Datica Podcast

November 19, 2019

Leadership Lessons from Healthcare and Beyond

In this powerful episode of 4x4 Health we learn about leadership from Dr. Bob Underwood through his nontraditional path to medicine. With a wide range of experience, Dr. Underwood discusses how to lead affectively and how leadership varies from management.


Dr. Dave Levin: Welcome to 4x4 Health sponsored by Datica. Datica; Bringing health care to the cloud. Check them out at www.datica.com. I'm your host Dr. Dave Levin.

Today I'm talking with Dr Bob Underwood, chief medical officer for San Juan regional medical center in Farmington, New Mexico, where he's also a practicing physician. Some of the most interesting and accomplished healthcare leaders I know have come from unusual backgrounds. While there are plenty of great people whose careers have followed a straight-line traditional path, there's something to be said for less traditional pathways and the potential they have to prepare one for even greater success in healthcare through a combination of unique prior experiences and points of view. Bob Underwood stands as an excellent example of this "Other way." Dr. Underwood graduated from the United States military Academy at West point in 1987 and was commissioned as a field artillery officer where he led men and women on a missile and cannon weapons system. After active duty in the army he worked for a short time as an operations manager with Caterpillar inc until being mobilized during operation desert storm. Upon discharge from active duty. He went back to school to complete his pre-medical education while also working as a manager in a large hospital and simultaneously continuing to serve in the army reserve. He obtained his medical degree from the university of South Carolina school of medicine in 1998 and completed a residency in emergency medicine at wake forest in 2001. In the eight years following residency, Dr. Underwood worked in a purely clinical capacity as an emergency physician in a busy emergency department. Like many fellow physicians, the advent of electronic medical records provided Bob with an opportunity to get involved in informatics. Given his background, it's no surprise that he was a natural to lead physician efforts around EMR implementation and optimization as the chief medical informatics officer at Sentara Rockingham Memorial hospital in Harrisonburg, Virginia. It was in that role that he and I became colleagues and friends and in a pattern I’ve seen elsewhere. Success in his EMR leadership role led to new administrative and leadership roles including director for clinical transformation and regional medical director for population health. He subsequently served as chief medical officer in the Centura health system and then San Juan regional medical center. Dynamic and experienced speaker, Dr. Underwood has taught leadership to interprofessional healthcare groups and it's been listed twice on Becker's hospital reviews, hospital and health system CMIO's to know. I vividly recall my first meeting with Bob because even in the opening moments of our relationship, I learned a valuable lesson in leadership from him that's worth recalling here. Bob and I were both in positions that required us to lead large groups of physicians at the time, knowing that he had come from a military background, I naively observed, Bob I guess it's going to be very different for you leading in a civilian environment. After all, the military has a chain of command and people are used to following orders. I'll never forget how Bob looked at me with a mixture of sort of compassion and pity, like I'd asked the dumbest question ever and shared this important lesson. I'm paraphrasing a bit, "Dave that's not how things work in the military, especially with military doctors or with leadership in general. Telling people to do things rarely works. You have to inspire, engage, and empower and do all the other hard work of leading." It's a lesson I remember and use on an almost daily basis in my work. I'm grateful that Bob had the background and the experience to be in a position to teach it to me, and I predict more of the same today in our discussion. Welcome to 4x4 health, Bob.

Dr. Underwood: Thanks Dave. I appreciate being here.

Dr. Dave Levin: I heard you laugh during that introduction. Do you remember that lunch as well?

Dr. Underwood: I do recall that lunch. Yes. In fact, I do.

Dr. Dave Levin: Yeah. I've made a career in asking stupid questions and sometimes it leads to great advice.

Dr. Underwood: You know, the thing is I don't know that it's really a stupid question. I think for people who are unfamiliar with the military that's really common is you think that, you know, somebody outranked somebody else, therefore they tell them what to do and then they have to do it. But like you said, and like I said back then, that's not really leadership. So, leadership is I think it was Eisenhower that said getting people to do things that you want to do, want them to do because they want to do it.

Dr. Dave Levin: Well said. And I know we're going to get much deeper into this topic in a few minutes. But I'm glad you recall that time as well. And as I said it made a huge impression on me at that moment. Well, let's go ahead and dive in here. I'm going to ask you a series of four questions and some follow ups and we'll take about four minutes on each one. Get us started, Tell us a bit about yourself and the organization that you're currently with.

