Dr. Robert Moore, MD, MPH, MBA, Chief Medical Officer

“To be 95% confident that a large-scale implementation will be successful, look for at least four independent small-scale tests all showing a significant benefit.”

– Summary from The Science of Using Science: Towards an Understanding of the Threats to Scaling Experiments (Al-Ubaydli, List, & Suskind, 2019).

The transition of integrating back into the community after being incarcerated marks one of the most dangerous periods in a person’s life. Overdose is the leading cause of death for people recently released from incarceration, with rates more than three times the national average for incarcerated populations. Building on a 2006 pilot in San Francisco that Partnership helped expand starting in 2012, California is now poised for state-wide implementation of an approach that transforms this vulnerable transition period from a health crisis into an opportunity for healing through comprehensive, coordinated care that begins before the prison gates open.

Justice-involved individuals typically face a constellation of health challenges. In California, approximately 35,000 people are released yearly from state prisons, while most of the 350,000 people booked into county jails are released within weeks. 66% have moderate or high need for substance use disorder treatment, while incarcerated individuals with active mental health cases rose by 63% over the last decade.

The racial disparities are stark: nearly 29% of incarcerated men in California are Black, while Black men comprise only 5.6% of the state’s population. This means health care interventions for justice-involved individuals must intersect with critical racial equity initiatives.

Origins: The Transitions Clinic Network

In 2006, the pilot project at a San Francisco community health center, partnering with San Quentin State Prison, launched what became the Transitions Clinic model. This evidence-based program included innovative components like community health workers (CHWs) with lived experience of incarceration as integral health care team members.

The model proved successful and expanded rapidly. By 2024, the Transitions Clinic Network (TCN) linked 48 clinics in 14 states and Puerto Rico, including 21 in California. Research demonstrates that the TCN model cut emergency department visits and hospitalizations in half.

Partnership HealthPlan of California recognized the potential early, embracing the pilot version with strategic use of reserves more than a decade ago. The organization ultimately funded three different sites, adding two locations to the original pilot in Vallejo, demonstrating how managed care organizations could collaborate effectively to serve justice-involved populations.

Based on the proven success of multiple pilot sites in the years that followed, the Transitions Clinic and Partnership discussed expanding this model state-wide with the California Department of Corrections, even before CalAIM existed.

California Builds a Statewide Model Using Medi-Cal

Fast forward to 2023, when California became the first state to receive federal approval to use Medicaid funds for services provided to people leaving jail or prison. This breakthrough came through a federal Medicaid 1115 demonstration waiver, representing a fundamental shift in approaching health care for incarcerated populations.

The Justice-Involved Initiative is part of California’s broader CalAIM transformation. When Medicaid was created in 1965, federal law barred the use of federal funds for services for incarcerated people. California’s waiver effectively bridges this gap, allowing continuity of care that was previously impossible.

Eligible individuals can receive targeted Medi-Cal services for up to 90 days prior to release, including:

• Reentry care management services
• Physical and behavioral health clinical consultations
• Laboratory and radiology services
• Medications and medication-assisted therapy
• Services from CHWs with lived experience

Most importantly, qualifying members receive prescribed medications and medical equipment upon release, addressing the critical “medication cliff” that often leads to rapid health deterioration.

Justice-Involved Implementation and Early Success

The rollout began strategically with three pilot counties—Inyo, Santa Clara, and Yuba—on October 1, 2024. By July 1, 2025, 17 counties plus the state prison system will have launched services. For Partnership, three counties—Yuba, Sutter and Siskiyou—are included in this initial wave. Nevada County is tentatively scheduled for September 1.

Partnership’s Justice-Involved team is now seeing a steadily increasing stream of referrals coming in from ECM providers within the state prison system.

An example of how coordination of implementation is as follows: An incarcerated person with specific mental health needs and nearing release qualifies for 90-day pre-release services. They are assigned a pre-release care manager who develops a reentry plan. Before release, the individual is connected to a community psychiatrist through a “warm handoff” meeting. Upon release, the individual receives Enhanced Care Management (ECM) and subsequently gets a supply of medication to take with them.

