Volume 6 no 3

OPINION: How a throughline focused on virtue may be a key strategy for physician leaders to stay in the infinite game

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OPINION: How a throughline focused on virtue may be a key strategy for physician leaders to stay in the infinite game

Duncan Rozario, MD



We are at a tipping point in society, where income inequality, employment instability, and a fundamental lack of societal virtue are poisoning the well of happiness. In his seminal 1776 work, An Inquiry into the Nature and Causes of the Wealth of Nations, Adam Smith1 said, “Consumption is the sole end and purpose of all production; and the interest of the producer ought to be attended to only so far as it may be necessary for promoting that of the consumer.” He spoke of the importance of allowing just and balanced market forces to allow optimization of the interests of the consumer and business alike, leading to centuries of incremental growth in the wealth of nations.


However, 50 years ago, Milton Friedman’s2 treatise on shareholder primacy helped change the focus of business culture. He stated that the responsibility of business is to increase its profits and serve the interests of the shareholder; any focus on social responsibility was akin to socialism. He also said that business should, “Use its resources and engage in activities designed to increase its profits so long as it stays within the rules of the game, which is to say, engages in open and free competition without deception or fraud.” Top


How well has that focus served our societies? Have the largest, most successful corporations stayed within the rules of the game and avoided deception or fraud to provide fundamental value to society? Or have we incentivized the wrong behaviours? In August of this year, the Business Roundtable,3 in its revised Statement on the Purpose of a Corporation, changed its focus from profit to, “delivering value to our customers, investing in our employees, dealing fairly and ethically with our suppliers, supporting the communities in which we work, and generating long-term value for shareholders.” Will this happen without an existential pivot to focus on virtue instead of profit in all that we do in business and in health care?


In public speaking, a throughline is an idea, theme, or concept that unites or links all of the narrative elements. It “traces the path that the journey takes,”4 so that leaders and followers end up at the same destination. As physician leaders, we share unique challenges as we fundamentally strive to change behaviours and beliefs in the delivery of health care with only the power of our actions and words. Coercion and use of authority will not produce the longstanding cultural changes we seek to improve the institutions we lead. Top


I propose that a leadership focus on the concept of virtue, and incentives that promote its value, will be the throughline that leads to success. We seek to motivate our staff and physicians to provide the best possible patient care and experiences, but have the mistaken belief that incentives and rules (otherwise known as carrots and sticks) are the key motivator. We institute more and more rules, but, at best, we get a baseline of compliance that leads to mere mediocrity. In its 2017 report on the state of the American workplace, the Gallup organization5 reported that only 33% of employees are engaged at work and demonstrate discretionary effort. Gallup’s CEO, Jim Clifton, states, “The old ways — annual reviews, forced rankings, outdated competencies — no longer achieve the intended results.” Top


In the truly infinite-minded book, Exception to the Rule, Rea and colleagues6 state that a focus on a virtuous business culture benefits both the bottom line and society. Twenty-five centuries ago, Plato described the seven virtues of trust, compassion, courage, justice, wisdom, temperance, and hope. They appear to be a common denominator that spans diverse cultures, societies, and religions. How can an approach to leadership based on virtue succeed? Top




Trust makes your workforce more agile, ready to respond efficiently to uncertainty and more tolerant of risk and failure. In health care, “trusting and meaningful relationships are more important than extrinsic rewards and recognition.”6 Innovation is a common organizational priority in health care and, at its core, means “new action.” This requires tolerance of risk, which speeds the decision-making process. This virtue is foundational to the patient–caregiver relationship and improves outcomes after care when treatment recommendations are embraced. It also improves resilience among our caregivers. Top


