CHAPTER 8

Communication: Delivering Influential Messages

In the 2016 Athena Health Physician Engagement and Leadership Index of over 2,000 physicians, leadership traits most valued by physicians were identified with regard to their organizations’ vision, culture, and day-to-day operations. It is notable that physicians overwhelmingly cited the ability to communicate as the most important skill for health care management! It was also the top leadership skill that physicians cited as the area of improvement that would most benefit the organization. When it was asked why physicians gave their leaders poor scores, the most common response was poor communication (Cosinuke 2015).

This finding is by no means a huge surprise. In our work with numerous organizations across industries, communication is the issue that surfaces the most with regard to leadership improvement. In his research, Joseph A. Klein, an Air Force psychologist and expert in leadership, has concluded that if you can’t communicate, don’t lead (Klein 2017).

We are always reluctant to present the basic, but necessary, guidelines for effective communication because we read and hear about them so often that it seems insulting to review them again. The subject of communication skills is well known to most of us. In fact, a search for communication books in Amazon turns up 80,000 results! We do not want to offend you with what may seem to be obvious. However, given that communication issues continue to surface most frequently as a significant problem in companies and organizations, we will provide an overview of what constitutes effective communication. After all, repetition is a required method for reinforcing what we know, and it does lead to a higher likelihood of utilization and implementation.

The primary purpose of any communication is to impact your audience in such a way that they will want to follow and follow through. Communication is a powerful way of creating understanding, connecting, and inspiring. According to communication studies, managers spend 70 to 90 percent of their time communicating with their team and others in the workplace. People at work will communicate more with each other than with their friends and family. Creating a culture that encourages successful communication increases the likelihood of having a productive staff. Effective communication gives a significant advantage to any leader. The goals of effective communication include the following (Luthra and Dahiya 2015):

• •Fostering understanding
• •Developing trust
• •Creating positive relationships
• •Creating a positive work environment
• •Motivating employees
• •Coordinating teams
• •Building cohesiveness

We will look at the elements of effective communication that are fundamental to achieving these goals.

Effective Communication: Content and Process

Given these goals, it is clear that communication is more than a just a transfer of information. Effective communication for the physician-leader is the foundation for developing deep and meaningful relationships for the purpose of achieving far more together than could be achieved singularly. When employees complain about their managers or organizations not communicating effectively, their complaints are typically about the volume of unrelated communications they receive, the consistency of the messages they receive, the frequency with which they are included in receiving information that impacts their work, and the manner in which they receive the information, relative to its importance.

Communication always has two complementary aspects: content and process. Content is the more obvious element; it is what is written or said. Process has to do with the delivery of the message, including both the means and the intent. Research in the 1960s at the Mental Research Institute first identified that how a message is sent is as important as the content of the message. It was then that things like body language and the emotion with which messages are expressed were seen as having the ability to either reinforce the content of messages or contradict them. For example, saying “I am not angry!” with a scowl on your face and in a hostile manner certainly calls the content into question. We will discuss both aspects as a reinforcement for your own communication.

With regard to content, there are guidelines that can serve as a checklist for physician-leaders. In communicating it is always critical that messages have:

• •Purpose: This answers the question “why am I interrupting your day?” When communicating to your target group, consider whether or not the communication reaches the threshold of warranting the time and attention it will be given. High levels of productivity are directly related to working on the most important issues. Diverting your team with unnecessary communication leads to reduced productivity and increased frustration.
• •Precision and focus: Particularly when trying to communicate simple information, keep messages short and to the point without excessive verbiage. In this age of ever-changing technology, attention spans are increasingly shortened. People are used to slick, well-produced 30-second advertisements, and even small children know instantly what is meant by a familiar logo like the McDonald’s golden arches. By providing headlines rather than the entire story, communications are much more likely to be read and understood. Invite your audience to ask for more information if they need it. When delivering complex information or tackling a difficult conversation (disciplinary or contentious), focus is key. Although conveying complex information may require a greater volume of communication, the skilled leader will take the time to pare down the message to just the essentials. Difficult conversations will sometimes require sacrificing brevity for the sake of navigating conflict or emotion. That said, approach the topic of the difficult conversation directly without straying on tangents or introducing too much small talk.
• •Transparency: Deliver communication that is clear with regard to intent, purpose, and expectations. This will help in increasing trust and loyalty. People are often suspicious that their superiors have some information that is not confidential but that they are not sharing with the rest of the employees. This veil of secrecy decreases trust and robs productivity by increasing speculation and gossip. When there is a lack of transparency, it implies that the managers do not trust the judgment of their team to use the information appropriately.
• •Consistency: Messages to the team should be consistent over time. This is particularly true of large initiatives. Large organizations are notorious for following “the next big thing” only to abandon it before adequate momentum has developed. This start–stop tendency creates discouragement, cynicism, and lack of trust in management.

