The future of physician leadership hinges on a skill money can’t buy — social capital. In this conversation, Thomas Lee, M.D., chief medical officer of Press Ganey and editor-in-chief of NEJM Catalyst, explores why social capital is becoming the most critical asset in leadership development, how it can drive organizational performance, and why physicians must act intentionally to enable high-reliability teams.

To learn more about the recent framework for physician leaders, please visit https://catalyst.nejm.org/doi/full/10.1056/CAT.25.0005

Tom Haederle

Welcome to Advancing Health. Being a doctor, both at the bedside and around the boardroom table often means channeling two different skill sets. And as we hear in this podcast, the successful physician leader must learn how to bridge the gaps in knowledge, exposure and experience needed to cross the bridge from clinical practice to leadership and master the art of social capital along the way.

Chris DeRienzo, M.D.

Hi everyone! Welcome to this episode of our podcast. I'm Dr. Chris DeRienzo and it is my true honor to welcome a long time mentor and friend to the podcast, Dr. Tom Lee. Dr. Lee is not only the chief medical officer of Press Ganey, he's the editor in chief of NEJM Catalyst. He's a practicing primary care doc. Got to know him many years ago through connections in the Asheville area.

Chris DeRienzo, M.D.

Tom is here to talk to us today about the intersection of social capital, and the AHA's physician leadership framework, which was just published. Tom, thank you so much again for joining us.

Thomas Lee, M.D.

I'm delighted to be here, Chris. And every time I talk with you, I learn stuff, too.

Chris DeRienzo, M.D.

Likewise, sir. As we get started, it would be good to note for listeners that the paper that I'm referencing, AHA's physician leadership framework - it was published in NEJM Catalyst earlier this year. We have links available to it and so you can read it at will, but at its core has been a challenge that we've wrestled with for some time. Which is there's a gap between, what we know it takes to be an excellent clinician, an outstanding bedside physician,

Chris DeRienzo, M.D.

and what it takes to become an outstanding physician leader. And Tom, that's a gap that you've explored for decades, not only in your research, but also as the editor in chief of NEJM Catalyst.

Thomas Lee, M.D.

Yeah. And these questions are interesting. I mean, they're core to our jobs. We have to actually deal with the situations were working hard is not enough, where it's not clear exactly what we should do. How do you figure out what we should do and how do we do it? That is the nature of the jobs of being a physician leader today.

Chris DeRienzo, M.D.

Working harder is something we've relied on for a long time in health care, and we've thought that we need a hero. And there are absolutely heroes in health care. But your construct of social capital is one that I think we should explore for listeners of the podcast, because the way it intersects with the bridges that we built in that framework, I think are not only interesting but important.

Chris DeRienzo, M.D.

And so perhaps you can just take a moment for listeners who aren't yet familiar with social capital to give them a sense of what it means and how do we develop it?

Thomas Lee, M.D.

Well, the concepts aren't really new or foreign, and they're going to feel very comfortable to everyone listening to this podcast. The different is framing it in a way where we approach it in a tough minded, businesslike way. You know, capital is anything that helps you improve. It helps you be better than your competitors, help you be better than yourself next year.

Thomas Lee, M.D.

Financial capital are the financial resources that enable you to do things you couldn't otherwise do. Human capital or the people with the expertise around you that help you do things you couldn't otherwise do. But social capital is how those people work with each other and with their infrastructure that enables you to do things you couldn't otherwise do. Social capital is based upon currencies like trust and respect and teamwork.

Thomas Lee, M.D.

These are things we're all for, but building them as opposed to just being grateful when we have them, that's what I'm suggesting we ought to all be doing. Getting tough minded like the CFO is about financial capital and building teamwork and trust in high reliability. I think we can do that work, and I don't think it will be annoying.

Thomas Lee, M.D.

I think it'll make our lives better.

Chris DeRienzo, M.D.