Dr. Underwood: Sure. Well thanks a lot. You did a great job in the background because a lot of times that's confusing to people. And how did I end up here as the chief medical officer in a facility or in a hospital that's our size. So, I'm in San Juan regional medical center. We're in Farmington, New Mexico. We have a huge footprint because there's just not a lot out here. We're on the edge of the desert, we are in the four corners region of the United States. So, we're a level three trauma center. I like to say we're a level three plus because we also have neurosurgical capability for trauma and that's not required for a level. We deliver over a thousand babies a year at our facility. We've got an ICU, we don't do peds ICU and we've got a San Juan health partners, which is our employed physician group. And it's multi multispecialty covering pretty much everything you could think of except I think ortho and OB are private docs in the community. But otherwise we have cross coverage in almost everything. So good facility, 194 bed inpatient facility. We also have a rehab hospital across the street, which is really good for both our trauma as well as stroke. We're a chest pain certified center stroke center, trauma center. Like I said very busy in this facility. And again, I said geographically, our footprint is huge. We've got helicopters and airplanes for transport here. Because we've got such vast distances to cover. And so, as I said to your kind of before we got going, if you hear a helicopter in the background just cause it's literally right outside the windows and it averages three flights a day, so it wouldn't be surprised to hear it come and go.

Dr. Dave Levin: Very good. Tell us a little bit about, you know, the scope of your responsibilities and what a typical day might be like.

Dr. Underwood: Sure. So, meetings is of course I think the bane of almost every hospital administrator. But the long and short of it is I’ve got the medical staff services office that reports to me. So, I’ve got folks in there that are doing credentialing, recredentialing privileging as well as peer review, quality etc., are all part of that. And then the quality department, which includes patient experience all of our reporting structures through the centers for Medicare and Medicaid also report through me. And then I’ve got another section that's part of quality that our data scientists and that really is around driving the data integrity. One of the things that I found when I got here, this literally happened. I had two of my quality folks tell us, Oh, we're doing so great and our readmission rates, we're well above our goal and well above average. And then the next day I was told by our data scientists that we were going to suffer a penalty for the centers of Medicare, Medicaid for readmissions. And I know that only the bottom court that'll actually get penalized for that. And so, it made me start looking a little bit deeper. That was probably within the first month or two that I was here and to okay, how are we really doing our data integrity? That's especially when you're working with physicians, you've got to have your data right. Because they'll pick it apart and you'll lose all credibility. You trying to get physicians to change behavior if your data is wrong and they could pick that apart. So that's a big piece of what I do. And then last I’ve got, our department we call organizational excellence and that is made up of black belt. And then we've got sort of six Sigma and lean black belt and we train other folks within the hospital and what we call an extended office in yellow belt. And our next phase is to go through the managers and get them at least up to green belt level. So quite a number of things that kind of fall under where I work and what I do. And of course, included in that as counseling physicians if necessary, for the usual stuff that I think is CMOs is often settled with. And that does not happen at this facility very often. I have to say I’ve worked in a number of organizations. You and I knew each other there in Virginia and Sentara I’ve worked in Centura and Colorado area and the ability of these physicians to a get along with each other, to get along with the nursing staff is really, really strong here. And some of them that have never worked anywhere else don't realize how good it is here because they don't have a point of comparison. But the physicians here are really, really strong and their ability to work collegially with each other’s is phenomenal.

Dr. Dave Levin: That's a great overview. You're also actively practicing as I understand it.

Dr. Underwood: Yeah. I work a couple of days a month. In fact, I’ll be working Friday and Saturday this week in our urgent care. I'm a trained emergency physician, but it's been a while since I worked in an ED. You know, doing things like central lines and chest tubes, I'm not sure I would want to jump back into the fray without some pretty significant oversight. But work in urgent care seems to be good for a, keeping my skills up. But there's also expectations that I have to, that I have to explain to providers in terms of use of the electronic medical record and throughput, etc. and documentation. And it lends credibility to myself when I'm actually seeing patients along with everybody else. And I can say, look this electronic prescribing thing isn't a big deal. It's easy to do. This is how you do it. And it also helps me understand when physicians come to me about difficulties with the electronic medical records, I know exactly where they're coming from cause I'm using it too.