With regard to process too, there are key elements to be kept as high priorities. These include the following:

• •Targets: Include only the people that will be impacted by the message, not everyone. This is not about CYA. E-mails and other communications that have a broad distribution list of people not impacted by the communication are a great time waster. When others are copied on communication, it creates the feeling that the communication is not personal, the sender is not discerning, and that there are hidden intentions for copying those for whom the message has little meaning. Leaders need to be diligent in regard to whom they are sending their communications and to send them only to those who need to know.
• •Frequency: Keep targeted recipients informed without too many or too few communications. Always communicate when the message impacts the individual or when a response is required. When in doubt, err on the side of too many, not too few. Complaints are rarely that my manager communicated with me too often. Employees are much more likely to complain that they did not receive communication in a timely manner that allowed for adequate preparation.
• •Attitude: All messages need to be respectful and gracious. Electronic messages (e-mails, texts, tweets, etc.), in particular, are not the right venue for airing differences, chastising, judging, or rebuking. These kinds of communications are always done privately and in person (see further on). Communications that consistently demonstrate respect and honor the involvement and time of the recipient always reap long-term rewards.
• •Methodology: The method of communication delivery depends on how critical and complex the communication is. Below are the guidelines we recommend:

• ○Personal: Any communication that is of a personal nature, particularly with either confidential or disciplinary messages, must always be conducted face-to-face. Although this seems obvious, when leaders are not effectively managing their emotions, they often violate this guideline and embarrass or humiliate the recipient.
• ○Complex information: Information that is either complex or critical should be delivered face-to-face. This kind of communication often requires the kind of interaction for which personal involvement is required. It is an incredible waste of time and effort to try and solve difficult, complex issues electronically!
• ○Confidential: There are often times when the leader has information that is very sensitive and can be shared only with a select number of people. As a general rule, this information should be shared face-to-face. Never e-mail or text confidential information unless you have electronic security.
• ○Simple information: Information that is simple and direct does not need to be conveyed face-to-face and can easily be sent by text or e-mail (e.g. scheduling, agendas). Be sure to include only the audience that will be impacted.

These reminders will serve to help you become a more intentional communicator and will serve to increase both impact and productivity in the organization. Communication is as much a matter of effective delivery as it is precision in content.

Difficult Conversations: I’d Rather Not!

A subcategory of effective communication is that of managing difficult conversations. In our work with leaders across organizations, without exception the most dreaded interactions are those that involve some kind of conflict or disagreement. As a result, these conversations are often avoided or managed poorly. The reluctance to engage in these types of conversations stems from the expectation that they will be unpleasant, create discomfort, and lead to emotional distancing between the parties. The perception is often that the situation being set up is a zero-sum game, that is, where there will be a winner and a loser. In our experience with leaders needing to have difficult conversations, we often encounter three dysfunctional types of communicators. Each one of them seeks change but is ineffective because of insecurity, uncertainty, lack of clarity, and lack of confidence.

The Avoidant Communicator

These leaders dislike conflict and difficult conversations so much that they do not have them. They live by the rationalization of “let sleeping dogs lie.” They justify their avoidance with the false belief that if you actually confront a situation it could become worse. They also hope that somehow things will get better on their own. Really? Often, you will know these leaders are unhappy only by their nonverbal behaviors like facial expressions or avoidance of certain people. It is a passive-aggressive way to demonstrate their displeasure. These leaders lose the respect of those they manage as they realize just how easy it is to take advantage of them because there are really no consequences!

