Leading the medical division: a small business in academia

Nahid Azad, MD





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The organization of academic medical staff is complex. A division, the smallest unit in the structure, is essentially a small business that needs full-time entrepreneurial leadership to succeed. The leader must develop a strategic plan, establish goals, build teams, and develop a budget. A division should strive to become a centre of excellence.


KEY WORDS: medical division, leadership, organizational structure, skill set


The organization of medical staff in an academic environment in Canada is complex and frequently confusing. The roles, responsibilities, and objectives of the various organizational units are often vague and difficult to understand, and the reporting and accountability structure unclear. Moreover, the organizational structure is often based on medical specialty (the service provider perspective) rather than quality, timeliness, and health outcomes (a patient-centred perspective).1 Within this environment, the division based on medical specialty is usually the lowest organizational unit. Top


In this article, we investigate the challenge of leading such a medical division, starting with an overview of its organizational environment, summarizing the key roles of the division leader, moving to the leadership skill set required for success, recommending a business plan, and ending with a leadership career planning roadmap.


Environmental context


What is a division? A simple question with a complicated answer. It is an organizational unit, usually based on a medical specialty. Division members and the division itself work in a complex interdependent network of organizations. The division provides various types of services (clinical, research, teaching, governance) and interacts with a variety of other medical organizations associated with operational dependencies, but typically it is not directly accountable to any of these other organizations. For example, as a minimum, the division will concurrently be providing clinical service to a hospital, research to a university or other sponsor, medical instruction to residents, and governance to various medical organizations. I will use the term “clients” to refer to the collection of organizations that receive services and products from the division. Top


Although there is talk about medicine becoming more “patient-centred,” such a transformation would require major organizational restructuring, which is unlikely to occur any time soon. Within the current organization, a division often comprises individual contributors, with teamwork and collaboration occurring both within the division and with other divisions. In this context, how does a division determine its shared core values and client value propositions? Top


What is the division trying to achieve? Another simple question with a complicated answer. There are many types of divisions: some large, some small, some with a visible agenda, some whose role is less clear. The division often operates in an environment where, at senior levels, there exists a strategic plan with a breakdown into specific initiatives. Sometimes these plans have a clear focus and specific goals; sometimes the high-level plans are vague and provide little direction. In either case, they often provide very little guidance at the division level. More important, the division operates in a partnership environment that contains multiple senior-level strategic plans, which do not necessarily align. The division does not benefit from the clarity provided by a hierarchical structure usually employed in the private sector. How does a division prioritize programs within a diverse set of opportunities and expectations? Top


We live in challenging times. Demands on the health care system are increasing, yet funding is often capped or even reduced. The care focus is shifting toward a patient-centred approach, giving patients and their families more control over their care plan at a time when the typical patient is becoming older and more complex, often suffering from many age-related diseases, such as heart failure and dementia. Universities are demanding both more pure and more translational research. Physicians are expected to expand the scope of their work as clerical and administrative functions are transferred to them to compensate for hospital cutbacks. Funding is gradually moving from a “best effort” to a goal-oriented, results-based model. In this new context, divisions will be competing for both funding and support staff. Times are tough and getting tougher. How does a division thrive in this disruptive environment? Top


For a variety of political and bureaucratic reasons, none of the above will change in the foreseeable future. Consequently, when examining division leadership, we must recognize and accept that help will not come from above, and we must focus on the division itself.


Roles of a division leader


The division leader must find a way to navigate this complex environment while balancing new program development with existing program commitments. “Vision and leadership matter. They embody the spirit and values of the organization.”2


I argue that the best way to think of a division is to recognize that it is essentially a small business. This business has a variety of clients for its products/services and a variety of suppliers providing products/services to it. The division must be responsive to the needs of its clients, or they will find alternative suppliers to meet their clinical, research, education, and governance requirements. Moreover, the division needs a diverse set of clients; for long-term success, it cannot be critically dependent on any one client as its funding source. Top


Consequently, the division leader must be an entrepreneur, constantly looking for business opportunities to strengthen and develop the division. The leader has to be continuously promoting and building new programs in conjunction with division clients and always seeking new clients and opportunities. This networking and marketing role is crucial for division success. Accepting the status quo is a recipe for the gradual decline of division productivity and reduced value to its clients. “Without reach, there is no challenge. Without risk, there is no reward. Without vision, there is no future.”2











Therefore, successful division leadership is a challenging full-time job. Key responsibilities of the division leader include the following.