ECM provides intensive care coordination for high-risk individuals, creating continuity that spans institutional and community settings. ECM providers address not just health care needs but social determinants of health including housing, employment, and transportation. Community Supports (CS) services complement ECM and address fundamental barriers to stability, including housing transition navigation, security deposits, and other services that promote community integration. Housing is perhaps most critical – homelessness rates among those being released from incarceration are extremely high, and unstable housing is associated with increased recidivism and poor health outcomes.

All counties must launch services by September 30, 2026. The initiative’s sustainability depends on demonstrating positive outcomes and cost-effectiveness. Success metrics include health care outcomes, community integration measures, and quality of life indicators for participants. Meanwhile, success in each county depends on local engagement activities and leadership commitment.

What Primary Care Providers Can Do

The initiative’s success ultimately depends on primary care providers’ willingness to serve justice-involved individuals effectively. Most importantly, providers must ensure that requests for initial appointments are addressed quickly. Discharged individuals typically receive only 30 days of medication and face complex medical and mental health issues. They’re at high risk of death after discharge, making rapid access to care a critical public health need.

Case managers from correctional facilities will reach out to schedule pre-release appointments. While members won’t be assigned to specific health plans while incarcerated, DHCS will make assignments retroactive to release dates. Providers should schedule these appointments immediately when requested—this transition period carries much higher mortality and recidivism rates without appropriate services.

Beyond rapid access, providers should anticipate that patients with complex needs will require comprehensive, coordinated care. This includes working collaboratively with ECM providers and community health workers, approaching patients without judgment, managing medication transitions carefully, and connecting patients to specialty care and community resources supporting long-term stability.

California’s Justice-Involved Initiative represents a fundamental shift in approaching the intersection of criminal justice and compassionate health care. Building on years of successful pilots, the state has created a model with a high likelihood of successfully spreading state-wide, which will help to transform outcomes for one of our most vulnerable populations.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Change happens by listening and then starting a dialogue with the people who are doing something you don’t believe is right.”

— Jane Goodall, English zoologist and primatologist

Disagreements about vaccinations, public health activities, and scientific research have escalated in the past few months, with an expanding chasm between the views and opinions of those with different political ideologies. Health professionals and public health leaders need to develop skills in communicating effectively with patients and members of the public who may have deeply held, but widely disparate views. Of course, this is easier said than done!

This challenge is exactly what Epidemiologist Dr. Katelyn Jetelina narrates in a recent post on her popular “Your Local Epidemiologist” Substack. She and several other famous U.S. public health leaders were invited to participate in a dialogue with leaders of U.S. Health and Human Services, Director Robert Kennedy’s, Make America Healthy Again (MAHA) coalition. Her summary of this meeting is introspective and very well-written, one of her best posts of the year. In the end, she gained a lot of understanding of the concerns and questions of the MAHA participants and found several areas of shared values.

In sharing her experience, Dr. Jetelina encourages us to find ways to have deep and meaningful conversations with those in our community who have different ideas about public health and science.

She concludes with three points:

“Fight for people, not institutions. Meet questions with empathy. Look for opportunity in the rubble— because it’s there, if we’re willing to see it. Even when it’s hard.”

Although her views expressed represent the opinions of the author and do not represent the official views of Partnership HealthPlan of California, there is value in her message for how we approach difficult conversations.

Enjoy!

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The only true wisdom is to know that you know nothing.”

— Socrates

Wisdom of the Elders

Tribal community members often hold respect for elders as one of their core values. This respect is shown in many ways such as allowing elders to eat first at communal meals, valuing elders’ knowledge of native languages and traditions, and listening to their wisdom expressed through stories passed down for generations.

These demonstrations of respect were evident at a cultural event recently at the Karuk Kahtishraam Wellness Center in Yreka. Teenagers and young adults watched attentively as one elder taught them how to carve traditional wooden cooking paddles. Another elder displayed his tight-weave basket[1]making skills using willow twigs and aged spruce roots. When lunch was served, tasty frybread tacos and fruit, the elders were invited to serve themselves first. During lunch, several elders recounted stories from their lives, gently conveying the life lessons these stories contained.

