are trained in a cul-ture in which we certainly try tonever miss a case. Because leader-ship is a murkier, more difficultenterprise with many (althoughperhaps not 50) shades of gray, ra-diologists may defer, delay, or ig-nore issues that they can’t addressin a “perfect” way. As Sun Tzu wrotemore than 2,500 years ago, if wedon’t use strategy to make our de-cisions, we will just be wasting ourefforts on the way to defeat. In thisdiscussion, I focus on why strategicgoals and priorities are difficult forradiologists and how to do better asa leader in setting them and carry-ing them out.

SETTING THE BIGSTRATEGIC GOALSStarting at the beginning, many ra-diologists are not yet sophisticatedstrategists. Many radiologists are,however, very good at tactics. Giveus a hard neurology case and we canmake all the findings, break it downinto what is important and whatisn’t, offer a robust differential di-agnosis, and provide important in-sights to our clinical colleagues.Then make it tougher by telling usthat we can’t administer gadolin-

ium because of renal failure, and we

can come up with clever alternativescanning protocols to get a moreprecise answer for the clinician de-spite that handicap. But ask us for acomprehensive strategy for makingfundamental changes in our prac-tice to work effectively in an ac-countable care organization, andwe may freeze up. We haven’t donethis before, and we don’t have aready plan for this. We are perhapsapprehensive about looking stupidor making a poor decision. And yetthese are exactly the kinds of chal-lenges we need to address as we leadour groups into the future.

As the start, the solution to thedeficiency in our abilities in therealm of planning is to plan to im-prove. You need to dedicate time todeveloping the skills to be able tocreate strategies, building plans,and setting priorities. As a startingpoint, the use of scenarios and stra-tegic planning in radiology hasbeen discussed by myself [2] andothers [3,4]. The interested readeris referred to those sources for amore detailed discussion of thisprocess. If you become more inter-ested in the topic, those resourcescan lead you to more of the primaryliterature on the subject and per-haps to live training offered by theRadiology Leadership Institute ofthe ACR. This training will helpyou clarify what you think youneed to prepare for in the future,and that will bring your prioritiesinto focus. Remember that you willneed to personalize this. It won’t beenough to use the strategic analysisof a think tank, the ACR, or an-other group of radiologists. Thosetypes of tools can give you a hugehead start and will certainly helpyou avoid missing a big, nasty ele-ment of the future. But always re-member that strategy and tactics

need to be applied locally.

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SO I KNOW WHAT TO DOAS A LEADER; WHY CAN’T IGET IT DONE?Next is the problem of having toomuch to do and not having the timeresources for the job of leading. Inmy consulting work with radiologypractices in the United States, Imeet a lot of very smart, very dedi-cated radiologist-leaders. Theyhave read the literature, they haveoften done leadership training ofone kind or another, and they al-ready know most what they need todo to be effective leaders. The miss-ing piece for many of them is thateither their groups won’t give themthe time to do the job or they them-selves won’t put the time into thework to do it well. Being a radiolo-gist is a demanding job, period. Be-ing the leader of a $50 million to$100 million a year company ontop of that is yet another demand-ing job. Doing both would requireabout 120 hours a week for most ofus to do well, perhaps requiringmore than a touch of mania to beable to keep at it.

As a leader, you need to be smartenough to first manage yourselfwell and then manage your group’sexpectations so that you have theresources you need. In 10 years ofdoing this, I don’t think I have seena private practice group whose radi-ologist-leader was given too muchtime off the clinical schedule to ful-fill nonclinical duties. In fact, theopposite is more the norm. When Isit down across from a leader, I canoften see within the first 15 minthat he or she is on a path to burn-out. Such leaders aren’t just tired;they are frustrated with their inabil-ity to accomplish their goals. Theyare angry at their groups both fornot supporting them and for notappreciating their efforts. Keep inmind that in most good jobs, you

don’t just fill a slot. You need to

© 2013 American College of Radiology36.00 ● http://dx.doi.org/10.1016/j.jacr.2013.02.022

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actually craft it and make it yourown.

LEADERSHIP AND OTHEROPEN-ENDED KNOWLEDGEWORKOne of the frustrating things formany radiologist-leaders is theopen-ended, amorphous nature ofthe job. Unlike reading head CTstudies for a 9-hour shift, leadershipdoesn’t involve a either a list-limited or a time-limited workshift. In some sense, it is neverdone. In another sense, it can fol-low you outside the normal timeand space limits of your clinicalwork. You have a responsibility toyourself to set the limits (if neces-sary) of your duties as a leader. Youwill also have to come up with pro-cesses to figure out what your job isand how to do it. This is muchmore nebulous than the roles thatyou trained for as a radiologist. Iwill close with a couple of pieces ofadvice about how to handle this.

First, once you have set yourgoals and priorities from your stra-tegic work, ask yourself if you haveset them too high or too low. Also,understand that most of us try todevelop a portfolio that includesboth hard goals (I will revamp this

department) and easier ones (I will

increase our academic output or Iwill improve our conferences withthe neurology department).

Second, on a week-to-week orday-to-day basis, you should con-tinue to prioritize. Ask yourself ifyou are focusing on the importantissues or getting too caught up inminutiae, such as the new wallpa-per in the waiting room. Somepeople find it helpful to map their“to-do” lists into a 2-by-2 matrix ofurgent versus routine and display thatagainst important versus unimport-ant. The resulting 4 categories thendevolve into 2 uninteresting catego-ries: unimportant and nonurgent(such as cleaning up your desk draw-ers, which you may not do until youretire) and the obviously urgent andimportant, such as putting out fires,like an angry emergency departmentphysician who thinks your residenthad a bad miss last night on thedean’s granddaughter’s head CTscan. The more interesting categoriesare the remaining 2. Those are oftenthe ones we procrastinate over. Try topush yourself into taking care of theseor perhaps decide whether they de-serve your attention. Keep in mindthat a great leader can’t do every-thing, so make sure to reevaluate

these priorities from time to time.

TAKE-HOME POINTS

● Strategic thinking and planningis one of the most importantthings a leader does. Otherwise,you are just rearranging deckchairs on the Titanic.

● Seek out formal training and ad-vice when you are figuring outwhat the future may hold.

● Make sure you have the resourcesfrom your group and from your-self to be the leader you want tobe. Well-intentioned failure isstill failure.

● Understand that your time as aleader is a valuable resource. Getthe important things done, andcontinually reevaluate what is re-ally important.

REFERENCES

1. ThinkExist.com. Sun Tzu quotes. Available at:http://thinkexist.com/quotes/sun_tzu/. Acces-sed February 25, 2013.

. Lexa FJ, Chan SC. Scenario analysis and stra-tegic planning: practical applications for radi-ology practices. J Am Coll Radiol 2010;7:369-73.

. Gill IE, Ondategui-Parra S, Nathanson E,Seiferth J, Ros P. Strategic planning in radi-ology. J Am Coll Radiol 2005;2:348-57.

. Enzmann DR, Beauchamp NJ, Norbash A.

Scenario planning. J Am Coll Radiol 2011;8:175-9.

Frank James Lexa, MD, MBA, Wharton School, University of Pennsylvania, GCP, 306 Gypsy, Wynnewood, PA 19096; e-mail:lexa@wharton.upenn.edu.