Developing the strategic/business plan


Naturally, the division must have its own strategic plan, and there are many ways to develop and reinforce such a plan.3,4 The plan provides the framework to focus and scope the division’s programs. It specifies what types of clients to seek, what type of patient population to focus on, what type of research to pursue, what services to offer, and what types of members to recruit. Top


This strategic plan should fit within, but not necessarily be directly coupled to, the variety of senior strategic plans. The plan must include a standard breakdown defining strategic directions and goals that allow the leader to clearly articulate what the division is doing, what it is trying to achieve, the performance and quality metrics, the business rationale, the timeline, and the help it needs for success.


Without a shared vision, how will members know where they are headed? To paraphrase Lewis Carroll5: “If you don’t know where you are going, any road will get you there.”


Within this context, flexibility is required to meet existing client requirements and to take advantage of new clients and opportunities. The division must also team with partners to provide new services. Agility and entrepreneurial spirit are required to take advantage of opportunities to advance toward the division’s goals, of course, with the ability to reliably deliver on commitments. Top


A division cannot be everything to everybody. It does need a value proposition that should be carefully chosen and clearly articulated on a client basis. Once this is done, the division should strive for excellence in its chosen field. The alternative is a slow decline in the relevance of the division, and its effectively “going out of business.”


Leading division programs and establishing goals


Within the context of the strategic/business plan, the leader must work with clients and members, both to develop programs and to define the division’s business goals and deliverables. Program decisions must be based on comprehensive business case analysis, which must be reviewed regularly to ensure that the funded programs are delivering optimal value. The division must follow best-practice project management processes to ensure on-time, on-budget program completion, of both its internal goals and its commitments to clients. Top


These program goals and commitments provide the framework to develop team and individual members’ roles, responsibilities, and accountabilities.


Medical staffing


Medicine is labour intensive. The division cannot succeed without proper membership, and the medical staff is the cornerstone of success. A high-quality strategic plan and the successful implementation of programs within this plan will help attract the best candidates.


The objective is to build teams, not a collection of independent contributors. The dynamics of high-functioning teams result in the most productive and valuable divisions. It is well said: the whole is greater than the sum of its parts.


The leader must work with individual staff members to develop job descriptions, negotiate objectives, build career development plans, and assign roles and responsibilities. To ensure program continuity, the leader should have succession plans for all division members.  Top


Assigning members to new leadership responsibilities brings innovation and revitalized energy to these roles. After about four years in a given position, members tend to move out of an innovation mode into a maintenance mode. That is the time to assign another member to that role to bring new ideas and energy.


Finally, the leader must mentor and support both individual members and teams, providing regular constructive feedback to help achieve agreed objectives. The leader must foster career development, both inside and outside the division.




The division leader is accountable for the budget. The budget process forces the leadership and members to make difficult program choices. The challenge is to be sufficiently transparent to lead the division through this process, yet keep all members fully engaged and actively supporting the funded programs.


In summary, all the above entrepreneurial roles are essential for the success of the division as a small business.


Leadership skill set


Countless books have been written about the essential entrepreneurial skills required to lead a small business. I will mention only a few that are particularly relevant to medical division leadership. Top


First, we must recognize that trust is mission critical. “Successful working relationships are built on reciprocal loyalty and trust. Reciprocal loyalty and trust are the foundation of any great working culture, large or small. They are the reasons people love what they do and where they do it. Trust is so easy to lose and so hard to get back.”2


Second, the leader must think strategically and creatively to work with division members, partners, and clients to build an aspirational strategic business plan. The leader must be able to inspire division members through active, progressive, constructive, and visible leadership to achieve the plan goals. Top


As Larry Page6 states: “My job as a leader is to make sure everybody in the company has great opportunities, and that they feel they’re having a meaningful impact and are contributing to the good of society.”


