The 3 Essential Responsibilities: A Leadership Story

The 3 fundamental and essential responsibilities of leadership—setting a compelling and appealing direction (vision), selecting the right people (talent), and creating and embracing the right set of guiding core values (culture)—are reviewed in the context of the many contributions and leadership legacy of Dr Stanley J. Dudrick, one of the giants of American surgery. Critical success factors which enable the development of leadership as an organizational capacity in any department or unit are emphasized. They include building a team of faculty and residents who are aligned on mission, vision, and values; forging a climate where people are willing to have difficult conversations rather than avoiding complex problems; and the establishment of an esprit d’corps where people experience that they are contributing to a purpose larger than themselves.

I first met Stan Dudrick in 1975 when I was a freshman medical student at the University of Texas Medical School in Houston. Dr Dudrick was Chairman of the Department of Surgery, having left Penn (University of Pennsylvania) in 1972 to come to Houston at the youthful age of 36 to help lead one of the youngest medical schools in the country. Unlike Penn, UT-Houston was a state institution. Unlike Penn, it was not established and did not have a legacy. Unlike Penn, it was not known for its training of academic surgeons or its contributions to the surgical literature. But it did have one thing that attracts a certain kind of leader: unrealized potential, vast possibilities, and a future promise. That leader was Stan Dudrick. His accomplishments at multiple academic medical centers, to include Penn, UT-Houston, Baylor (University), and Yale (University), have been staggering to say the least. He would be the first to tell that they were not his achievements; they were the achievements of the team that was built.

I remember my first encounter with Dr Dudrick. I was studying the effects of various diets on protein metabolism in a rat burn injury model when he walked in the laboratory and introduced himself. He was not pretentious, or presumptuous, or preoccupied. Rather, he was curious about what I was doing, inquisitive about the research model and the findings, as if he was trying to also learn. That special leadership attribute of being 100% present in the moment with whomever you are with, regardless of what other pressing issues you may have on your mind, continues to be one of his most wonderful qualities. It came across as personable and authentic, and it left me feeling empowered and energized. Like a transcription factor that activates specific genes, he had turned me on to academic surgery.

Little did I know at the time, I started paying attention to the kind of philosophy and culture that was beginning to emerge in the department. Dr Dudrick had a game plan, and it was beginning to materialize. A transformation was under way. The emphasis shifted away from training only private practice surgeons to also training academic surgeons. Residents were encouraged to spend dedicated time in the laboratory. Partnerships with hospitals like MD Anderson (Cancer Center), the Texas Heart Institute, and several key community hospitals were more tightly forged. There was an uncompromising underlying commitment to translating the innovations that took place in the research and education arenas to improve patient care. Nowhere, not surprisingly, was that more evident than in the parenteral nutrition research that made its way quickly into the hospitals. Though I never heard him articulate it, I’m sure Dr Dudrick would say that our hospitals are our largest classrooms and research laboratories.

David Gergen, Professor of Public Service and Director of the Center for Public Leadership at the Kennedy School of Government notes, “The inner soul of a leader flows into every aspect of his leadership far more than is generally recognized and his passions in life usually form the basis for his central mission during his time at the helm.”¹ There is no question that such inner convictions shaped the kind of department that Dr Dudrick aspired to build. He would be the first to tell you that leadership must begin on the inside.

To help achieve the transformation and bring that aspired future to life, Dr Dudrick needed people. As Larry Bossidy, former CEO (chief executive officer) of the Honeywell Corporation, once said, “At the end of the day, you bet on people, not strategies.”² Jim Collins, author of Built to Last and Good to Great, points out that good-to-great leaders begin the transformation of their organizations by first getting the right people on the bus (and the wrong people off the bus), and then they figure out where to drive it.³

That strategy was central for Dr Dudrick, and it started with the recruitment of 2 key people. Ted Copeland, who had finished 2 years behind Dr Dudrick in the residency at Penn, was about to go into private practice in Jackson, Mississippi, when Dr Dudrick lured him to Houston. That was critical because Dr Copeland had done his surgical oncology fellowship at MD Anderson and became our faculty point person at that institution. In that role, he was the key nodal point for training the residents in the practice of cancer surgery and spearheading the clinical studies on the use of parenteral nutrition in cancer patients.

