The First 90 Days — Review for Academic Medicine
The Book You Need Before You Start
Michael Watkins' The First 90 Days: Proven Strategies for Getting Up to Speed Faster and Smarter is the most practical leadership transition book I have ever read. It is not written for physicians. It is written for anyone stepping into a new leadership role — corporate executives, nonprofit directors, military officers. But the framework maps onto academic medicine so cleanly that I now recommend it to every physician who is about to take on a new leadership position.
Division chief. Program director. Department chair. Associate dean. It does not matter which role. The first ninety days will define how people see you. Watkins' argument is that those early weeks are not just an orientation period. They are a proving ground. And most new leaders walk in without a plan.
Why Transitions Are So Dangerous
Watkins opens with a sobering claim. Leaders are most vulnerable during transitions. The skills and relationships that made you successful in your previous role do not automatically transfer to the new one. You are simultaneously expected to learn, build credibility, and deliver results — all while people are forming opinions about you that will be very difficult to change later.
In academic medicine, this problem is amplified. Most physician leaders are promoted from within. You go from being a colleague to being the boss. Yesterday you were sitting next to someone at grand rounds. Today you are responsible for their annual review. That shift is disorienting for everyone involved. And unlike a corporate hire who arrives with no history, you carry every relationship, every favor, every disagreement from your previous role into the new one.
I see this constantly in coaching. A new division chief gets the title and immediately starts trying to fix things. They reorganize the call schedule. They change the meeting structure. They launch new initiatives. And within six weeks, the faculty are resentful and the chief is wondering why no one is following their lead. The problem is not the ideas. The problem is the sequence. Watkins would say they skipped the most important steps.
The STARS Framework
One of the most valuable tools in the book is what Watkins calls the STARS framework. Every new role falls into one of five categories: Start-up, Turnaround, Accelerated growth, Realignment, or Sustaining success. Each category demands a fundamentally different approach.
This matters enormously for academic medicine because most new physician leaders do not accurately diagnose the situation they are walking into. A new program director who thinks they are in a sustaining success situation when they are actually in a turnaround will make very different choices — and most of them will be wrong. A division chief who treats an accelerated growth situation like a realignment will frustrate everyone by slowing things down.
I recommend sitting with this framework before your first day. Talk to people who know the division or department. Read the last few annual reports. Look at faculty retention data. Understand what you are inheriting. The diagnosis shapes everything that follows.
Secure Early Wins
Watkins is emphatic about the importance of early wins. Not big, flashy changes. Small, visible improvements that build credibility and momentum. The key is that early wins need to align with the priorities that matter to the people you are now leading.
In academic medicine, I have seen this go wrong in a specific way. A new leader comes in and announces a major strategic initiative — a new research center, a curriculum overhaul, a faculty wellness program. It sounds impressive. But the faculty are dealing with a broken clinic template, an unfair call schedule, or a promotion process that no one understands. The leader is playing long-term chess while the team needs someone to fix the plumbing.
I love Watkins' advice here because it requires humility. Your early wins should not be about demonstrating your vision. They should be about demonstrating that you listen and that you can get things done. Fix the thing that has been driving people crazy for three years. Respond to the problem your predecessor ignored. That builds more credibility in sixty days than any strategic plan ever will.
Learn Before You Lead
The chapter on accelerating your learning is one I come back to again and again. Watkins argues that new leaders need a structured learning plan — not just absorbing information passively, but actively seeking out the right conversations, the right data, and the right questions.
He recommends a series of one-on-one meetings with key stakeholders during the first few weeks. Not to present your agenda. To listen. He even provides a set of five questions to ask each person, including "What are the biggest challenges facing this organization?" and "If you were me, what would you focus on first?"
I have adapted this approach for every physician leader I coach through a transition. Before you change anything, schedule thirty-minute meetings with every faculty member, every key administrator, and every clinical partner. Ask the same three or four questions. Take notes. Look for patterns. You will learn more in those conversations than in six months of observation.
This is hard for physicians. We are trained to assess, diagnose, and act. Sitting in a learning posture for sixty or ninety days feels passive. It is not passive. It is strategic. The leaders who skip this step almost always end up solving the wrong problems.
Build Your Team
Watkins devotes significant attention to evaluating and restructuring your team. This is where the book gets uncomfortable for academic medicine. In corporate settings, new leaders can replace underperformers relatively quickly. In academic medicine, you are often working with tenured faculty, long-standing staff, and institutional relationships that predate you by decades.
But the principle still holds. You need to assess who is on your team, what their capabilities are, and whether they are in the right roles. Watkins uses a framework of keep, develop, move, or replace. In academic medicine, "replace" is rarely an option. But "develop" and "move" are more available than most new leaders realize.
I appreciate that Watkins does not sugarcoat this. He acknowledges that team evaluation is one of the most stressful parts of a transition. But he also makes the case that avoiding it is worse. A leader who inherits a dysfunctional team and does nothing about it will own that dysfunction within a few months. The team becomes yours the moment you decide to keep it as it is.
Create Alliances
The chapter on building alliances is particularly relevant for academic medicine. Watkins describes the political landscape of any organization as a network of supporters, opponents, and persuadables. He argues that new leaders need to map this landscape early and build coalitions deliberately.
Physicians tend to resist this idea. Politics feels distasteful. We want to believe that good ideas win on their merits. But academic medicine is a deeply political environment. Promotions, resources, space, hires — all of these involve competing interests and power dynamics. Watkins gives you a practical framework for navigating that reality without becoming cynical about it.
His advice is not about manipulation. It is about understanding whose support you need, what they care about, and how to align your priorities with theirs. That is not politics. That is leadership.
The 90-Day Plan
Watkins recommends building a written ninety-day plan with clear milestones for learning, relationship building, and early wins. He breaks it into three phases: the first thirty days for learning and listening, the next thirty for shaping your agenda, and the final thirty for beginning to drive change.
I have seen physician leaders resist the idea of a written plan. They think it is too corporate. Too rigid. But the ones who do it almost universally say the same thing: it kept them from getting pulled in twenty directions during the most chaotic weeks of their transition. The plan is not a straitjacket. It is an anchor.
What This Book Will Not Give You
The First 90 Days is not a book about the emotional experience of leadership transitions. It does not talk much about imposter syndrome, the loneliness of being new in charge, or the grief of leaving a role you loved. Those are real challenges, and you will need other resources for them.
It is also not written for academic medicine specifically. You will need to translate some of the corporate language into your context. When Watkins talks about "direct reports," think faculty. When he talks about "board alignment," think dean. The concepts transfer. The vocabulary needs adjustment.
Who Should Read This
If you are about to step into a new leadership role in academic medicine, read this book before your first day. Not during your first week. Before. The framework is most useful when you can implement it from the beginning, not retrofit it after you have already made early mistakes.
I also recommend it to physicians who are a year or two away from a leadership transition. Understanding what a good transition looks like will help you prepare — building relationships, developing skills, and positioning yourself for the role you want.
And if you are already past your first ninety days and feeling like you stumbled through the transition, it is not too late. Many of Watkins' strategies can be applied retroactively. You can still go on a listening tour. You can still secure early wins. You can still build your coalition. The best time to read this book was before you started. The second-best time is now.
You can find The First 90 Days and my other recommendations on the book recommendations page. And if you are navigating a leadership transition and want a thought partner to help you plan your first ninety days, I would be glad to talk.