As leaders, we are often responsible for explaining “why” we are doing things, but we need to devolve the responsibility of “what and how” to our teams. The concept is simple but challenging: as leaders, we develop trust by being vulnerable and, first, trusting our followers by giving them the responsibility to implement that what and how. Increasing the portion of our workforce willing to demonstrate discretionary effort will require a focus on managers in our organizations. Gallup5 reports that up to 70% of an employee’s engagement depends on their supervisor, who must be empowered to build trust and relationships in the group. In a world filled with volatility, uncertainty, complexity, and ambiguity, a culture based on virtue, and the resulting reputation for integrity, has the best chance to succeed. Top




Compassion improves customer and employee care and experiences and is one of the most important virtues in health care. It involves empathy, being able to feel the pain and suffering of others, but also requires instituting the actions needed to alleviate that suffering for our patients and colleagues. This is how compassion is superior to empathy and is a key strategy to build resilience and reduce burnout in our caregivers. “Empathy needs to be demonstrated throughout the entire continuum of health care, from patients to nurses to physicians and administrators. The institution of health care needs to understand that its very survival depends on an existential pivot to focus on the wellness of caregivers.”7  Top


In Give and Take, Adam Grant8 divides people into givers, takers, and matchers. He demonstrates that givers, those who help unconditionally but are not doormats, are the key to successful long-term team performance. Compassion for colleagues and customers reduces risk, improves engagement and belonging, and changes culture. Health care has become a team undertaking, and one challenge has been melding a cohesive and successful team out of disparate individuals. Top


In Google’s project Aristotle,9 the researchers identified a consistent characteristic, “the good teams all had high ‘average social sensitivity’ — a fancy way of saying they were skilled at intuiting how others felt based on their tone of voice, their expressions and other nonverbal cues.”10 In other words, empathy is a key aspect of psychological safety, which creates a safe environment for risk taking and collaboration. Although the focus on quality and efficiency in health care is necessary, we need to feel safe to develop the relationships that will lead to great work.11




Courage encourages tempered risk taking and promotes doing “the hard right,” rather than the “easy wrong.” We ask teams to innovate and produce exemplary care and experiences. Grit describes the learned determination that leads to the ability to weather multiple failures on the path to success. It allows us to manage ethical storms, de-escalate conflict, and maintain our work relationships. Top




Justice promotes equality, diversity, accountability, and discretionary effort. Politics is fundamentally about who gets what, and if we care about the distribution of resources and power at our institutions, we need to get involved in our local politics. Discretionary effort depends on our team members’ perception of just and fair treatment and opportunities.


Rather than a sole focus on profits, Rosa Chun12 wrote about corporate social responsibility, virtue, and business saying, “when customers perceive an organization to show strong empathy, it enhances their emotional attachment to the company. This leads to satisfaction and eventually differentiation.”  Top


The tides are turning among most large corporate shareholders and CEOs, who are now speaking up about the importance of environmental, social, and governance (ESG) issues. “In 2018, Bank of America Merrill Lynch found that firms with a better ESG record than their peers produced higher three-year returns, were more likely to become high-quality stocks, were less likely to have large price declines, and were less likely to go bankrupt.”13


Forgiveness is also a key way to obtain justice. It reduces one’s tendency to be consumed by hate and allows one to be free. A focus on self is a quick way to enhance suffering, whereas a focus on others before self allows one to act with justice and compassion. Top


Former United States President Barack Obama14 emphasized the importance of diversity in the workplace saying, “Diversity is not charity. It is not something you do to be nice. If you don’t have diversity around that table, you are missing a market. You are misunderstanding how your message is being received. Organizations that have a bunch of women on their boards do better. They make more money, they get in less trouble, they’re more successful.”




Wisdom promotes common sense and foresight and requires us to learn from our experiences or those of others. As Ray Dalio15 describes, “the satisfaction of success doesn’t come from achieving your goals, but from struggling well.”


As leaders, we have a long list of deliverables and goals in our programs, and to maximize our potential we need to be willing to push our limits, and fail at times. At times, our cognitive bias will prevent us from seeing the truth and, if we completely disagree with our colleagues, then someone must be wrong — could it be you? We need to move out of the “it’s this or that” mindset to get “this and that” accomplished. Top




Temperance allows balance and discipline in the workplace. Recognizing that our perception of reality is individually flawed, we must understand the importance of learning what we do not know and being open minded. Considering opposing views has the remarkable effect of showing us the distortions in our own reality.