Many in the United States use a different word to describe older residents: elderly. Although the difference is subtle, elderly is often used in association with a sense of responsibility to provide care, food, shelter, and entertainment. There is less of a sense respect for the wisdom of their life experiences, more of a sense that interacting with the elderly is necessary from time to time. This is a barrier to older adults feeling a sense of purpose as they age. Dr. Victoria Sweet’s excellent book, “God’s Hotel,” about San Francisco’s Laguna Honda Hospital elaborates on the evolution of modern American society’s conceptualization of our older residents.

Of course, there are exceptions to this. In his famous study of communities around the world where substantial populations live to over age 100, author Dan Buettner found that, in addition to a healthy diet, regular exercise, and six other factors, centenarians had an ongoing sense of purpose for their lives, usually including providing advice and support to the younger members of their families. The term “Blue Zones” is used to describe such communities in the Nuoro province of the Mediterranean island of Sardinia, the Nicoya Peninsula of Costa Rica, and Loma Linda, California.

In our early lives, our brains are wired for “fluid intelligence”: the ability to reason and think abstractly and flexibly. This allows us to learn everything from kinesthetic skills like sports or playing a musical instrument to mental reasoning skills involving creative solutions to mathematical or logical problems. As we age, the integration of what we have learned in our lifetimes — from books, other people and from our own experiences — can be manifested in “crystalized intelligence,” sometimes known as accumulated wisdom. Fluid intelligence generally peaks in our 20s and 30s and then declines steadily, whereas crystalized intelligence peaks in our later decades of life. Crystalized intelligence is helpful for teachers, with history professors actually reaching peak intellectual productivity in their 60s and 70s. Interestingly, our ability to learn new words and even new languages can persist well into our older years because the hippocampus, the seat of memory, continues to grow throughout life.

In his book, “From Strength to Strength: Finding Success, Happiness, and Deep Purpose in the Second Half of Life,” economics professor Arthur C. Brooks notes that high-achieving younger professionals who start to decline in their career should intentionally make the jump from the declining fluid intelligence curve to the rising crystalized intelligence curve.

American society celebrates the success of young entrepreneurs, young performing artists, and young scientists who make important breakthrough discoveries that require fluid intelligence. Success in early life, with its attendant public recognition, can make it hard to give it up to make the jump to the second, crystallized intelligence curve. Interestingly, societal belief systems that emphasize the idea that deceased ancestors support those who are living sometimes have more formal ways of recognizing the development of wisdom as a high goal in the second half of life. Confucian stages of life include the ideas of early education, social engagement with accumulation of wisdom in the middle of life, and tapping into the wisdom of elders, sages, and ancestors. As noted earlier, writings summarizing historic and current-day Tribal community values and beliefs include respect for the wisdom of the elders, and the important influence of one’s ancestors on those living today.

A more codified version of these stages is found in the ancient Hindu theory of Ashrama. Ashrama specifies that life should be lived in four stages, each lasting roughly 25 years:

• The first, in childhood and young adulthood, is devoted to learning.
• In the second phase, one focuses on working to build a career and financial stability, as well as to building a family and social connections.
• In the third phase, one retires from personal and professional duties to consolidate their wisdom through teaching and spiritual practices. Moving from the second phase to the third phase is analogous to the shift from the fluid intelligence curve to the crystallized intelligence curve, noted above.
• The fourth phase (if one lives long enough!) is devoted exclusively to spiritual understanding.

Clinician Wisdom

What are the implications of this framework to clinicians?

The scientific framework of evidence-based practice, where activities are tested objectively and rigorously, is at odds with a framework that draws on “ancient wisdom.” In fact, the current standard of care is evolving rapidly. The half-life of medical best practice is roughly five years. Put another way, half of today’s best practices for a given disease condition (e.g., which medication or surgical treatment is the safest and most effective) will no longer be the best practice in five years.

New graduates of physician residency programs, better trained than previous generations in evidence-based practice, will view some of the practices of older physicians as out-of-date. In some ways, though, the skills and experiences of older clinicians integrate knowledge that is not out of date and which younger clinicians would benefit from. Physical exam skills, for example, are becoming a bit of a lost art, resulting in over-use of radiology studies. Surgical skills for non-laparoscopic surgery of older physicians are often impressive, as they had a large volume of such cases before the newer surgical methods became available. Conversely, younger surgeons often have more robust experience with robotic surgery.