Dr. Dave Levin: This is, that's a really beautiful explanation of that. This is a question that comes up all the time with our colleagues who are in leadership roles and are trying to balance that with practice and with having a private life and a full life. You and I had a mutual colleague, he used to say, this is eating the dog food we make. And I think there's a lot to be said for that. So, thanks for sharing that. I want to, I want to drill a little bit deeper. One of the things you said you, you shared an anecdote about data quality that arose almost from the beginning. And before I do this, I want to remind you one of the roles of the 4x4 health podcast is you can call BS on the host at any time. In fact, we encourage that. So, but what struck me about that is this seems like a pattern to me. And the pattern is, organizations deploy their EHR. Part of the reason for doing that is that they expect it's going to generate a lot of clinical data that can then be used for all kinds of improvement activities and reporting and other things. And then pretty quickly they find out, well they didn't really do adequate data governance and the data's dirty or it's hard to find or there's a bunch of other issues and this, it sort of opens up this whole next phase of work to actually be able to harvest and make that information actionable. Now I don't want to put words in your mouth and that may not be the situation, but I guess my question is, is that a pattern you've observed you know widely and is that sort of what you guys have been living through?

Dr. Underwood: Yeah. Absolutely. And it goes all the way back to when I first became a CMIO back in 2008, you know garbage in, garbage out as we like to say. And so, what was actually kind of interesting is you talk about you know, implementing an electronic medical record expecting that you're going to get all of this information out of it. I've been through, so I went through a Meditech go live in Virginia, then I went through an Epic conversion from Meditech. And then I moved to Colorado and went from a conversion from Meditech to Epic. And then I moved here, and I’ve gone through a conversion from Meditech to Cerner. So, my experience with electronic medical records is quite extensive now. And conversions and yes, that's a, it seems that getting ready to go live. We talked about the operational functionality of the system. And the quality piece seems to be an afterthought right now. And I think I have a helicopter outside, just like I said. Yeah, the quality of the data is difficult. We finally got up to greater than 90% data integrity and submitted to our state, quality information just this week. And so, we've been live since January, so we're nine months into this and only now are we getting to where the data quality is, where we want it to be and we're able to harvest the data the way think we need to out of our data repository. So, yeah, that's huge. And the other question is, you know, who's putting the data in and how is it being entered in and what is the clinical skill set of the people that are entering the data? And is that taking away from their clinical functions of taking care of patients? You know, you hear a physician say all the time, I'm not a clerical person. Why am I the person who has to enter all of this data? And I have to say there's a lot of legitimacy to that. You know, you and I as clinicians see that side of it very, very clearly. That's not what I originally went to med school to do. So where do we meet the appropriate balance and still make sure that the data that's being input into the system is appropriate, accurate, actionable in the long run. And I have to say that, you know, the amount of data, we've got nine months’ worth of data that we're able to access right now within our system. But even then, I'm still wrestling with how accurate a lot of that data is basically through the way it's input by the providers, but also how it's coded after the patient is discharged. You know, I’ve got lots of examples of that where I’ll have a patient who will be listed as yeah, I'm trying to come up with an example, but I have one wouldn't be appropriate. But the primary, this is a mortality and the primary diagnosis was Volvo vaginal candidiasis. And I'm like, okay, the patient did not die of a Yeast infection. And so, the third diagnosis down was stage four liver cancer. And I'm like, okay, now I’ve got a cause of death, but it makes my mortality numbers of the organization look horrible. Because, the acuity of the patient isn't being captured by that diagnosis. So yeah, we struggle with that and I think most organizations do at one point or another.

Dr. Dave Levin: Boy, I think we just scratched the surface on that. We could probably do a whole series of podcasts on this.

Dr. Underwood: No doubt.

Dr. Dave Levin: The one thing I’ll just call out is, as you said at the end of the day, the important question is, so what? And it's about at being actionable and that's again, that's a whole another podcast because we, I, I see a spend a lot of time measuring things, but then we don't really have ways to make it actionable or put it back into the workflow or all the rest.