As leaders, we need to learn how to balance competing interests simultaneously. Habits such as meditation, morning exercise, and gratitude journals can change one’s mindset for the day and beyond.16 Benjamin Franklin, who could be considered the father of temperance, was noted to meticulously plan his day, with the morning question, “What good shall I do today,” followed by his evening question, “What good have I done today?”17 Top




Hope leads to an optimistic, future vision. Robert Waldinger of Harvard’s 75-year longitudinal Grant and Glueck study said, “You could have all the money you’ve ever wanted, a successful career, and be in good physical health, but without meaningful relationships, you won’t be happy.”15


Pursuing our collective interests will almost always win out over an individual focus. Talking about virtue moments at the beginning of our meetings is one key way to practise optimism and can set the tone. Gratitude journals, gratitude letters or walls, and a conscious focus on optimism can help us focus on a better future. Top




These are all learned traits, and if they don’t exist in our business culture, they can be taught. We need to incentivize the right behaviours that will lead to more virtuous actions that benefit the entire system.


In health care, we have a deficit-based approach to our work. What is the problem (disease) and how do I resolve it (surgery or medication)? In the management of groups, however, an appreciative-based approach has proven to be superior. How many times in meetings do we start by asking, “What great work are we doing here, and how do we do more of that?” Instead, most of us are constantly engaged in a perpetual loop of “whack-a-mole” going after problems reactively as they appear. While values are beliefs, virtue is fundamentally demonstrated by actions, and we need to see that discussed and incentives provided at all levels of our organization. Top




As a physician leader, what will be your throughline? How will your leadership fundamentally alter the culture of your organization to produce sustainable improvement? The CMA Code of Ethics and Professionalism18 provides great leadership and inspiration as we struggle with these existential challenges. It emphasizes the importance of civil and respectful communication, justice, and treating our colleagues with dignity and compassion. As leaders, we must understand that, in a debate, more important than who is right or wrong, is what is true. Top


Leadership is a learned skill, and one should not underestimate the importance of developing local talent though rounds, journal clubs, management training, and mentoring (and a subscription to the Harvard Business Review!). Fundamental health care system reform will only happen when physicians get involved and embrace politics, which is fundamentally about who gets what.


We must mentor and foster our successors and understand that there are limits to the effectiveness and term of our leadership. Joseph Simone19 states that the maximum term for a physician leader should be 10 ± 3 years. Fresh ideas and renewal are essential, and we need to understand that, once we accomplish 80% of our objectives, it may be time to go. Find people who are better than you and retain them. What you do is noble, and despite the immense challenges, medical leadership is immensely fulfilling and rewarding when you take a moment to reflect. Top


We must have an understanding of how any business is fundamentally an infinite game and, to stay in the game, our vision must drive all decisions and actions.20 A vision based on virtue is one that focuses on excellence, promotes engagement in both employees and customers, and simultaneously creates economic value. For this to happen, we need to lead a cultural change — to focus on our planet, our employees, our customers, and our community. Virtue is a skill that can be taught and strengthened like any other.


A focus on profit or other short-term goals may be successful in the short term. However, as physician leaders, if we want to create an environment of psychological safety where passionate colleagues and staff feel inspired to display discretionary effort and innovate, an infinite-minded focus on virtue has the potential to engage your entire workforce and lead to the type of innovative culture that will allow our health care system to aspire to excellence in the years to come. Top



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Duncan Rozario, MD, FRCSC, FACS, is chief of surgery at Oakville Trafalgar Memorial Hospital and medical director of the Oakville Virtual Care Program. He is also an assistant clinical professor (adjunct) in the Department of Surgery at McMaster University.


Correspondence to:



This article has been peer reviewed.