Not only make our lives better, but, but lead to better outcomes. In order to get there, though, that requires some intentionality. Relying on working harder is in some ways a simple answer, but reconfiguring a system to enable teamwork, to enable high reliability, I love the way that you frame that. It's like a book that I read recently by the person who founded Panera that that there are things that emerge from the system.

Chris DeRienzo, M.D.

Profits emerge from a high functioning system that is differentiated against other folks operating in that market. You describe teamwork and high reliability as secondary effects of high functioning social capital. Am I getting that right?

Thomas Lee, M.D.

Very much so. But to really have a great team...many of us have been on great teams and we know it took work to get there. It takes sacrifice, sacrifice of some of your autonomy to get there. It means having norms, behavioral norms and enforcement mechanisms for the norms so that if someone isn't being a good team member, they hear about it.

Thomas Lee, M.D.

We don't just say anything. I mean, just very recently, one of my colleagues was saying in the emergency department, you can see everything. You can see who's behaving like a jerk. And he said, do we say anything? And he said, hardly ever. But if you're being tough minded about social capital, you give your colleagues feedback. I know that's uncomfortable.

Thomas Lee, M.D.

But getting into that kind of culture where people give each other feedback on what will make us all better collectively for our patients and for the way we feel coming to work. That is what we're talking about here.

Chris DeRienzo, M.D.

And it's foundationally a different way of thinking than sometimes we would historically apply to physician training. I like to describe for folks that in the medical education world, we are taught to sit on top of a pyramid, and there's a whole lot of weight that sits on our shoulders. The order carries our signature. Our professional license is on the line for the decisions that we make, the patients and their families outcomes

Chris DeRienzo, M.D.

we are personally responsible for. And when that's the world that you've lived in for decades, and you envisioned the pyramid this way, it's pretty hard to invert it. Many folks do. But, it strikes me that leading teams in health care and the getting to the right side of the framework that that we described in our paper is fully grounded in that construct of social capital. That we have to realize that we may be an expert in the things in which we are expert, but that doesn't make us an expert in everything.

Thomas Lee, M.D.

Well, you know, instead of picturing pyramids, but I encourage our audience to think about is think about social network diagrams, you know, web of nodes. Some people right in the middle of things, connected to everyone. Some people just on the edges, you know maybe loosely connected, if at all. And the truth of the matter is, we're all in social networks.

Thomas Lee, M.D.

And social capital means making those social networks more effective, making them stronger, making the connections real among everyone and making them compelling. And then spreading the right norms and values across those connections so that the team can be more effective. And so the teams can interact so that the organization can be more effective. It is real work, but it's cool work, actually.

Chris DeRienzo, M.D.

It can be fun. And, you know, it strikes me that for a long time physician leaders have somewhat informally relied on that social capital to accrete some of the knowledge that it takes to move from outstanding practicing physician to outstanding physician leader. I'll give you one example. I don't have an MBA or an MHA. I learned about EBIDTA from my CFO.

Chris DeRienzo, M.D.

EBIDTA, which for those who don't yet know, is, a commonly used finance abbreviation for earnings before interest, depreciation, taxes and amortization. And when I was in my first C-suite level role as a physician leader, that CFO sat down with me every month and walked their income statement and our balance sheet. So I not only accreted knowledge

Chris DeRienzo, M.D.

and in the framework we describe sort of three gaps. There's a knowledge gap, but then there's an exposure gap. We have to get exposed to how that applies in a hospital and health system. And then ultimately, in order to be able to own that skillset, we need some experience in being accountable for it. And for me, my CFO was a node in that network who was willing to sit down and share with me enough -

Chris DeRienzo, M.D.

I'm never going to refinance bonds - but I know enough now to be a competent operator. And you're exactly right. That is a outcome of social capital.

Chris DeRienzo, M.D.