Dr. Underwood: Actually, a colleague of ours Gary Yates recently wrote an article about actionable data and is the board reviewing appropriate quality data that has actually actionable. Just because you can measure it doesn't mean you should measure it.

Dr. Dave Levin: That's exactly right. Boy, like I said, we could probably do a whole series of podcasts on this topic. Now I want to go ahead and move onto our second question, which may be hard for you to answer given all the things you're involved in, but you know, what's the most important or interesting that you're working on right now?

Dr. Underwood: Well to me, the most interesting thing that I'm working on right now is a, is a book through a company called Academy of leadership. I'm working on it with a gentleman named Dennis Haley. He's a Naval Academy graduate, which is of course my archrival, but nonetheless we're working together. But it's a book on leadership and so it's called leadership compass for healthcare professionals. And it really is taking what you and I have talked about in the past. But what I see as often a gap in healthcare is physicians really understanding all the basic principles of leadership. Starting from the ground up. If you look at the physicians, you talked about it a little bit earlier, the kind of standard training that a physician goes through. You know, they start in high school and they do very well, and then they go to college and they do very well, and they get accepted to medical school and they do well enough to get into the residency of their choice. And then they finish their residency and suddenly somebody slaps credentials on the end of their name and they're in charge. And nowhere along that pathway was the appropriate way to handle authority and leadership ever really passed on. There are organizations that are out there that actually do teach some of the basic leaderships, but I think that they're more in the managerial side. And I differentiate very strongly between leadership and management. And so, you know, an organization, the American association of physician leaders, they do a lot of discussion about healthcare finance and healthcare law. Recently I’ve seen they've started to get into legitimate leadership, leadership with character, etc. And that's really what the book is about. And it's a story. It's not a, if this do this, if that, then do this instead. It's actually a story about a young physician or a younger physician who finds himself in a position as a medical director of a service line. And he's kind of put into some leadership challenges and through a mentor who happens to have also been prior military. He's kind of guided along the way of, well, what do you stand for and what is your, what is your compass in terms of leadership? What are the things that are important to you and what are your expectations of your team? And then they go through conversations about kind of how to manage that and how to explain that to the folks that work on your team and work with you and how to look out for folks and stuff like that. So, it's really a story. And I got into a discussion recently with somebody who was working on another project in terms of employee engagement. And we got into the discussion of quality versus, not quantity. What's the word I'm thinking of? A qualitative explanation versus quantitative explanation. And so, we can look at things objectively and measure those, but the subjective of piece is more difficult. And how do you explain quality? And really, it's through telling stories and sharing anecdotes and giving examples. And that's really what this book is. It's really an example of what's a good way to handle things. Now it is in no by no means mean that you know, somebody is going to read this book and suddenly walk out and be a great leader. You know, leadership is actually trial and error and learning something new and then going out and trying it and then it doesn't work. And so, you go back, and you tweak it and then you go back and try again and then you finally get that right. And then somebody gives you a bigger piece of pie to eat and you'd go through the whole rundown again. And that's really leadership. But I think it's a, it's a great opportunity to kind of explore some basic things about what is leadership? What does it mean to me? What does it mean to me as a provider and how do I work with my colleagues who really don't even answer to me? Which is how we find ourselves often in the medical field as leaders, physicians or even nurses often is that, you know I have to lead my peers and I have no authority over them at all. And so how do we get, how do we motivate those people? How do we move forward and implement changes that we know are necessary in the healthcare realm when there's always a little bit of resistance to change? And so, there's a lot more nuance when you're trying to do that among your peers. And there is when you're, when you're doing it with a sense of authority behind you. So yeah, it's exciting stuff to be sure.

Dr. Dave Levin: Well, that was terrific. There's a lot to unpack in there and I want to go through a couple things there. I would share with the audience, I had a chance to see some early galleys of the manuscript and I’ve encouraged folks to read it when it's released. We'll be sure to have a link from our website with the podcast as well. It's an easy read. And what I liked about it was, it's told from the point of view of a story, it's a journey that this new young leader is going on. And it, it really resonated with me. It's not unlike the journey I went on and the journey I’ve observed many others to go on. I wish I'd had that damn book before I had lunch with you that day. I might've asked a smarter question than the one I did. So, but you've set up a number of things in there. Let's try to take a few of these apart. You said you make up a big deal about the difference between leadership and management. What do you mean by that?