Clinicians need to track the evidence base for the conditions they commonly treat. Having a sense of curiosity and skepticism when reviewing the medical literature is key to critically evaluating new knowledge. As clinicians age, the wisdom reflected in their clinical judgement can continue to grow, if they systematically keep up with new knowledge.

Leadership Wisdom

This is also true for clinician leaders, although the nature of new knowledge related to leadership is very different.

Our understanding of the psychological and sociological aspects of human behavior is more scientific than previously, both through more advanced social science research methods, and with greater understanding of how this relates to underlying brain structure and function. The book, “Behave: The Biology of Humans at our Best and Worst,” by Robert Sapolsky is an impressive integration of these fields.

However, clinician leaders generally learn new leadership lessons more slowly, since we are often spending time maintaining our clinical knowledge while concurrently learning business operations and health care policy.

Fortunately, some core leadership wisdom is timeless, and so can be gained through literature, movies, and reading philosophy. An additional vital resource is the crystallized intelligence of our “medical elders,” experienced clinician leaders, such as Dr. Paul Farmer, Dr. Fitzhugh Mullen, and Dr. Anthony Fauci, as well as local clinical leaders in your communities.

To grow and age wisely as clinician leaders, we must embrace the opportunity to absorb the wisdom of elders even while we systematically strive to integrate new evidence-based knowledge!

By Robert L. Moore, MD, MPH, MPA, Chief Medical Officer

“The tipping point is that magic moment when an idea, trend, or social behavior crosses a threshold, tips, and spreads like wildfire.”

– Author Malcom Gladwell

Malcolm Gladwell’s first book, The Tipping Point: How Little Things Can Make a Big Difference, published in 2000, was one of the earliest popular books in the field now called behavioral economics. Classics that followed include Freakonomics, written by Steven Levitt and Stephen Dubner in 2005, Predictably Irrational, by Dan Ariely in 2008, Nudge by Nobel Laureate Richard Thaler and Cass Sunstein, and Thinking Fast and Slow, written by Nobel Laureate Daniel Kahneman in 2011. Collectively, these books combine elegant psychological experiments and data analysis using novel economic methods to dispel age-old assumptions about motivation and human behavior.

In his just-released eighth book, Revenge of the Tipping Point, Malcolm Gladwell examines the factors leading individuals to dramatically change their beliefs and values in response to the people around them. The many healthcare examples alone make it a worthwhile read for Medical Directors.

A particularly thought-provoking chapter is Chapter 4, The Magic Third. He presents a series of studies that show that 25-33% of a group of people can sway the rest of the group to the same set of beliefs/behaviors/values – the “Magic Third.” Examples include studies of the number of women on corporate boards, the number of Black children in mixed-race kindergarten classes, the percentage of Black residents in a neighborhood, and an elegant psychological experiment involving groups of people agreeing on names of random people in images. The “tipping point” in which major changes in the group cascaded rapidly was between 25 and 33 percent of the group. Gladwell goes as far as calling the Magic Third a “Universal Law,” a term social scientists and philosophers use in a way that is disconcerting to physicists.

One interesting experimental finding is that if 25-30% of a group are coordinated in trying to sway an entire group to their view (say on length of two lines, or the number of objects in a picture), they will generally be successful, even if the view they are agreeing on is demonstrably untrue! Social pressure is powerful!

On the other hand, the current political environment in Washington D.C. demonstrates that deeply held beliefs are not as susceptible to the “Universal Law” of the Magic Third.

I have observed cases where less than one third of a group can sway the entire group. In the 1980s, vintners in different areas of California formed local trade groups to promote wines from their region. They sometimes held charity fundraisers, combining marketing of their products with philanthropy. In one case, the Napa Valley Vintners, the target of fundraising shifted substantially from supporting local hospitals to focus on supporting the farmworkers and their families who worked in the region. This change occurred when just two board members (former publisher John Shafer, owner of Shafer Vineyards, and Bill and Kathy Collins of Conn Creek Winery) worked together to sway the views of their fellow vintners. For approximately 30 years (even after the deaths of Shafer and the Collins’s), vintners throughout the valley would all say that the focus of their wine auction and other philanthropic activities was to care for the farmworkers who worked in the fields, making their wine possible. Vintner groups in surrounding counties did not develop the same shared goal.