The Under Communicator

These leaders recognize that a conversation needs to take place, but their discomfort leads them to provide only the scantiest details of their concerns. They can be blunt and overly direct, believing that their forcefulness will bring about the desired change. They may also be vague and nonspecific. In either case, these are sniper communicators who “pop in, pop off, and pop out,” leaving the recipient confused and often resentful. You may feel dressed down with no recourse to respond or discuss the issue in any depth. These communicators succeed only at transferring their anxiety onto others!

The Circuitous Communicator

These leaders also recognize the need to have difficult conversations, but their discomfort leads them to take the long route. When approaching difficult conversations, these leaders spend excessive time talking about everything else such as your family, last week’s ball game, the latest movie they saw, and anything but the topic of discord. Their communication is opaque and requires great powers of interpretation to understand the real reason for the meeting. Their “tell” is that they are having a lengthy conversation with you about innocuous content without ever getting to the point. Recipients of such communications begin to understand that their manager is upset but do not know about what. Worse yet, these circuitous communicators will let others know of their displeasure with you, but not tell you directly. You may learn about their displeasure only from the organization’s grapevine. This is another passive-aggressive approach to dealing with conflict.

Managing Difficult Conversations

Leaders with high levels of emotional intelligence recognize that people are usually trying their best at any particular time. They do not shy away from having meetings when performance problems exist, and they recognize that they must be managed. These leaders enter difficult conversations with positive intent. They hold the belief that people want to be successful and recognize that when they are not, it is an opportunity for problem-solving, greater mutual understanding, and creating solutions that will be beneficial to the individuals and the organization. The desired outcome is not domination or win/lose. When entering conversations within this mental framework, it changes the situation from one that is fraught with pressure and antagonism to one in which both parties can become partners in creating solutions. The framework for these conversations is a multistep process that includes:

• •Purpose: The leader must have a clear purpose in mind for the meeting. Clarifying what needs to be addressed and what is to be achieved are critical foundations to having a positive meeting. If the purpose is unclear, the leader should not proceed with the meeting.
• •Preparation: These are not conversations where the leader can “shoot from the hip.” These meetings are too important for haphazard planning. The leader needs to fully understand the issue(s) to be discussed and have an idea about what some acceptable outcomes may be. These meetings need to focus on the issue, not the person. The less emotion involved, the more effective the meeting can be. Managing emotions requires the leader to think about how to best bring up the issue and how to best respond. This is where leaders must have an attitude of positive intent and a belief that people want to learn and succeed. They trust that when people are not succeeding, creating the best environment or learning the right skills will prepare them for success.
• •Presentation: These meetings are more formal and not “watercooler” chats. It is the leader’s responsibility to lay out the issue in as much detail as is necessary to understand it. In presenting the issue, the leader must focus on the expectations, the results, and the gap between the two. Developing an understanding of root causes is central to creating viable solutions. The tone is not one of accusation or judgment but one of greater mutual understanding. The leader invites conversation to understand what may have led to the problem and what can be done to achieve the initial goals. The leader guides the conversation in such a way that both parties produce a mutually desired outcome, complete with clear expectations on quality, quantity, and timelines. In addition, they reach an understanding of what additional resources, if any, will be required to achieve the outcome agreed upon. The leader documents the conversation and shares a summary of the documentation with the employee.
• •Follow-up: Initiatives often fail because a solid follow-up process has not been created or followed. Follow-up is a means of accountability and is critical for success. In order for the expectations and outcomes to be successful, the leader and the employee must have a process in place for follow-up. The leader will need to establish a schedule for “checking-in” and for monitoring progress as well as an understanding of when the issue discussed will be resolved.

By creating the above framework and following these steps, the dysfunctions associated with having difficult conversations can be avoided, or at least mitigated. Leaders need to keep in mind the principle of positive intent and remember that the goal of these conversations is greater mutual understanding and problem-solving for better results.

Special Exceptions

Although we advocate giving employees a second chance and positive thinking, we also recognize that when themes emerge they need to be treated differently than one-time events. There are two exceptions to the framework as outlined. In both cases, action is required.

