Leadership

Perspective: The Language of LeadershipChip Souba, MD, ScD, MBA

Abstract

Human meaning is not given beforelanguage in and by some detached,prelinguistic domain and then labeledwith words. Rather, language itself,always already ardently at play in ourlives, is constitutive of the realities of ourexperience, opening up to us a uniquelyhuman world. Language is the bridgebetween the created present and theuncreated future, affording leaders ofmedical schools with an underusedopportunity to transform academicmedicine. In creating and exchangingmeaning, good leaders translateambiguity into clear messages that

convey the rationale for change andenroll others in a compelling strategythat fosters alignment and commitment.Because language influences ourthinking and emotions, it is mostpowerful and effective for tacklingchallenges that rely heavily onconceptual, innovative solutions asopposed to those problems whosesolutions are simple and technical innature. However, many leaders inacademic medicine spend much of theirtime in the domain of content, whereissues are understandable, strategies arefamiliar, and solutions are seemingly

apparent. Complex problems cannot betackled by solely addressing content; theissue in question must be situated withinan appropriate conversational context toprovide a basis for action. Leaders do thisby creating linguistic distinctions thatprompt cognitive shifts in others, jarringthem loose from their entrenchedworldviews. This property of language—its ability to bring forth, out of theunspoken realm, innovative ideas andpossibilities—will determine the future ofour health care system and our world.

Imagine practicing medicine withoutbeing versed in the language of medicine,including all its formal terminology andinformal jargon. Without access to thisspecialized linguistic domain, physicianscouldn’t understand normal physiologyor pathophysiology. They would beincapable of synthesizing findings fromthe history and physical, labwork, andimaging studies to make a diagnosis.Words like marasmus, fistula, and tinnituswould make no sense. Communication inany kind of meaningful way with peers orpatients would be unworkable.

Similarly, picture being a basic moleculargeneticist without an understanding ofterms like knockout, transgenic, vector,phenotype, or RNA interference. Withoutconversational access to the specializedlanguage of molecular genetics, thecontext in which molecular geneticistswork to make discoveries would notexist. Research would have little meaningto them, and they would be unable torelate to other scientists.

Command of the language of medicineprovides clinicians with a resource thatallows them to make sense of and interactwith the world of illness and patientsdifferently from those individuals wholack that faculty. Similarly, the languageof research affords researchers a specialperspective that enables them toexperience the world of science uniquelyand to connect with colleaguesdistinctively. These conversationaldomains (linguistic spheres), whenlearned, become contextual frameworksthat use their practitioners to create thebeing and action that is necessary to beexperts in their fields. Bruffee1 writes, “Inany discipline … entities we normally callreality, knowledge, thought, facts, texts,selves, and so on are constructs generatedby communities of like-minded peers.”

The language of leadership is nodifferent. It is a context that generatesaccess to the world of teams,departments, and organizations in adistinctive way, creating an opportunityto lead more effectively. But unlike thelanguage of medicine and science—whichis adeptly used by physicians andresearchers—the language of leadership isuncommonly practiced with equivalentcompetence. One reason for this disparityis that we don’t have a consistent andagreed-on language of leadership.2,3 Thewords leader and manager are usedinterchangeably by some people. Toothers, they denote very different

activities. Moreover, language is generallythought of as a tool that labels; itsconstitutive nature (defined below) is lessfrequently appreciated. It is difficult totalk consistently about leadership, letalone exercise it effectively, without ashared understanding.

When we talk of mastering the languageof leadership, we mean much more thanbecoming familiar with the meaning andapplication of words like vision, strategy,and culture. Kockelmans4 points out that“language is not essentially andexclusively for communication, it has amore important function within thetissue of experience. It is because manspeaks that he has a world.” Everythingwe have created today, from the CTscanner to the U.S. health care system tothe salaries we pay our faculty to themicrochip, has been brought intoexistence through language. Language isthe vehicle we use for making decisions,resolving most disputes, enactinglegislation, sharing research discoveries,and articulating new possibilities.Without command of the language of aparticular domain, be it leadership,medicine, business, or science, onecannot practice effectively in thatdomain.

Language is the critical link between thecreated present and the uncreatedfuture.5 This connection gives languageenormous clout. But the language ofleadership, unlike the language of

Dr. Souba was vice president for health sciences,executive dean for the health sciences, and dean,College of Medicine, Ohio State University,Columbus, Ohio, at the time this was written.