A key lesson from the Napa Valley Vintners is that two charismatic leaders, working together, can shift the views of an entire group, even if they initially comprised less than 25% of the group. However, it takes a bit of effort and time to get to the tipping point and beyond.

A look at major public health initiatives in California and other major health policies find this pattern repeating: two passionate dedicated individuals focus their energy to changing the framing or narrative, gradually swaying the larger group (or even the whole population) to their frame/narrative.

If one person has an innovative policy idea, their first important task is to find a second charismatic person who will support the idea. Together, with time and attention, these two can often sway the rest of the group.

Patience and focus are key. Having too many priorities means that insufficient attention goes to any one of them, and success will be limited. Partnership HealthPlan of California tracks the public health priorities of all 24 of our counties. In some counties, there are so many priorities that the health officer cannot remember them all without looking them up. Lake County has adopted a different model inspired by a framework called Collective Impact. The health department is mobilizing all major county stakeholders to focus intensively on one high priority issue: nicotine consumption in youth. I have no doubt that this approach will have a substantial impact.

So, don’t make too many New Year’s Resolutions. Choose no more than one difficult-to-achieve goal and stick with it. If your goal requires changing the behavior or views of people around you, first find a partner to work with you.

As we look ahead to 2025, which may bring many changes, finding ways to make meaningful differences in our communities can provide resilience. We at Partnership look forward to working with you to make our local healthcare system as functional as we can, providing care and comfort to the communities we serve.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

 “I am often reminded of the adage, ‘If you are not at the table, then you could be on the menu.’ If I am not getting out and having my voice heard by those who make decisions, I am not doing my job.”

– Pat Rusk, elementary school teacher and former president of the Utah Education Association

In an energetic meeting marked by some controversy, California physicians debated priorities for supporting health care in rural parts of California and ensuring access to safe obstetrical services at the California Medical Association (CMA) House of Delegates (HOD) meeting in Sacramento, October 26-27, 2024.

CMA membership is dominated by physicians working in urban and large suburban areas, especially those working at large medical groups such as Kaiser and Sutter. Although the two issues under discussion were especially important for rural clinicians most CMA members expressed support for their colleagues who have chosen to practice in rural settings.

For rural health, 14 recommendations were adopted by the HOD, including:

• Supporting public health-funding allocation models to ensure adequate funding for small rural counties.
• Calling on congress to increase the number of visa waiver slots available in California for physicians practicing in rural areas.
• Calling on Department of Health Care Services (DHCS) to remedy the systematic undercounting of American Indians in Medi-Cal data.

One area of controversy was a proposal to create a Section of Rural Physicians with influence at the Board of Trustees level. The executive leadership and governance committees agreed to take up this topic at a future meeting.

To kick off the OB access topic, Surgeon General (OB/GYN) Dr. Diana Ramos presented up-to-date data on serious maternal morbidity and mortality in California and unveiled her pre-conception screening program, “Strong Start & Beyond.”

For obstetrical services, 18 recommendations were adopted by the HOD, including:

• Support for funding low volume hospitals using mechanisms such as standby capacity payments.
• Alignment with increasing the support for training clinician workforce to provide obstetrical care, including perinatal case managers.

The role of family physicians (FP) that are trained to provide operative obstetrical services in rural areas generated some controversy, with urban/academic OB/GYNs expressing skepticism that FP[1]OBs can provide safe care in rural areas, while family physicians working in rural areas spoke up to defend their role in providing rural obstetrical care. This is not a settled issue; continued advocacy is needed to educate urban OB/GYNs on how OB care is provided in rural areas.

The other important action of the HOD was that in a tight, three-way race, pediatrician Dr. Rene Bravo of San Luis Obispo won the election for president-elect. He presented an excellent understanding of rural issues and primary care; representatives from district X and XI were pleased with his election.

Many physicians from Partnership’s 24 counties enthusiastically participated in the activities, including seven Partnership medical directors. County medical societies in CMA districts X and XI represent 23 of Partnership’s counties (Marin is served by district VIII). These districts were especially active in presenting amendments and debating the proposals.