Dr. Underwood: So, management is putting the right resources in the right places to get the mission done. Or to accomplish a particular task. So that is a, it is a maneuvering of resources. Whether those resources be people, equipment. You know, I'm thinking x-ray and what happens in the radiology department and making sure that you've got your MRI available at certain times and making sure that it's full. That's all management. Making sure that people knew who know how to use that device are available to use that device when it's necessary to be used. Leadership on the other hand is inspiring change. And so, the often you will if you read about it, you will read that there's actually a somewhat of an intentional conflict between managers and leaders. Managers are there to keep the status quo almost to make sure that the machine is running the way that it's supposed to run. Leaders are there to change the machine, leaders are there to try to induce change, improvement, to look at new ways of doing things. And you've got to inspire people to be able to do that. And so, one of the things that I have seen also written is managers do things right, Leaders do the right thing. And so, it's about how you really look at making sure the organization is running the way that it ought to be and continuously improving along its process.

Dr. Dave Levin: That's really nice. You know, my little shorthand for this is you manage stuff, you lead people. And the other thing for me that's so important about this is it's not necessarily even my idea. In fact, I got to be careful about that. What I really need to be doing is gathering groups and sort of facilitating the process that brings out the best of them. As we look at the situation, as we imagine what we might do, we're more likely to get a better answer that way. And it also creates buy in, that creates ownership. Very different from the so-called quote leader stand up in the front of the room and saying, we're all going to do X. Well, that may work, but it's not, X may not be the best thing to do. And people are not going to be highly motivated.

Dr. Underwood: No, absolutely. If you are a part of the decision making, then you're bought into the process that you're going to be going through. And I’ve got a great group of physicians here, some that are really working towards those changes and yeah, they're bought in and they're driving it forward almost with me trying to catch up in some areas. And I can't ask for anything more than that, that's just awesome. But yeah, leadership is again, it's nuanced. Yes. It's part of making sure that you've got the buy in. But it's also leading with character. It's also you know, making sure an example came up yesterday, I was in a senior leadership meeting and there was a discussion about whether or not we supported a particular medical procedure that's not available right now. And we looked at, you know, does that kind of create a conflict or is that going to actually create competition among providers within the community? And my statement was, if you look at our values and our mission statement as an organization, it is providing a necessary service to our community that currently doesn't exist. It's the right thing to do for our patients. And that's really what we need to be grounded on. So, it also in leadership is making sure that you are focused on what is your mission, what is your why as an organization and rallying folks around that. And that was really my kind of appeal at that discussion yesterday.

Dr. Dave Levin: There's another principle that I’ve observed. I'm curious if you'd agree with this. It's that the, typically the higher you go in an organization or the more the role is a leader role versus a manager role, the less time you should spend thinking about what needs to be done and more time thinking about who's going to do it. And that's both figuring out the solution and executing on that. And I'm just curious, I mean, again, it's a generalization and of course, great leaders adjust, and they choose the tool for the moment. But I'm just curious, is that something that you've also observed, or you need to call BS on me at this point?

Dr. Underwood: No, I'm not going to call BS on you. It absolutely is the case. I mean, folks come to you as the leader because you're the one who could break down the barriers or make the connections that need to be made, so that something can be accomplished. So often in terms of, I gave the example of the data integrity, you know, I'm making sure that they're in touch with the person who actually knows where the data lives so that they can go find it. That's, you know, part of what I do, we have a new CIO at our organization and he and I worked very closely together, and you know, both of us work hard to make sure that we have appropriate connections to get things done. He's new to the organization and so being able to talk to him about you know who to go to for this piece of information or to get this done. You know, sometimes those people are formal, sometimes they're not, you know, who are the people that are successful in getting things done, often actually don't even have the physician in your hospital. But they're the people to know and they're the people that connect with, because they get things done.

Dr. Dave Levin: That's right. So true. There's something else you said earlier on in your description. And it's this, it's so common we take someone who's good at their frontline job and we promote them into management and there's two points I want to make about that. I see that lots of places. And it's not just physicians, it's rampant and nursing and other fields. And frankly I see it at other industries as well as, has that been your experience too?

