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Three Questions

Three Questions: Dr. Howard Forman on Who Should Lead the VA

When President Trump nominated his personal physician to lead the U.S. Department of Veterans Affairs, it started a debate about not only the nominee’s qualifications but also what kind of leader can step in and effectively run an organization that delivers healthcare to millions of veterans. We asked Dr. Howard Forman, an expert in healthcare leadership and policy, about the profile of a good leader for the VA, and what it takes for physicians to become great leaders.

VA building

The Veterans Administration Medical Center in Waco, Texas. Photo: Larry D. Moore/Wikimedia.

  • Howard P. Forman
    Professor of Radiology and Biomedical Imaging, Economics, Public Health, and Management; Co-founder, Pozen-Commonwealth Fund Fellowship in Health Equity Leadership, MD/MBA Program, and MBA for Executives Program

You opposed the nomination of Dr. Ronny Jackson to head the VA. Why?

My issue with Dr. Jackson was not that he is not a qualified emergency department doc (he seems to be, even if he might have operated outside the norms of practice). My issue was purely that he had no experience managing a vast enterprise: The VA is an enormous operating unit of the executive branch, comparable to some of our largest companies (nearly 400,000 employees and $200 billion in annual expenditures). Nobody would hand the keys to Apple to someone who had only worked at a startup; nobody would take over ExxonMobil if they had only worked at a small refinery.

We should expect our public-sector leaders to be as experienced and capable as those in the private sector.

What qualities and experience should the leader of the VA have?

The VA is a complex organization with many moving parts and immediate needs and challenges. It needs someone who has experience working in a large organization, has a healthcare services background (not just a clinical background), and shares the vision and mission of the VA. This person needs to be capable of listening and collaborating and inspiring people near the top as well as those who do the most menial tasks. David Shulkin was a great choice, but he wasn’t the only option: Toby Cosgrove and others would have been equally good. And they do not have to be a physician, though that does seem to help with the more acute challenges.

What advantages and disadvantages do physicians generally face when moving into leadership roles in large organizations?

Physicians are generally disadvantaged by the nature of practice (which is non-collaborative and siloed, though changing, for sure). They also have generally spent too much time in clinical care and too little developing leadership and management capacity.

The best physician leaders have been good listeners; they have taken on increasing responsibilities to systems and care delivery, rather than just clinical care; They have (almost always) taken more coursework (not necessarily an additional degree) in management and leadership; they have been able to consistently put institutional and colleague priorities ahead of their own.

Making the transition from prioritizing individual patients to prioritizing populations is not an easy one. It requires an individual who is willing to work with uncertainty, limited resources, and ever-changing rules.

Department: Three Questions