A Picaresque Leadership Journey

Chris Rose, MD, FASTRO, played a key role in significantly growing a large private practice and held leadership roles within ASTRO, including serving as ASTRO’s president during Society’s shift to stand up as an independent society from ACR. We sat down with Dr. Rose to hear his unique perspectives on strategy and execution from the lens of private practice and society leadership.

ASTROnews: You’ve played a key role in growing a large private practice. How did you approach strategic decision making during that experience?

Dr. Chris Rose:I had no formal training in implementation science. Over my career, I guess I learned to be flexible and retain a certain cynicism about strategic plans and top-down management. When Valley Radiotherapy Associates (VRA) was small, it was easy: Les Botnick and I had no strategy other than attempting to provide our patients care as good or better than they could receive at any other institution in Los Angeles. As VRA grew, we hired a managerial psychologist to take the temperature of all the docs and to keep the hierarchy flatter than what we had experienced in academics. We also regionalized management at VRA with a centralized professional manager, medical directors for the various regions, and a council for the medical directors. None of us had gone to business school so this was on the job training.

The framework was a yearly two-day strategic planning retreat for all the docs. We were quite intentional to keep the number of goals small (I recall we had four or five every year). At each of the meetings of the regional council, the practice manager summarized our progress toward meeting the goals. The outcomes were financial and non-clinical (reputation in the community, patient satisfaction, our docs’ satisfaction, our referrers’ satisfaction).

AN: What were your observations of the strategic planning process in ASTRO when you were president?

CR: When I was elected to the leadership track, ASTRO had just undertaken an important strategic planning effort. There was dissatisfaction with how the ACR had managed ASTRO, and there was a new plan that set ASTRO on the path to self-governance. In retrospect the process was naïve. In those days, the volunteer leadership was spread thin. After five rather chaotic years, Laura Thevenot was hired as CEO. She brought in her own team, which allowed the volunteers to focus on larger strategic goals to be implemented by the staff. Strategic planning occurred with retreats every three to five years.

My main concern was that the size of the organization and the governance did not allow for agility. Society, economics and science were changing at a very fast pace, and the three-to-five-year strategic plan sometimes did not accommodate new and pressing changes. For example, during the end of my time at ASTRO, radiation safety and the need for QA for IMRT at smaller institutions was not recognized. The New York Times famously excoriated radiation therapy as unsafe.¹ ASTRO, the medical device manufacturers and the medical physicists needed to provide a response. This eventually happened but none of this was on the “strategic plan dashboard.”

AN: What are the key differences in executing strategy in a private practice versus when you took on a leadership role within a large corporation like McKesson?

CR: In private practice I had only one master: my docs. At McKesson I had two masters: my employer and their clients, the US Oncology Network. I would like to think that McKesson leadership and the physician practices were always aligned but sometimes this was not the case.

AN: Given competing demands, how did you ensure your teams focused on what truly matters?

CR: What truly mattered for my team at US Oncology was what mattered for the physicians. We surveyed them, had focus groups, and gathered the senior radiation oncology leadership to listen to their concerns. Then we prioritized the concerns and modified them with respect to what we could accomplish in the short and medium term. We limited the focus to five items that we could achieve. When enthusiastic staff members suggested additional items, we reminded them that we could not “boil the ocean” and that adding items outside of the implementation cycle would detract from successful accomplishment of the prioritized items.

AN: What approach have you found most effective in translating high-level strategic plans into real, measurable outcomes? Are there metrics you rely on to track progress and ensure accountability?

CR: This was a method that Rehman Meghani, MBAS, my business partner at McKesson/US Oncology, formulated and taught me. After the yearly strategic plans were formulated, he and I would create quantitative commitments to each other. Every other month, we were responsible for assessing our individual and joint progress. We asked other individuals to also provide a list of commitments in their lanes that would afford achievement of the strategic plans, and each of us would jointly assess their efforts six times a year. These check-ins would take at most 30 minutes to document the progress, or the lack thereof.

AN: Based on your experience, what are the biggest pitfalls leaders face when trying to close the strategy-execution gap?

CR: First is resistance to change: “Why do we have to do things differently?” Second, lack of incentives (mainly financial, but also lack of understanding) to change, closely followed by rapidity of change/burnout and the unwillingness of institution to recognize the need to change.

AN: If you could go back to the beginning and give yourself advice about strategy and execution in health care, what would it be?

CR: I would tell myself that being an excellent clinician is necessary but not sufficient in service to the patient. I’d tell myself that medicine is not an individual effort but it is a team practice. That one needed the cooperation and understanding of all the team members within the practice (i.e., therapists, nurses, dosimetrists, physicists) and administrators whose views and priorities might be different than mine but who probably chose this vocation for similar reasons — to be of service.