The medical directors at Partnership strongly encourage all physicians in our service area to join the CMA and their local medical society to ensure representation and a voice in CMA policy decisions. Ideally, the organizations hiring these physicians would support the membership dues because physician advocacy complements other mechanisms for influencing health policy in Sacramento, such as trade organizations and specialty organizations.

In addition to being a member of your local medical society, if you have interest in influencing health policy, the first step is to attend the county medical society events and executive committee meetings, volunteering to be a delegate or alternate delegate for the HOD.

The next HOD meeting will be on October 18-19, 2025, in downtown Los Angeles. If you want to learn more about how to influence our health care delivery system and support policies that support the health care system in rural California, we encourage you to consider attending!

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The fact that we have the term “servant leadership” means to me that the definition of leadership is broken. To lead is to have a service orientation.”

–Stephen Shedletzky, author of Speak Up Culture

Job interviews for leadership positions often include the question, “what is your leadership style?” How does one answer such a question? Formal leadership training programs invariably include content on leadership styles which have been described and analyzed over the last few decades.

Before considering these, I will digress and note that there are centuries of writings in non-western cultures examining leadership frameworks with roots in the different cultural values in other societies. Descriptions of leadership are all frameworks that may ring true for some cultural and organizational settings, but are dependent on the place, time and mindset of the leaders being considered. This is an area of great interest to those working in companies with a multinational workforce. An excellent review article on this topic was written in 2019 by Vietnamese education scholar Nhung-Binh Ly.

The English-language leadership literature collectively includes more than 20 different leadership styles, although several are similar enough to be grouped together. Most authors select three to eight styles and describe these in more digestible comparisons. Here is a list of leadership styles that might apply to leaders of clinicians based in California:

1. Top-down Leadership: Autocratic, Authoritarian, Bureaucratic, Coercive, and Commanding

These styles are more common (but not universal) in military, veterans administration, and large, bureaucratic organizations. In these cases, leaders make decisions themselves with little input from anyone else. This works best if the leader’s knowledge and experience is much greater than that of their followers, when decisiveness is critical (such as emergency settings), and when following a hierarchy or dogma is highly valued. Downsides include stifling of innovation and feedback and disengaging of employees. In a setting of clinician shortages where clinicians are free to change jobs, this will lead to turnover in staff. Several years ago, a medical school classmate of mine had an autocratic leader of a community health center in Washington state; the entire clinical staff quit simultaneously.

Turnover is less likely when there is a significant penalty for a clinician to leave a position, such as a military enlistment contract, restrictions associated with immigrant visa status, a requirement to pay back a sizable advance or loan, or loss of large retirement benefits (sometimes called golden handcuffs). There is a cost to such binding covenants: those who stay in a position unwillingly will often be less efficient and empathetic towards patients.

2. Minimal Oversight: Laissez-faire, Delegative, or Absentee Leadership

These “hands-off” approaches assume that each clinician has their own way of practicing medicine and organizing their work which can be allowed to exist without interference. Many clinicians are partial to bosses who have this approach, feeling that their autonomy and expertise are being honored and respected. This comes with a cost, however: wide variation in practice styles leads to lower office productivity and office staff dissatisfaction associated with the mental gymnastics of meeting many different individual clinicians’ idiosyncratic “rules.” Similarly, improving quality of care across a practice requires standardization of processes, which is difficult in a delegative leadership environment.

3. Bottom-Up Leadership: Participative, Consensus-based, Collaborative and Democratic

Inspired by the ideals of egalitarianism, in these leadership styles, team members are encouraged to work together and give meaningful input into policies, decisions, and strategic direction. In the absence of consensus, the leader makes the final decision. This approach allows more engagement than the top-down leadership styles, but with more standardization than the minimal oversight styles. Ideally, decisions are made based on facts and quality of arguments presented by participants. In reality, there is often a social hierarchy at play with the participation process, with some participants having more sway than others not just due to the quality of the ideas presented, but by the social standing of each participant, and their desire to influence that social standing. If this social hierarchy is unchecked by a leader who is aware of these factors, the decisions made may be suboptimal.

4. Transactional Leadership

In this leadership style, tangible rewards and punishments are used to achieve goals. In the realm of leading clinicians, the tangible rewards may be financial (e.g. productivity incentives or quality incentives), or non-financial, such as allowing clinicians more flexible schedules or non-clinical administrative roles. Behavioral economic studies show that punishments are twice as effective at eliciting changed behavior than rewards of equivalent value but using punishments on individual clinicians often leads to turnover, so it is less likely to be useful in a setting of clinician scarcity.