The second key recruit right up front was Red Duke. Red had trained at Parkland (Hospital) with Tom Shires, where his interest in trauma and the metabolic response to injury led him to pursue a NIH (National Institutes of Health) fellowship at Columbia (University). After 4 years, in 1970, he moved his family to Afghanistan to help establish a new medical school. He served as the founding Chairman of the Department of Surgery of Nangarhar University in Jalalabad. The clinical experience was rather unique in that it varied from shrapnel wounds to camel bites to bizarre infectious diseases. Dr Dudrick recruited Red to Houston in 1972 to be the lead in the trauma program. With the Red on board, general surgery, surgical oncology, and trauma/critical care had stakes in the ground, and a strong foundation had been poured.

To complement this trio and help with some of the heavy lifting, Dr Dudrick recruited John Bowen in 1973, who had come to UT-Houston after completing his surgical residency at Case Western (University) to study the relationship between intestinal blood flow and mucosal integrity in the physiology department. During his fellowship, Dr Bowen rotated on the call schedule, helped cover the surgical service, and gave many of the lectures to the third-year medical students. In 1976, Dr Bowen moved to the Department of Surgery at the Ochsner Clinic, where he currently practices general and vascular surgery and serves as Chairman Emeritus.

Tom Miller, who trained at the University of Michigan and then spent several years studying gut physiology and developing a radioimmunoassay at the University of Texas Medical Branch at Galveston with Jim Thompson at Galveston, was another key addition. Tom helped build the relationship with the physiology department at the medical school, then headed by Gene Jacobsen. That partnership led to major advances in our understanding of the impact of parenteral nutrition on gastrointestinal structure and function. Tom later became the program director at UT-Houston and subsequently served as chairman of the Department of Surgery at St Louis University.

There were other key recruits as well. Ross Kyger, a surgical resident at Penn, did his cardiothoracic fellowship at the Texas Heart Institute. There he and Bud Frazier, who had been recruited from Baylor, helped solidify the partnership between the Texas Heart Institute and UT medical school. Two other important surgeons, Graham Hill from New Zealand and Brian Rowlands from Great Britain, both of whom had strong interests in surgical nutrition and published extensively in the field, brought an international flavor to the young school and department. Dr Hill subsequently became the Chairman of the Department of Surgery at the University of Auckland (New Zealand), and Dr Rowlands became Chair of Surgery at the Queen's Hospital in Belfast (Ireland) and then Professor of Gastrointestinal Surgery at (University of) Nottingham in Great Britain.

Jim Long joined the department from the Brooke Army Hospital in San Antonio. Dr Long had also trained at Penn and brought experience in managing burn patients, running a residency, and conducting research on the body's response to catabolic illness. The team was growing and was approaching critical mass. To complement these faculty, Bruce MacFadyen, a surgical resident at Penn, joined the team in the middle of his training to work with Dr Dudrick. Fadge, as he is affectionately known, brought a monster work ethic to the program and played a central role in teaching the residents the Dudrick philosophy, since he had come from Penn. Shortly thereafter, John Daly, who had worked with Dr Dudrick when he was an undergraduate and had subsequently gone to Temple (University) for medical school, came to UT-Houston to train and subsequently became another key linchpin with Dr Copeland at MD Anderson. Fadge has been a pioneer in minimally invasive surgery, and is currently Chairman of the Department of Surgery at the Medical College of Georgia. John Daly has served as the Rhoads Professor and Chief of Surgical Oncology at Penn, Chairman of the Department of Surgery at Cornell, and is currently the Dean of the Medical School at Temple.

David Ota came to UT-Houston from Hopkins (Johns Hopkins University) in the middle of his residency to work on animal models of parenteral nutrition. He stayed on with us to complete his surgical training, joined the MD Anderson faculty, and later became the Medical Director of the University of Missouri of Ellis Fischel Cancer Center. Currently, he is Co-Chair of the American College of Surgeons Oncology Group.

Several key division leaders also joined Dr Dudrick, rounding out the specialty care training for the program. Joe Corriere came from Penn, where he had trained, and became Chief of Urology at UT-Houston and served as President of the American Urological Association in 2006. Helmuth Goepfert, who had done his general surgery residency in his native Chile, an Oncology fellowship at UCLA (University of California, Los Angeles), and an Otolaryngology residency at Baylor, joined the faculty at MD Anderson and eventually became the Chairman of Head and Neck Surgery. Bruce Browner was a key recruit in building an academic Department of Orthopedics and currently heads the Department of Orthopaedic Surgery at Hartford Hospital in Connecticut.