Third, the leader needs people skills and emotional intelligence. The best leaders have a sense about people, empathy, timing, and communication. At all levels of management, leaders with more emotional intelligence tend to have greater success. Everyone likes to recognize and celebrate success, often starting with a simple “thank you” and potentially leading to a division celebration. Margaret Heffernan7 states: “It’s the mortar, not just the bricks” and “the dynamic between people is what brings organizations to life.” More and more attention is being paid to the power of organizational culture.8 Top


Fourth, a leader must have excellent communication skills. Most of the leader’s time will be spent communicating with members, stakeholders, and both existing and potential clients. Consequently, the leader must be a good listener, build strong relationships, have good negotiating skills, be an effective speaker, have good networking and influencing skills, and, finally, good coaching and mentoring skills.


Fifth, the leader must be passionate and demonstrate total commitment to achieving the business plan. All change is introduced by projects; all deliverables are delivered by projects. The leader must demonstrate best-practice project management skills. The leader must lead by example. Division members will emulate the leader’s behaviour, good or bad.9


Note that the division leader need not be and cannot be a subject matter technical expert in all the areas of division activity. His or her leadership skills are more important than technical skills. The leader needs only general technical knowledge of the division’s technical work. Top


In summary, at Google,10 human resources assess managers’ performance partly based on the following nine behaviours:

  • They communicate clear goals for their team.
  • They regularly share with their team relevant information from their own manager and senior leadership.
  • They give actionable feedback that helps their employees improve their performance.
  • They show consideration for their employees as individuals.
  • They keep their team focused on its priority results/deliverables.
  • They have meaningful discussions about career development with each member of their team at least once every six months.
  • They possess the technical expertise required to manage their team effectively.
  • They do not micromanage by getting involved in details that should be handled at other levels.
  • Their employees would  recommend them to their colleagues.


Selection of a division leader is challenging. Management accreditation, such as Canadian Certified Physician Executive or others, is recommended. The required leadership skills are different from division member skills. Senior management must avoid the Peter Principle11 at all cost — promoting people to leadership roles simply because they were successful in their previous roles is a flawed strategy with serious consequences. Moreover, leadership approaches are shifting to become less hierarchical and more empowering.12 Many senior leaders believe that one of their most important responsibilities is succession planning and the selection of the right junior leaders. Top


The division as a centre of excellence


In the private sector, market competition dictates that companies have to manage resources and prioritize programs very carefully. To this end, many companies support only products or services that they believe will have the potential to be in the top three positions in the marketplace. The market will tell them if they made the correct decisions.


Given that retaining the status quo will lead to a slow decline in the relevance of an academic division, what can divisions use to provide guidance and help determine whether they are successful? I propose that a division should try to become a centre of excellence. A centre of excellence is a premier organization, known for providing exceptional service in a sphere of expertise that provides leadership, advocacy, best practices, research, support, and training. Not all divisions will succeed, but all divisions should try to achieve this aspirational strategic goal. Top


The centre of excellence model provides sufficient scope to encompass all division goals and commitments. The division strategic plan must provide the framework to achieve success as a centre of excellence.


Leading the division on the journey to becoming a centre of excellence is a difficult, demanding job that requires the full attention of the division leader to navigate the complex academic medical environment. The role requires small business and entrepreneurial leadership skills, and senior management must ensure that the leader has the requisite aptitude and skills for such a demanding role. Top


Navigating the journey to leadership


As discussed above, a diverse set of leadership skills is essential to the success of the division. But how does one prepare for such responsibility? I suggest the following roadmap as part of your career development plan to help navigate this journey.


The first step is to determine whether you have the aptitude for leadership. Do you have the passion, energy, vision, and entrepreneurial spirit for this demanding role? Leadership is not for everyone, despite his or her best efforts. I recommend an “Is management for me?” type of course to provide an honest assessment of your personality traits and behaviours and determine your fit for a leadership role.


Observing leaders is the second step. We can all recognize superior leadership and role models. Start to learn the skills and emulate the behaviours that contribute to their success.


