#FUTUREOFMEDED: Vertical Development

By: Ezgi Tiryaki, MD (@Neuro_Edu_ET) and Felix Ankel, MD (@felixankel)

You are a postgraduate dean embedded in a large health system with multiple residencies. The COVID-19 pandemic brought unprecedented challenges and opportunities to your postgraduate enterprise. Residents and program directors rose to the occasion. They leaned-in to patient volume surges and incorporated innovations into the clinical learning environment. Many program directors faced novel and unique leadership challenges. More recently, things have calmed. You would like to create a leadership development program for program directors that prepares them for the future. Past development efforts focused on the 101 of being a program director, the transactional and technical aspects. You would like to develop an explicit design for how the mind of the program director grows with time. You hear about the concept of vertical development and want to learn more. What is vertical development? How is it different from horizontal development?

Vertical Development

One can look at development from two axis: horizontal and vertical. Horizontal development focuses on what you know (gaining knowledge, skill, competencies, and qualities that result in specific measurable behaviors and actions). Vertical development is concerned with how you think (developing the mind, creating internal capacity to make sense and respond to a given situation). A great summary can be found in this graphic (See stages of vertical development’ graphic here) by two authors from the Center for Creative Leadership which is based on the work by Kegan and Lahey.

You can read more about the concept of vertical development from the Center for Creative Leadership at: https://www.ccl.org/wp-content/uploads/2015/04/VerticalLeadersPart1.pdf

How does that apply to a medical educator? Below is a first-person account of Ezgi’s professional development through a vertical development lens.

My Professional Development Journey

As a medical educator, recovering program director and former faculty adviser, I have had over a decade of experience with looking at competencies and milestones when it comes to the students and residents. I have written about EPAs and how the concept should best be applied to my own discipline of neurology. Looking at trainees from a developmental standpoint and helping them move from novice to proficiency and gain greater levels of entrustment was my approach. Seeing the MedEd world with the lens of the growth mindset was never in question. However, until very recently, I had never given thought to how all of that may apply to myself and my own trajectory as an educational leader.

Four things changed that. The first was a purely technical issue. I am going up for promotion and must write my narrative statement. In my department there has not been anybody to date who was promoted on the academic track with an emphasis on education. The Dean of Faculty Affairs reviewed my CV and suggested that I think about how to best put my trajectory in words to show how I have grown professionally, and how my impact has changed and expanded over time. The second impetus was related to my work. I had started working with a team of assessment experts from the school of education at my university. We are trying to determine how a leadership development program for physicians that I co-lead for the last 4 years could be assessed to show value and impact. What does it mean to teach leadership and how does one know if great leaders were created in the process of running a program? This got me looking more at different frameworks of leadership competency and development and ponder what an assessable leadership trajectory looks like. The third nudge happened in my professional learning network . I was having a conversation with Daniel Pesut , an expert on nursing leadership, foresight leadership and coaching, about what to look for when applying to a leadership coaching program. During our discussion Dan encouraged me to investigate the concept of vertical development . It sounded like an abstract concept, but anytime Dan mentions an idea, I have the habit of looking it up and reading more about it. The fourth nudge happened serendipitously. I attended the inaugural summit by the Center for Coaching in Organizations , a new non-profit organization that aims to create greater social justice through coaching. Some of the speakers at this conference used vertical development frameworks in their talks, to help coaches better understand developmental needs and promote growth in their clients.

All these unrelated things taken together created a light bulb moment, a new way of sense-making for me. Vertical development seemed like the missing piece in our physician leadership program assessment work. But even more so, it was as if the threads of my own life came together and made me see educational leadership development in a new light. I was itching to apply the vertical leadership development framework to medical education leadership. It was suddenly clear how to write my narrative for my dossier.

I came to realize that I started out in a dependent stage, as a conformer. Kegan calls this the socialized mind. I was giving lectures at the medical school in neuroscience topics and was always happy when a student shared with me how they were considering a career in neurology. I was the subject matter expert on the things I taught. These were all content areas I loved and was passionate about (like neuroanatomy or how to work with patients with motor neuron disease). My standard response to any invitation to give a talk was “yes, when is it scheduled”. I remember a senior faculty looking over my resume and telling me, she would not often see such a long list of lectures and talks. She could tell I was a team player and did a lot of service, but she would recommend that I shift my energy to directing courses and creating curriculum and learn to say no.