And I think that the framework that you recently wrote about, breaking down the types of work it takes is a great framework. And, I admire your clear thinking. And it's so much more sophisticated than the advice I was thinking about, which is telling the audience, go watch the TV show The Pit and, the HBO show about the emergency department and watch how over the course of season one, the 15 episodes, the relationships, they get stronger and stronger among the people down in the emergency department together where people are ready to do whatever it takes.

Thomas Lee, M.D.

They're not thinking about their job description. They're doing whatever it takes. They're actually building social capital, including the part where they're sitting on a park bench sharing beer from a cooler in the next to the last episode of the season. So even though they make a big joke about Press Ganey in the first ten minutes and despite that start, it's a fantastic show that captures something what leaders in who are physicians can do and should do.

Chris DeRienzo, M.D.

And that's the kind of experience that I think we are accustomed to clinically having. Some folks have shared, you know, it gets lonely because you're used to - when you're a neonatologist like me, a primary care doc like you, an ER doc, a trauma doc, you know, you get this team camaraderie that builds when you go through those kinds of really hard things together.

Chris DeRienzo, M.D.

It's a different kind of a team when you're sitting around the health system CEO's table, because frequently you're the last doctor left at the party, unless the CEO also happens to be a doctor. And it takes a different degree of intentionality to find ways to connect and as you pointed out, crucially, to build some informal opportunities to relate to each other as people.

Thomas Lee, M.D.

Well, you know, actually, I've an article that'll be coming out soon with Dr. Ale Quiroga, a physician who's the CEO at Children's Mercy Hospital in Kansas City. And what we write about is how the way clinicians think it may be very appropriate for the kind of management challenges that we face in health care today. Because clinicians like us, you know, we're used to complex situations where the right thing to do may not be clear, but we try things and we get some data and we modify things.

Thomas Lee, M.D.

And, you know, we iterate. We're constantly gathering information. Now, that kind of approach to complex patients, for example, that may be more the right thing for complex problems like overcrowded hospitals, overcrowded emergency departments flow through a system more so than complicated management strategy. You know, complicated tasks. There's many people must do many things, but it's pretty clear everyone's got a job,

Thomas Lee, M.D.

do your job. You need those kind, that kind of approach. But it only takes you so far with the kind of complex challenges we have today. So I do think that thinking like a clinician, Ale and I have an article coming out very soon making the case: yeah, we need to do that more in our management life too.

Chris DeRienzo, M.D.

I look forward to reading that. And if anything, Tom, looking back over the papers you've written, many have a degree of foresight that one historically might one only apply to Nostradamus. And I'd like to close on one of those quotes. And this was from ten years ago. You wrote in New England Journal of Medicine that we believe "social capital is likely to be even more important than financial capital in the era ahead.

Chris DeRienzo, M.D.

After all, one can go to the bank to borrow money, but there is nowhere to go to borrow trust, teamwork, reliability, and the desire to innovate and improve." You said that ten years ago. It feels just as relevant today, but I wanted to give you just a chance to share with listeners a closing thought.

Thomas Lee, M.D.

Thanks. Chris and I do still feel that way, and even more so. Because I'm not naive about money, but I know the limits of what money can do. You can get money from the outside, but you can't get teamwork and trust and high reliability and safety. You know, you've got to build that from the inside. And our organizations are not going to differentiate themselves from other organizations on the basis of who can borrow the most money.

Thomas Lee, M.D.

They're not going to differentiate themselves on the basis of who has the best AI. You know, you've got to be competitive and all these things. But where will differentiate ourselves is how we work together. That will enable us to hold on to great employees, and that will enable us to hold on to our patients as well. So I really think that focusing on social capital, how we work together, that is every bit as strategic and really more so than financial capital issues alone.

Chris DeRienzo, M.D.

You know, health care is and will always be a uniquely human experience. And in the words of Tom Lee, you can buy things, but you can't buy trust. You've got to build it. Thank you so much for spending time with us on the podcast, Tom. It is it is really one of the honors of my career.

Tom Haederle

Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.