Correspondence should be addressed to Dr. Souba,Dean, Dartmouth Medical School, 1 Rope FerryRoad, Hanover, NH 03755; telephone: (603) 650-1200; e-mail: wiley.w.souba@dartmouth.edu.

Acad Med. 2010;85:1609–1618.First published online August 10, 2010doi: 10.1097/ACM.0b013e3181ee0045

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medicine, is not a skill that students,residents, or faculty necessarily acquireduring their training. While we prepareour young people well for the practice ofmedicine and research, we often fall shortin preparing them for the practice ofleadership.5,6 Like mastering anylanguage or skill, the language ofleadership has to be learned, honed, andpracticed.

Consider the microvascular surgeon who,on discovering the “distinguishing”power of his or her optical magnifyingloupes, remarked “I had no idea howmuch better I could see through theselenses. I notice things in a whole newcontext, one that I was unaware of before.I can see the tissue relationships from adifferent perspective, in a new light.”Much as surgical loupes can provide thesurgeon with an advantage, leaders haveaccess to a linguistic equivalent thatallows them to distinguish the worldmore perceptively, thereby enhancingtheir effectiveness. In exploring thelinkage between language and leadershipin this article, the word language is takento include not only spoken and writtencommunication but also body language,facial expressions, tone of voice, and anyother actions that have symbolic intent.7

Language and Human Evolution

Our ability to use language in asophisticated manner is the singledistinguishing characteristic that sets usapart from other animals.8 Language hasenabled humans to bring to fruitioninventions (urbanization, manufacturing,telecommunications) that have madesocial progress possible. UnlikeDarwinian evolution, where theenvironment is the genetic sculptor, traitsin cultural evolution are passed onthrough language from one generation tothe next.9 This process, however, is notrandom—it is faster, more purposeful,and more strategic. For language to enterthe repertoire of human activities, it hadto convey an adaptive advantage from itsearliest stages, or it would never havebeen conserved.10

Today, language is the critical sculptor ofour future. Tom Wolfe, author of TheRight Stuff, notes,

Once you have speech, you don’t have towait for natural selection! If you wantmore strength, you build a stealthbomber; if you don’t like bacteria, you

invent penicillin; if you want tocommunicate faster, you invent theInternet. Once speech evolved, all ofhuman life changed.11

Whereas biologic evolution was theprincipal if not sole determinant ofchange for hundreds of millions of years,the recent introduction of language as anadaptive tool changed the possibilities. Anoted authority12 explains, “What ishappening is cultural change; within theenvelope of the language faculty,languages are recycling the limitedalternatives that this biological envelopemakes available.”

Talk is the most ubiquitous social activitythat human beings engage in. Notsurprisingly, it is language that builds thesocial and cultural worlds we live in. It isa critical exploitable resource forexercising more effective leadership inacademic medicine.

The Constitutive–SymbolicDuality of Language

It is increasingly accepted that humanmeanings are not given beforehand in anobjective, prelinguistic realm, and thenrepresented in words; rather, languageitself, at work in the interactions of dailyhuman existence, adds the meanings, andin so doing shapes the world.13 Thewritings of Dewey,14 Heidegger,15

Gadamer,16 Hyde,13 Deetz,17 Stewart,18

and Anton19 maintain that language(communication) is not merely symbolicbut first and foremost constitutive.Speech is firstly consequential andsecondarily referential.19 To say thatlanguage is constitutive means thatlanguage itself grants the specific nature ofwhat it refers to, as something known thatpossesses characteristics that aredistinguished and described using words(e.g., “The table is brown and three feettall). Everything that is known is knownby someone. There isn’t somethingknown that isn’t known by someone.There is, of course, much that isunknown— unlanguaged and not knownby anyone. How we “know” something—how we make sense of it and experienceit—lives in language. Relativity was notknown until Einstein discovered(“languaged”) it.

A desk, for example, is not a desk beforelanguage, even though it may exist as aphysical object. Moreover, when weconsider an object such as a desk, we are

less interested in the desk itself and morein “the how of its intendedness.”19 Weare interested in how the desk disclosesitself through and by the different wayswe can meaningfully engage and interactwith it: by writing on it, decorating it,situating it in an office, etc. As succinctlystated by Gerkin,

Language constructs world. To have aworld, to live in a world, means, forhumans, to inhabit a time and place inwhich a certain language is connectedwith experience to give meaning to thatexperience…. Whenever any event occursin our lives, be that so small an event asstubbing one’s toe on a crack in thesidewalk, or so large and significant anevent as entering into a marriage orcontracting a dread disease, it does notbecome an experience to us untillanguage is attached to the event and it isgiven meaning.20

This performative function of languageconveys its ability not just tocommunicate information or labelthings but also to bring about or effectactions in accordance with socialconventions.21 Heidegger15 reminds usthat we do not just speak language;language also speaks us.