Thus, over a relatively short period of time, Dr Dudrick recruited an all-star faculty. Not only were they each clinically superb in their own right, they were deeply committed to the research and teaching missions in the school and, equally important, they all contributed to creating the right culture. Recently I sat down with Dr Dudrick to pick his brain about that culture. It was a culture, he said, that was intended to be anchored in 6 core values: excellence, teamwork, service, innovation, mentoring, and trust. These values were to define how the department lived as it pursued its vision. These values would guide recruitment, and promotion, and every decision we made. They were not to be compromised no matter what. Dr Dudrick himself embodied them all, and thus set the example at the top.

Over the span of a decade, Dr Dudrick has trained no fewer than a dozen department chairs, 2 deans, multiple division chiefs, and numerous leaders. What lessons can we learn from his leadership?

With all its demands and unpredictabilities, being a leader in academic medicine is no easy job. But it is not complicated like chaos theory or quantum mechanics. It is not difficult to learn. It is actually relatively straightforward. Whether you're a department chair, a division chief, a dean, a director of a large research program, a chief nursing officer, or an institute director, there are 3 essential leadership responsibilities that, depending on how you exercise them, will determine your effectiveness and the success of your work unit and organization in the long run. These responsibilities are (1) setting a clear direction, (2) building the right leadership team, and (3) creating the right culture. They are not so much tasks or jobs as they are responsibilities. While they are different from the activities of management, they complement them. All other leadership endeavors fall under one of them. How you execute on these responsibilities will vary as a function of personality and circumstance but they are fundamentally the same.

Some say that leadership is much too elusive and mysterious to boil it down to a set of fundamentals. They bring up all the uncertainties that have kiboshed well-meaning strategies and their best laid plans that have gone awry. They argue that the volatility of the marketplace and inadequate resources make leadership difficult, if not impossible but, for the most part, these complaints are manifestations of their unwillingness to execute on 3 fundamental leadership responsibilities.

In its direction-setting role, leadership articulates an appealing picture of the future (a vision) and outlines a strategy for attaining that future. Being forward-looking, envisioning compelling possibilities, and enrolling others in creating that future is the single most important attribute that distinguishes leaders.⁴ An effective vision should always take into consideration the legitimate needs of the various constituencies (eg, patients, trainees, faculty, staff, donors) that have a stake in the organization; it should be a vision of the people, by the people, and for the people. In building a better future, short-term compromises or temporary concessions may be necessary but the most powerful visions are shaped by the rightful long-term interests of the people involved, interests such as well-being, professional development, personal growth, and fulfillment.

This direction-setting role of leadership is crucial because it clarifies for people what is important and what is not. The vision must be a clear, compelling direction aligned with a focused, understandable strategy that everyone comprehends, is aligned with, committed to, and contributes to. It is important that the vision provide each individual the opportunity to realize his or her own personal goals within the larger organizational purpose and objectives.⁵ The future must also be attractive enough to motivate people to create a healthy culture, one where people are willing to acknowledge the elephants in the middle of the room, confront the brutal facts, and tackle the complex problems that arise over the course of time.

Organizations get into trouble when they develop vision statements that merely hang on the wall as an anthology of words or when they behave in ways that clash with the message. This happens all too frequently. When people get jerked around by this kind of deceptive charade, they become cynical very quickly. Dr Dudrick ensured that did not happen.

Because major organizational change is fraught with many obstacles, a powerful force is necessary to fuel the process. The challenges and problems that confront our academic medical centers today are so complex and unpredictable that it is impossible for 1 person to accomplish the work of leadership alone. A strong leadership team is required, and it begins with selecting the right mix of faculty with shared goals and values.

Academic medical centers have been burned all too frequently by self-proclaimed giants whose personas so dominate an organization that they suppress alternative points of view, strangle open communication, and create outright fear. Fortunately, there has been a clear shift to building teams comprised of authentic leaders who lead by example, have high ethical standards, are good listeners, and never compromise excellence. Dr Dudrick was able to inspire people to play off the same sheet of music while still allowing each of them to play their own instrument. He was superb at putting the right man or woman in the right job and removing obstacles so they could be successful. How often do we see this ability of the leader to enable others to do their job? Not nearly often enough.