The third step is to find a mentor — a person with coaching skills and wisdom that can only come from experience. This person will often be in the same field, but outside your immediate organization. Top


Training is next. Medical education focuses on hard-core medical competencies. Additional hard-skill training is needed in areas such as project management. However, leadership is mostly about working with people, and inspiring a division requires a host of soft skills. These skills include communication, networking, collaboration, influencing, building relationships and trust, emotional intelligence, and conflict resolution, among many others. These skills are more important than the traditional medical competencies.


Practice is the next step. As part of your career development, take advantage of project management opportunities with increasing complexity, particularly those that require extended teamwork and networking that allow you to practise your leadership skills. Top


Finally, work with senior management to become part of their succession management plan. Once part of this plan, you will have many opportunities to practise your leadership skills and build a positive track record.


With this background, training, and practice, you will be well positioned to take on division leadership with confidence. You will be able to bring new energy and ideas to the division and have an immediate positive impact. Top




At this point, some may feel that successful leadership is an impossible task. But this is not true. I am sure that, within your faculty, there are many excellent leaders and their divisions are thriving. In my case, as an example, I can recommend the Division of Cardiology at the University of Ottawa Heart Institute. My recommendation is based on the complex Ottawa Hospital, Heart Institute, and Department of Medicine operating environment and the nine Google behaviours mentioned above.


The division is a recognized Centre of Excellence, and the team wins many awards at the annual department recognition ceremony. With this track record, the division is able to recruit new energetic and innovative members. The division leader clearly demonstrates his pride in the accomplishments of all team members. The results of excellent leadership speak for themselves. Top



1. Health care transformation. Better health. Better care. Better value. CMA issue sheet. Ottawa: Canadian Medical Association; 2013. Available: http://tinyurl.com/pr9e2eu

(accessed 16 Sept. 2015).

2. Tyson JF. Adventures in innovation: inside the rise and fall of Nortel. Ottawa: John F. Tyson; 2014.

3. Vermeulen F. 5 strategy questions every leader should make time for. Harv Bus Rev 2015;3 Sept. Available: http://tinyurl.com/oy23tj3

(accessed 16 Sept. 2015).

4. Zuckerman AM. Healthcare strategic planning (3rd ed). Chicago: Health Administration Press; 2012.

5. Carroll L. Alice’s adventures in Wonderland. London, UK: Macmillan; 1865.

6. Lashinsky A. Larry Page: Google should be like a family. Fortune 2012; Jan. Available: http://tinyurl.com/nqkukcn (accessed 23 Sept. 2015).

7. Heffernan M. Beyond measure: the big impact of small changes. New York: TED Books; 2015.

8.Dickens P. Don’t underestimate the power of organizational culture. Rethink Leadership (blog); July 2015. Available: http://tinyurl.com/ogb87cb (accessed 16 Sept. 2015).

9. Azad N. Hospital strategic planning in a period of disruptive, transformative change: creating opportunities amid turbulent waters. Ont Med Rev 2015;April:1–4.

10. Feloni R. Google’s HR boss says the best managers practice these 9 habits. Business Insider 2015; April. Available: http://tinyurl.com/lag8d28 (accessed 16 Sept. 2015).

11. Peter LJ, Hull R. The Peter Principle: why things always go wrong. New York: William Morrow and Company; 1969.

12. Murray A. Bill George: the hierarchical leader is out. The empowering leader is in. Fortune 2015; Aug. Available: http://tinyurl.com/oukvpnx (accessed 16 Sept. 2015).



Nahid Azad MD, FRCPC, CCPE, is a professor of medicine at the University of Ottawa. She is a full-time geriatrician at the Ottawa Hospital and has held many leadership positions. Her research and leadership focus on cardiovascular disease, heart failure, gender health, and quality improvement. In 2013, she received the Canadian Certified Physician Executive designation from the Canadian Society of Physician Leaders.


Correspondence to: nazad@toh.on.ca


This article has been reviewed by a panel of physician leaders.



The organization of medical staff in an academic environment in Canada is complex and frequently confusing. The roles, responsibilities, and objectives of the various organizational units are often vague and difficult to understand, and the reporting and accountability structure unclear. Moreover, the organizational structure is often based on medical specialty (the service provider perspective) rather than quality, timeliness, and health outcomes (a patient-centred perspective).1 Within this environment, the division based on medical specialty is usually the lowest organizational unit. Top