Having Difficult Conversations as a Leader
The Conversation You Keep Postponing
You know the one. The underperforming colleague. The passive-aggressive team member. The co-leader who keeps overstepping. You've been meaning to address it for weeks. Maybe months.
You're not alone. In my experience coaching physician leaders, the single most avoided responsibility is the direct, honest conversation. And the cost of avoidance is enormous.
Why Physicians Struggle With This
We're trained to deliver bad news to patients. We do it regularly, and most of us do it well. But delivering difficult feedback to a peer or a direct report? Completely different. The power dynamics are murkier. The relationship is ongoing. And in academic medicine, you'll probably be on a committee with this person for the next decade.
So we hint. We send vague emails. We hope someone else will handle it. Or we wait until we're so frustrated that the conversation comes out sideways.
None of that works.
A Simple Framework
I use a version of the SBI model from the Center for Creative Leadership—Situation, Behavior, Impact. It's not complicated, and that's the point.
Situation. Name the specific context. "In last Tuesday's faculty meeting..."
Behavior. Describe what you observed. Not your interpretation. Not your feelings about it. What actually happened. "You interrupted Dr. Chen three times during her presentation."
Impact. Explain the effect. "It made it difficult for the group to hear her proposal, and I noticed several people disengaged after that."
That's it. No character judgments. No sweeping generalizations. Just a clear, specific observation and its consequence.
Before You Start Talking
The conversation itself is only half the work. The other half is your preparation. Before you sit down, get honest with yourself about two things.
First, what outcome do you actually want? If you just want to vent, call a friend. If you want behavior to change, you need to be clear about what that change looks like.
Second, check your story. Are you assuming intent? We almost always are. As Douglas Stone and his co-authors put it in Difficult Conversations: How to Discuss What Matters Most, most conflicts involve a gap between our intentions and someone else's perception. You're probably sitting in that gap right now.
The Longer You Wait, the Harder It Gets
Every week you postpone, the conversation gets heavier. Resentment builds. Other people notice. Your credibility as a leader quietly erodes.
The best physician leaders I work with aren't people who enjoy these conversations. They're people who've learned to have them anyway—early, directly, and with respect.
If you're navigating a difficult leadership dynamic and want to think it through before you walk into the room, that's exactly what individual coaching is for. Sometimes thirty minutes of preparation changes everything.