Next, I became a program director. I started looking at our program strategically and set an agenda of creating fair process and greater resident-participation in decision making. I faced resistance for some of the decisions I made, but I sought out allies and was able to make changes that persist to this day (like dedicated didactic time during which the attendings hold the pagers for the trainees). I had a strong sense of where we needed to go as a program and took a stance on those issues. In retrospect I had transitioned into the independent mindset and had become an achiever. Kegan would label this the self-authoring mind.

Shortly after becoming a PD, I took on the role of a faculty adviser to the medical school and started mentoring small groups of students from their white coat ceremony to graduation day. My work was no longer based on my content expertise as a neurologist, but my ability to help each individual student go through their professional identity formation and uncover what the best way to navigate medical school for them would be. Nobody told us faculty advisers when and how to meet my students and there was no micromanagement of the logistics of our work. It was up to us to set our schedule, think about the best way of sharing key information and how to engage with our groups. When not in 1:1 meetings, the role of the faculty adviser was one of facilitation of discussion and reflection. I was not the subject matter expert, but somebody who interacted with the students in a way that was very akin to shared decision making with patients. I had some insider knowledge about the options and possibilities that were out there, but the students were the experts on who they were and what it was like to stand in the middle of their own lives. I would tell my students and residents that I learned as much from them as they learned from me. As an achiever, I would advance others by using my influence and position. I expanded the types of learners I mentored as well as sponsored.

Finally, I took on the role of a designated education officer, working at a Veterans health system with an institutional oversight role not only for resident and medical student education, but for the learning environment of all health professions trainees. Beyond trainees, the education of all 4000 employees and our patients also became part of my work as the department head for the education service line. This role was much more interdependent than any role I had ever had. No longer was it about neurology or medical education, but health systems-wide learning . The focus shifted from meeting program requirements to creating learning conditions and improving culture. Initially, I mourned the loss of the direct connection to my learners. This loss was offset by the possibility of system-wide impact, by making a difference at a scale that was not achievable in an individual program. I am not alone in doing this work as it requires partnering, influencing, sharing of feedback and information, and co-creating. The problems are far more complex and multifaceted and uncertainty and ambiguity are more prevalent than in all my previous roles. There is never a simple answer and multiple perspectives co-exist. My relationship to other leaders in similar roles across other systems grew stronger and created a rich personal learning network that helped me create a new sense of community and connection. My work is marked by interdependence and collaboration and often consists of managing polarities, rather than simple problems that can be solved.

Nick Petrie has created an illustrative table (see p. 11 here) that lists the leadership competencies of strategic thinking, leading change, conflict management and leading across boundaries as they relate to the vertical stages of conforming, achieving, and collaborating.

My education journey evolved from helping medical students learn about neurology to delivering the best possible neurology residency experience to helping individuals develop their professional identity and career paths in medicine to eventually creating the best possible learning environment in which everyone can lead fulfilled and healthy lives. This parallels my own developing mind from thinking like a conformer to becoming an achiever and growing into a collaborator. My own development and the actual work I did were tightly connected. One required and facilitated the other, each stage laid out the foundation for the next stage to follow, it was a developmental process that unfolded over a decade.

A Framework for Faculty Development

As we look at creating education career pipelines, designing educator training programs and embarking on succession planning, it makes sense to me to use the principles of vertical development in the design and delivery. Instead of passing along more tools and skills, we must create the conditions that help leaders in developing their mind. As Nick Petrie states so eloquently in his CCL paper: “In a VUCA world, it is the developmental stage of the thinker that matters. For this reason, a vertically focused program places less emphasis on the content to be poured into the leader and more on the cup itself (the mind-set, identity, and mental models of the leader). The aim of Vertical Development is not to add more to the cup but to grow the size of the cup itself.”

This will require different strategies and a different kind of design for the programs we create for developing our education leaders and we for one cannot wait to see what this type of vertical leadership development can do for our field.