Dr. Underwood: Absolutely. You know, there are a few organizations that have really gone out of their way to do a leadership development pathway. The military of course where I come from is very prescribed in your leadership development. You know, as an officer, you come out of your basic, your training in college and the first thing you do is your officer basic course. And then you go out into the force and you do some things for a while, like three years, and then you're brought back to an advanced course. And these are all about leadership and what does that next level of leadership and then you're back in, you're in command in general staff school and the same thing for the enlisted ranks. It's, you go to basic NCO course and advanced NCO course and sometimes the first Sergeant course, etc. And so, I think GE also developed a very strong leadership pathway within their organization. And that's one of the things that my organizational excellence team and I are working on is how do we develop a leadership, often the terminology's leadership Academy. But how do we develop that, so our growing managers know so basic leadership skills, how do I have difficult conversations? How do I have counseling conversations? How do I do performance evaluations in a way that they're constructive to inspire and encourage the positive behaviors that I want. Those are skill sets that we forget. They don't just come naturally to people. And so yeah, it's definitely the case in all industries. I used to think it was unique to healthcare as well, but then I talked to folks in the newspaper industry and tried to explain my point of view and they're like, oh yeah, we have this exact same issue. And you're right, the farther up the chain of command you get, if you will, the less management you do and the more leadership you do. And so, teaching that balance is also important. We've got new managers. We would have never thought of this. I've got a manager who I call my boss because she's the manager over the urgent care clinic. But she was recently moved into a management position from a nursing, bedside nursing role and she needed guidance on email. And you know, things that we take for granted, but you know, she really, you know, how do you sort your email, how do you prioritize email, etc. that, you know, often there are those of us who take that for granted and don't even think about it. How do I do our payroll? How do I do personnel evaluations? Those are all managerial skills in my opinion. But they're very, very important and the farther along you go, the less important some of those tasks are and more the leadership component. But that leadership Academy that we're talking about developing here is going to be a combination of management and leadership and what's the right balance as you move up that chain.

Dr. Dave Levin: I want to ask you one last question about this topic, and again, we probably could devote an entire podcast to this which you and I would really enjoy. How is this journey of yours into consciously and intentionally developing leadership skills and doing that in others around you? How has that affected your personal life?

Dr. Underwood: For me it's been really fulfilling to tell you the truth. Because I came from the Academy from West point which their vision is to be the quintessential leadership organization in the world, not in the United States, not in the world. And so, it's a passion. It's a passion that I developed early on in the military. And then going to med school. Of course, another passion. I chose emergency medicine because I like to say I have a hero complex. I like to help people in the time that they most need it. And then sort of take these two passions of medicine and leadership and be able to combine those is just awesome for me. So, I’ve got a helicopter taking off behind me again.

Dr. Dave Levin: No worries. The thing that I’ve observed both for myself and for the times that I’ve had the honor of serving as an executive coach to others is almost inevitably at some point in the process, they will say, you know, I started using some of this stuff at home and it's really making a difference. And hopefully my wife would say the same thing. But it's just, that part has been fascinating to me. These are lessons about life and human interaction that while really powerful at work I think are generalizable and I'd like to believe that it's made me a somewhat better human being as well. Am I over the top there or would you agree?

Dr. Underwood: It depends on the individual, but I think so. I think that a huge amount of leadership is all around communication and I think that it builds better communication in your home life if you're willing to, if you're willing to take those lessons and have those communications elsewhere. Yeah, I would agree.

Dr. Dave Levin: Yeah, I would add, I think a lot of it too is its kind of a juror pretty of self-discovery and self-knowledge that part of this is learning about yourself and what moves you and what doesn't move you about emotional self-regulation, about how to engage in conflict and productive ways. I mean there's, it's a long list of things that are great leadership skills and great for work that turn out to be actually quite valuable in interpersonal relationship in general.