Deetz17 elaborated on this generative(constitutive) nature of language:

That which is revealed, understood, andheld is in language…. Things withoutwords are static entities; language makesthings into possibilities of experience….The object is constituted— given itsspecific nature— only in the humanencounter.

John Searle22 characterized this uniquelyhuman capability when he wrote, “Mydog can see a person carry a ball across aline; but what he cannot see is the personscoring a touchdown.”

The constitutive (presentational) andsymbolic (representational) properties oflanguage are thus two sides of the samecoin. They are complementary—“whatwe talk about, refer to, or symbolize, isnever independent of us; we alwaysalready have had something to do withanything we make meaningful assertionsabout.”19 We are born into language suchthat we inevitably continuously stand andlive in language. Things (objects, people,conversations, situations, relationships)are events in the world whose meaningreflects how they are perceived,interpreted, experienced, andrepresented. As Wachterhauser explains,

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Far from separating the intelligibility ofthe world from us, or substituting its ownintelligibility, the thesis that “Being thatcan be understood is language” rootslanguage in the world and points insteadto its integral connection with the thingsthemselves.23

Reality does not exist outside the processof representation. Hence, to speak is to bein collusion with reality as eloquentlyarticulated by John Dewey14 in hismagnum opus Experience and Nature:

When communication occurs…. Eventsturn into objects, things with ameaning…. Where communicationexists, things in acquiring meaningthereby acquire representatives,surrogates, signs and implicates, whichare infinitely more amenable tomanagement, more permanent and moreaccommodating, than events in theirestate.

Dewey is affirming that language enablesus to convert events and occurrings into“talkable” objects that are meaningful inthe sense that we can name them,categorize them, debate them, and engagethem. Consider the phenomenon we calla sunset. You might describe theexperience as a mix of orange and redcolors. A photochemist would say thatthe intense hues are due to light travelingat a shallower angle and traversing moreatmosphere such that longer wavelengths(reds and oranges) are detected by theeye. A theoretical physicist might explainthat all those photons and particles atplay in creating the visual image we call asunset are really not matter; rather, theyare complex subatomic events oroccurrings that we turn into things byusing words like wavicles and strings.Without this ability to convert an eventor an occurring into an object, we couldnot make meaning of or participatemeaningfully in the world. Our “reality”is a constructed interpretationconstituted inside a shared language thatfunctions as a kind of lens that makesreality more intelligible, opening up to usa distinctively human world. Thus, whilereality is not created solely by language,as humans we have the world we havebecause we have language. Our truthreflects the way the world haslinguistically disclosed itself to each of usin our experience.

Language and Sensemaking

Sensemaking, that is, making something“sensible,” is a uniquely human

capability.24 “What gave our species itsascendency,” writes Bickerton,10 “was notso much the power to communicate asthe power to think, to imagine, and toplan, using our language-constructedmodel of reality as an arena in which torehearse possible future actions.”Virtually all sensemaking is sociallyconstructed inside of the conversationsthat we have had, are having, and willhave. “Sensemaking,” note Weick andcolleagues,25 “is central because it is theprimary site where meanings materializethat inform and constrain identity andaction.” Conversations are thus powerful,underleveraged instruments leaders canuse to invent a high-performance future.5

In the leader’s role as a sensemaker andsensegiver, language can provide acompetitive advantage in leadingorganizational change.26

Organizational members ascribe andcredit leadership to people who structureexperience in a meaningful way. Smircichand Morgan27 write, “They emerge asleaders because of their role in framingexperience in a way that provides a viablebasis for action, e.g., by mobilizingmeaning, [and] articulating and definingwhat has been previously remainedimplicit or unsaid.” Notice how PresidentBarack Obama acts as “sensemaker” and“sensegiver” by clarifying an uncertainreality for the members of the NationalAcademy of Sciences in his speech tothem at their 2009 annual meeting:

