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During the two or three short years of a rheumatology fellowship, there is so much to learn: the subtle art of the musculoskeletal examination, the intricacies of the immune system and the indications for a dizzyingly increasing array of new medications, to name just a few topics. One topic that you rarely hear about, but that gets to the heart of training, is upward management.
Upward management refers to the art of influencing those who have executive power over you.1 Many fellows may be unfamiliar with the term, but most have an intuitive grasp of the concept. After all, fellows occupy a middle ground between residency and independent practice. They must learn not only how to supervise medical students and residents, but also learn how to deal with bosses—attending physicians, research mentors and program directors, among others. Surprisingly, not much has been written about upward management, especially in the medical setting. However, from my experience, here are some pointers to help build those skills.
1 Upward management is a form of empowerment: When I first read about upward management, I immediately recalled a whole host of people from junior high school up through residency who were, for lack of a better term, suck-ups. Their form of upward management was to please their bosses through any number of insincere, and occasionally humiliating, acts. I remember being appalled that they would justify their behavior by saying that things like, “It’s how to get ahead. It’s the only way to survive,” or “Everybody does it.” But upward management doesn’t need to be so degrading.
Believe it or not, fellows have a lot of power that is not always clearly seen. Leveraging that power wisely helps promote one’s own sense of dignity and builds capacity so that the helplessness and power asymmetry, which occurs in all training environments, becomes less of an issue. It may not feel comfortable to talk about the sense of conflict that comes inherently with being a subordinate to a boss—but it is important to acknowledge, even if you work in a very benign environment with a great boss. Indeed, how we make sense of this simmering conflict and how we assert ourselves in the relationship gets to the heart of upward management.
2 There’s more than one way to manage up: Before you know what you’re doing, you have to know who you’re dealing with. People, particularly physicians, are incredibly diverse in terms of attitudes, perspectives and backgrounds. So when you take two physicians, one trainee and one supervisor, that range of possible interactions becomes mind-bogglingly diverse. The key to successful upward management is to understand who you are and who your attending physician (or program director) is.
Does your boss prefer casual interactions? Or are they more formal? What priorities are most important to them—and you? What is their preferred mode of communication?
Adding to those complications are contextual factors. Are they new to the organization? Is the task at hand extremely urgent? Do they have problems with their boss?
All these things and more play an important role in deciding how to hone your own style of upward management.
3 Observation informs management style: The first step in establishing an upward management style is learning how to observe. Sometimes, small things can make a huge difference. I would advise you not to stalk your supervisors, but taking mental notes about how best to harmonize personalities may be very useful. For example, early in my fellowship, I learned that one of my attending physicians was insistent on sitting in a larger, higher chair when in examining rooms. Of course, that was the chair in front of the computer, so when both of us were in the room, this posed a significant obstacle for my workflow. It frustrated me at first, but I realized there was a simple solution: I just placed the lower, humbler stool in front of the computer, so that he could sit in the bigger chair elsewhere. It was a small victory and a simple solution, but one that allowed both of us to avoid conflict and, in our own ways, win.
4 Regular communication is key: As with all management, communication is really front and center. Clear communication not only improves efficiency and aids in team building, but it also elevates your esteem. Initiating communication makes you the leader (even if you lack the executive position), and demonstrating responsiveness shows commitment and maturity. Moreover, your supervisor may be grateful that you’re doing the valuable task of communicating that they no longer need to.
Of course, the amount and type of communication is informed by your personality styles, underscoring the first three points. For my supervisors, I typically send e-mails before and after meetings to document the agenda and to track the progress of whatever we discussed. My research mentors find this useful, but I can imagine others may find it patronizing. That’s why individualization is so important.
5 Build a long-term relationship: One reason of communication is to foster trust, and ultimately, trust is the currency of effective management. For all the lofty talk about upward management, your supervisor still has power over you. But if you establish trust, you can help ease that sense of vulnerability.
That sounds pretty easy, but in practice, it is considerably difficult. It requires constant discipline in upholding values and principles that are shared between subordinate and supervisor. Even a single misstep can undo weeks, months, even years, of hard work. With some, more prickly supervisors, establishing trust may require a lot of effort and planning.
Here is where sucking up is likely going to backfire, because after some time, the inauthenticity of constant flattery will become obvious.
6 Develop a repertoire of skills through practice and reflection: One curious aspect of upward management is that it has great applicability but not a lot of theoretic underpinnings. That means that it is basically up to the fellow to continue honing their skills by reflecting periodically on what works and what doesn’t. As noted before, what works for one relationship may spell disaster for another. Therefore, the art of upward management requires development of a repertoire of different skills for use with different people and environments. Complicating matters is that our environment will continue to be in flux as we grow. No matter how far it seems, it won’t be long until graduation. And at that point, the direction of your management may not be so upward anymore.
7 Upward management is an extension of self-management: As mentioned earlier, upward management requires discipline and focus. It means that you are in a position of control even if you aren’t in a position of power. That demands a lot of hard work and breaking maladaptive habits, such as procrastination and impulsiveness. That’s not easy to do, by any stretch of the imagination. Moreover, it is never fair to expect anything more out of anyone else than what you can expect from yourself. Therefore, you have got to commit to self-management as much as managing upward.
Conclusion
It’s unrealistic to expect fellowship programs to suddenly start teaching about leadership and management styles, but whether subtly or more overtly, fellows learn a lot about management throughout their years in training. Fellows would be well advised to take these lessons and reflect on upward management. It is guaranteed that these skills will come in handy long after graduation. After all, if you ever hope to move upward, you’ll also have to manage upward.
Bharat Kumar, MD, MME, FACP, RhMSUS, is a clinical assistant professor of internal medicine at the University of Iowa. He completed a dual fellowship in rheumatology and allergy/immunology, as well as a Master’s in Medical Education in 2017. He has a special interest in journalism, healthcare policy and ethics. Follow him on Twitter @BharatKumarMD.
Reference
- Rousmaniere D. What everyone should know about managing up. Harvard Business Review. 2015 Jan 23;93:1.