Dr. Underwood: Going back to the book, that's actually a huge part of the book is this, the mentor of the new medical director essentially gives him an assignment to write his own leadership philosophy. And it really gets down into values. And I have taught that to other folks, and I’ve had people come to me and say how emotional of an exercise it turns out to be and it doesn't seem to be, it seems mechanical when you start to talk about, okay, what's important to you? What are the important things that I expect of my team and what are the things that my team should expect of me? And if I'm not doing those things, you need to hold me accountable team and I have had people come back to me say this was a big self-exploration for me in writing this down in basically a 500-word document. So yeah, very rewarding in that way.

Dr. Dave Levin: Very good. If you've just joined us, you're listening to 4x4 health sponsored by Datica. And we're talking with Dr Bob Underwood, chief medical officer for San Juan regional medical center. So, Bob, for question three, I want to remind you this show is PG 13, so I need you to keep it family friendly. But what's your pet peeve or favorite rant these days?

Dr. Underwood: This is actually, it's in my leadership philosophy as a matter of fact is, I will always step in and take up for those who cannot defend themselves and that is often directed towards physicians. In other words, if I know of a physician who is leveraging their power in an inappropriate way and belittling a nurse, a respiratory therapist or anyone else, I will be there. That is my pet peeve. I cannot stand people who cannot defend themselves being abused by other people. So that's my pet peeve.

Dr. Dave Levin: That's a good one. There's an article from the Harvard business review. It's probably more than five years ago and I guess I got to remind myself this show's PG 13. The title is something like A holes, they're not worth it. Yeah. And well, what was fascinating to me about it at the time is, it sort of goes through you know in an organization where you may have someone who you think is incredibly valuable, maybe they're a big Rainmaker in the organization, but they truly meet the definition of be an A hole, which you sort of, which you alluded to, which is essentially abusing differences in power in ways and they basically make the case and they back it up. That if you do the analysis, these people are never worth what you think they're going to be worth.

Dr. Underwood: No, absolutely. The damage that they cause along the way, the demotivation that they present to other people yeah, you're better off with a team without him, even if they may have seen productive at the time. So, you know, when we called them in residency, they're malignant, and we use the term, you know, because it does follow the medical term of it spreads in a negative way.

Dr. Dave Levin: Yeah, that's exactly right. So, this last question may be also hard for you. You've shared a lot of Sage advice with us today, but as we wrap up today what's your most Sage advice?

Dr. Underwood: That we're actually all trying to get to the same place, that we often have conflict in healthcare organizations. You know, healthcare organizations are the other than the military, again, and I’ve had the privilege of serving in both is one of the most complex organizations that you can work in. And often we feel that we have a conflict in terms of what our goals are, but in reality, we're all trying to get to the same place, whether you're the chief financial officer or an emergency physician, we really are just trying to do what is best for our organizations, patients that we take care of on a day to day basis. Now the methodologies that we follow may be different, which is why it seems different from where you're geographically located next to the patient versus in another office. But the outcome we're trying to get to is the same. The scope may be a little bit shifted based on your perspective.

Dr. Dave Levin: Yeah, I could not agree more. And my experience after three plus decades in healthcare is that is true for the vast majority of people. They are there to make healthcare better, to take care of their neighbors, to make their community stronger. We're all human beings. We make mistakes, we stumble, we get angry, we do stupid things. But my experience is the vast majority are there for the right reasons and are doing the best they can under often trying circumstances.

Dr. Underwood: Yeah. I definitely see that as the case and you know, often the series of rewards and punishments I'm talking financially, regulatory wise you know, we're trying to work the best that we can within those constraints and sometimes they're counterproductive to what you're trying to accomplish. And healthcare is made up of really smart, well intentioned people and we're working the best we can within the constraints that were given. And it does generate conflict, but you know, you got to know, the ultimate outcome is still the same for all of us.

Dr. Dave Levin: Yeah, very well said. We've been talking with Dr Bob Underwood, chief medical officer for San Juan regional medical center. Bob, thanks for joining us today for your service to our country and for everything you're doing to make healthcare better and in your community.

Dr. Underwood: Thanks, Dave. Thanks for having me on. Good to talk to you again. I always enjoy it.

Dr. Dave Levin: You've been listening to 4x4 Health sponsored by Datica. Datica; Bringing health care to the cloud. Check them out at www.datica.com. I hope you'll join us next time for another 4x4 discussion with health care innovators. Until then I'm your host Dr. Dave Levin. Thanks for listening.