5. Evangelical Leadership: Visionary, Charismatic, and Pacesetter

These focus on the leader themselves convincingly connecting the clinician work to a larger cause. Visionary leaders focus on the future state of the organization, and may or may not be able to connect that vision with the operational steps and staff motivation needed achieve that vision. Charismatic leaders tap into the human-mirror neuron system, building an unconscious desire to please the leader. Pacesetting leadership involves a hard-driving leader pushing followers to ever higher levels of excellence with no tolerance for mediocre effort or results.

6. Positive Leadership: Affiliative, Coaching, and Servant

These are hands-on styles that seek to promote longevity and performance by being supportive of clinicians. There are some important differences in the three subtypes. Affiliative leaders seek to create emotional bonds with followers, which can lead to hesitancy to have difficult conversations about performance and lack of feedback to leaders about organizational challenges. Coaching is important for new clinicians, but experienced clinicians may not see their boss as having the experience to be worthy of being a coach. Servant leaders attend to the needs of their high-performing staff, yet can give constructive feedback and have difficult conversations. Servant leadership was first described in 1970 in an essay by Robert Greenleaf, and many books have subsequently described and celebrated it. It has become so popular that author Stephen Shedletzgy implies in the quote above that all effective leaders are servant leaders.

7. Integrating Leadership: Adaptive, Situational, and Transformational

In real life, clinician leaders use elements of several of the above leadership styles, depending on the situation and the characteristics of the clinician they are supervising. Having an awareness of the usefulness and limitations of each style can help a leader of clinicians choose the best leadership style for a given situation. Transformational leaders use the best elements of several of the earlier leadership styles simultaneously, conveying the vision effectively, taking input from the team, using charisma to build trust and buy-in, while serving their employees and setting an expectation of excellence.

Returning to the quote by Stephen Shedletzgy, does all leadership require a service orientation? Not necessarily, although effective clinical leaders are more likely to choose to leverage a servant leadership style, much of the time.

I close with two questions for clinician leaders to reflect upon:
•   Which leadership style do you most see yourself using?
•   Which leadership style do you want to strive to use more often?

By Dr. Ashley Sens, CMO Woodland Healthcare

“Teaching is more than imparting knowledge; it is inspiring change. Learning is more than absorbing facts; it is acquiring understanding.”

– William Arthur Ward, Author

In my role as Chief Medical Officer for Woodland Memorial Hospital, I am sometimes asked to meet with patients whom physicians and nurses are concerned may decide to leave the hospital prior to the treating team feeling they are safe to discharge. When I get involved, it is typically because the team is concerned a patient-directed discharge could lead to the patient’s death. The stakes are very high for everyone.

I want to share with you an encounter I had with such a patient who taught me one of the most important lessons of my career.

Typically, the treating team and I would emphasize with these patients the dangers to them if they leave the hospital: “You are making an unsafe choice.” “You could die.”

However, this particular patient (we will call her Rose) helped me hear what those words sound like and feel like from the perspective of someone who has lived a life of severe trauma. The “aha” moment I experienced with Rose came when I realized Rose did not feel she was worthy of the care we were providing to her. All the threats to her safety and wellbeing were actually feeding into her impulse to leave – to run away, because, after all, what we were threatening is what she felt she deserved.

This insight did not happen because Rose told me explicitly she was not worthy of our care. The “aha” happened when I listened to her talk about her life and watched her squirm in the hospital bed. That was when I realized just how uncomfortable she must feel. For those who have lived a life of repeated and ongoing trauma, the trauma itself can feel more comfortable than safety, care, concern, or love – because it is familiar, and because their life experiences tell them they are not worthy of love.

So I stopped telling her she could die. I told her how much we care about her. I told her she was worthy of our care, that she deserved to be safe, and that she deserved to be well.

“We care about you.”

“You are worthy of our care.”

“Please stay with us and allow us to care for you. You deserve this.”

“You are worthy. You deserve to be well.”

Rose stayed.

— Dr. Ashley Sens, CMO, Woodland Memorial Hospital