1. 1.Repetition Compulsion: We believe that the past is a prologue to the future. It has been our experience that when the process noted above has failed, repeating the process a second time will not usually yield different results. Unless there are unforeseen, and observable, obstacles or challenges, the employee’s inability to effectively stick to the plan agreed upon is more closely related to either skill or will. If the employee is “in over his/her head,” it may mean that a different position for the employee may be the answer. It could also mean that the employee needs further development or education to be successful. On the other hand, if it is a matter of lack of effort, it is unlikely that the employee will succeed in another position, and the leader needs to make a difficult choice in regard to the individual’s employability.
2. 2.Cause: When an employee has violated an ethical, moral, legal, or regulatory statute, the leader must manage the issue differently than noted previously. Any issue related to these violations carries a more serious weight than more routine performance-related problems. In all cases, the conversations must be factual, direct, and to the point. These violations typically entail more severe consequences that can range from personal improvement plans to suspensions or terminations. In all cases, clear documentation is required, and the human resources function is involved.

The Physician-Leader Challenge

Physician-leaders face unique challenges when it comes to difficult conversations. For physician-leaders, many of their difficult conversations involve other physicians and often relate to disruptive, unprofessional behavior. How should a physician-leader approach these difficult conversations as both colleague and superior, clinician and administrator? In our experience, the strategy developed by Dr. Gerald Hickson and his colleagues at Vanderbilt is among the most effective for these difficult conversations (Hickson et al. 2007).

Dr. Hickson’s model is a progressive approach that begins with an informal “cup of coffee” conversation. This is generally employed for seemingly new or isolated incidents. An important component of this intervention is to convey how much the physician is valued by the organization and how their current behavior is inconsistent with both organizational goals and the physician’s reputation. The purpose of this informal conversation is to introduce awareness and early intervention with the hope of preventing a pattern of disruptive behavior.

When a pattern of disruptive behavior emerges, the next step is a more formal “Awareness” conversation, where data and information on the pattern is presented. If the behavior persists, an “Authority” intervention where repercussions are discussed occurs before the final step, the “Disciplinary” intervention occurs. For physician-leaders, it is important to understand and communicate which “hat” you are wearing during each conversation. The informal “cup of coffee” conversation is often conducted colleague to colleague, whereas the more formal conversations are typically superior to subordinate. Communicating which “hat” they are wearing allows physician-leaders to more clearly frame each conversation and its implications.

Coach’s Corner

Despite being recognized for its importance, communication is the most common failure mode of leaders. Embracing the basics of effective communication will lay the groundwork for good leadership. Mastering the skills to successfully conduct difficult conversations is the foundation of great leadership.

1. 1.Identify your communication style

• •Reflect on your natural inclination and current communication style as it relates to content and process discussed in this chapter. Is your communication style as effective as your organization needs? If not, what alterations to your communication style will make you more effective?

1. 2.Develop/refine your approach to difficult conversations

• •Consider your approach to difficult conversations. Do you have any traits identified in the dysfunctional types of communicators? (Most leaders do!) Identify three specific tactics that you will work on to improve your skills in embracing or executing difficult conversations.

References

Cosinuke, R. July, 2015. “Communication Is the Most Important Leadership Trait.” athenainsight. https://www.athenahealth.com/insight/communication-is-the-most-important-healthcare-leadership-trait (accessed February 1, 2019).

Hickson, G.B., J.W. Pichert, L.E. Webb, and S.G. Gabbe. November, 2007. “A Complementary Approach to Promoting Professionalism: Identifying, Measuring, and Addressing Unprofessional Behaviors.” Academic Medicine 82, no. 11, pp. 1040–1048.

Kaiser, R. 2019. “The Accountability Crisis.” Talent Quarterly 5, no. 3, pp. 57–63.

Klein, J. July, 2017. “Leadership and Communication.” APA Member Services. https://www.apa.org/members/content/secure/leadership-communication (accessed February 7, 2019).

Luthra, A., and R. Dahiya. July–Sept 2015. “Effective Leadership Is All about Communicating Effectively: Connecting Leadership and Communication.” International Journal of Management & Business Studies 5, no. 3, pp. 43–48. https://www.mcgill.ca/engage/files/engage/effective_leadership_is_all_about_communicating_effectively_luthra_dahiya_2015.pdf (accessed February 2, 2019).