Teamwork is absolutely imperative to create meaningful change. Teamwork can be developed in multiple ways and in multiple different arenas—the laboratory, the operating room, the trauma bay, and the ICU (intensive care unit)—but regardless of the means used, one ingredient is essential: trust. When trust is present, teamwork usually follows. When trust is missing, teamwork is virtually impossible.

Why is selecting the right people and building the right leadership team so important? Because you need the right people on the team to create the right culture.

Creating the right culture is the most difficult of all leadership responsibilities. It also takes the most time. Pat Lencioni, who wrote a fine little fable titled The Five Temptations of a CEO, notes that abiding by one's values is no easy task: “Values can set a company apart from the competition by clarifying its identity and serving as a rallying point for employees. But coming up with strong values—and sticking to them—requires real guts. Indeed, an organization considering a values initiative must first come to terms with the fact that, when properly practiced, values inflict pain. They make some employees feel like outcasts. They limit an organization's strategic and operational freedom and constrain the behavior of its people. They leave executives open to heavy criticism for even minor violations. And they demand constant vigilance.”⁶

A weak culture, one that is built on hollow, empty values is a disaster. An impotent culture, where the values mean nothing, can drive the organization off a cliff. In such organizations, and you’ve seen them, the dysfunctional culture will, to quote an old adage, “eat strategy for breakfast, process and structure for lunch, and well-meaning people for dinner.”

The culture that Dr Dudrick stood for had a strong backbone. As a consequence, there was healthy debate. Faculty and residents could disagree and still work together. They could handle the heat and pressure that comes with being accountable. It was powerful and sustainable because the faculty and residents were selected and taught so well, because the actions of hundreds of faculty and residents were consistent and aligned, and because over time it became woven into the fabric of the department. As a consequence, it became bolted to the department's DNA and became second nature.

That culture resulted in an across-the-board commitment to doing whatever it took to provide the best care to our patients (service excellence), emphasized knowledge creation and creativity (innovation), was built on the backs of great teams, and placed a premium on developing people and building trust. In the best of ways, everyone drank the Kool-Aid.

The word leader has its roots in the Gothic word ga-leiban, which meant “to go.” It not infrequently denoted “to go forward or upward” for the benefit of the community. Hence, there is a service connotation to the word leader. The suffix ship in the word leadership has its roots in the Gothic word schaeppen.^7,8 Its meaning was “to create a thing of value.” Thus leadership, as we generally understand it today, has something to do with people in front whose efforts move a community or an organization forward or upward to add value to the lives of the people it serves. Interestingly, the old Gothic word schaeppen, from which the suffix ship originates, also had to do with creativity. Leadership is thus a creative activity. Go forward, serve, and create; Stan Dudrick continues to live out these elements of leadership.

Dr Dudrick has made the world a little better, touching the lives of thousands of people along the way. Has he made some mistakes? Of course; we all have, but in a self-effacing way, he has helped each of us understand that leadership is a risky business. People will push back against the leader's agendas and, in some sense, Stan has paid a price for doing the right thing. Alas, no good deed goes unpunished. He has handled things with grace and dignity, choosing to take the high road at every turn. We see so far because we stand on the shoulders of giants, Isaac Newton once said.⁹ And for those of us who have had the privilege of working along side him, Dr Dudrick is such a giant.

Today he continues to exhibit one of the most important attributes of senior seasoned leaders: the ability, in engaging the next generation of leaders, our young people, to be curious rather than dogmatic, to be inquisitive rather than judgmental, to be empowering rather than patronizing, and to be approachable rather than come across as a know it all. That was how I experienced him when we first met, and he hasn't changed.

Ralph Waldo Emerson was credited with saying that success in this life is “to earn the appreciation of honest critics and endure the betrayal of false friends; to find the best in others; and to leave the world a bit better whether by a healthy child, a garden patch, or a redeemed social condition.”¹⁰ By each of these measures, Dr Dudrick, you have been more than successful. For me and for many others you are simply Chief, and we are here today to honor you.

Correspondence: Wiley W. Souba, MD, ScD, MBA, Dean's Office, The Ohio State University College of Medicine, 254 Meiling Hall, 370 W 9th Ave, Columbus, OH 43210 (chip.souba@osumc.edu).

Accepted for Publication: August 10, 2009.

Financial Disclosure: None reported.

Previous Presentations: Presented at the Stanley J. Dudrick Symposium, sponsored by the Department of Surgery of the Yale University College of Medicine; March 28, 2009; New Haven, Connecticut.

This article was corrected online for typographical errors on 6/21/2010.