[T]here are those who say we cannotafford to invest in science, that supportfor research is somehow a luxury atmoments defined by necessities. Ifundamentally disagree. Science is moreessential for our prosperity, our security,our health, our environment, and ourquality of life than it has ever been before[Applause]…. [S]o I’m here today to setthis goal: We will devote more than 3% ofour GDP to research and development.We will not just meet, but we will exceedthe level achieved at the height of thespace race, through policies that invest inbasic and applied research, create newincentives for private innovation,promote breakthroughs in energy andmedicine, and improve education in mathand science [Applause].28

In creating and exchanging meaning,good leaders translate inchoatepsychological experiences into an explicitand communicable form to explain theirreasons for a decision, to convey theirfeelings, and to make comprehensibletheir complex experiences in narrative

form.29 This process of meaning-makingin a community of practice30 helps peopletackle their problems and, in so doing,achieve their collective goals; it isrelatively routine for problems that aresimple (technical) because, by and large,the issues and their solutions arestraightforward.

Adaptive challenges, in contrast totechnical problems, are complex learningproblems31–34 for which the organizationhas little or no preexisting experience orsolutions. They are complex because theyare difficult to get our arms around. Theycan be solved only by people learningnew ways of working them out. Not onlyare adaptive challenges difficult to graspand tackle, they are easy to avoid, deflect,or deny. We often unsuccessfully attemptto solve them using technical solutions.For example, we throw money at them—but this tactic is at best a temporary onethat may be useful but is never sufficient.Failure to differentiate technicalproblems from adaptive challenges maybe the single most important reason forleadership failure today.34

A consistent characteristic of an adaptivechallenge is that there is no commonagreed-on understanding of theproblem.2,32–35 In other words, differentpeople make sense of the problemdifferently. They have trouble describingthe challenge succinctly. They haveconflicting opinions about its causes.They propose different solutions. Theyhave varied opinions about whoseresponsibility it is to solve the problem.The current debate over health carereform is an adaptive challenge.Physicians “see” the problem throughtheir filters, the payers have a differentperspective, the government has its pointof view, and the public has its biases.Technical solutions will not adequatelyreform our health care system; adaptivework will be essential. Adaptive work isalways required when our deeply heldbeliefs are challenged, when the valuesthat made us successful are less relevantor obsolete, and when legitimate yetcompeting perspectives emerge.33 Nowonder the health care reform debate hasbeen contentious.

The professionalism challenge inmedicine is another example of acomplex challenge. Lucey and Souba36

maintain that the current approaches toenhancing professionalism—reinforcing

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rules, rewarding right behavior, andremoving those who falter—areimportant but inadequate tactics. Theywrite,

Tackling the professionalism problem as acomplex adaptive challenge begins withdeveloping a shared vision (the aspiredfuture state) and a shared understandingof the problem (the current reality). Theproblem begins here because, typical of alladaptive challenges, there is considerabledisagreement about what a culture ofprofessionalism should look like and howmuch of a professionalism problem existstoday.36

Tackling complex challenges is no easytask. The work begins by engaging thevarious stakeholders in a dialogue inorder to develop a shared understandingof the challenge: What are the issues asyou see them? What are the hiddenassumptions and “elephants” in theroom? What are you willing to give up inorder to solve this challenge?Accordingly, language is especially criticalwhen it comes to solving adaptivechallenges. Why? Because reality issocially constructed24,37 and the languagewe live inside of and in which we haveour conversations prominently affectshow we experience circumstances,problems, and people; in other words,how they “show up” for us.

Because language influences ourthinking, reasoning, emotions, andactions,38 –45 it is most powerful fortackling challenges that rely heavily onconceptual, innovative solutions asopposed to those problems that areintelligible and more technical in nature.Holtgraves and Kashima29 maintain that“the effects of language on cognition willtend to be greater for more abstract andambiguous domains (e.g., personperception) relative to moreunambiguous and concrete domains(e.g., object perception).” This“criticality” of language becomes all themore important, given that the challengeswe face in medicine are becoming morecomplex, more inexact, and morediscombobulating.

It is not easy to master and practicelanguage that fosters a sharedunderstanding of challenges that areabstract, associated with palpableemotions, and have less of a physicalcounterpart. But it can be done, and theoutcome can be transformational. WhenMartin Luther King, Jr., said, “I have a

dream that my four little children willone day live in a nation where they willnot be judged by the color of their skinbut by the content of their character,” hiswords made sense to and resonated withvirtually everyone, regardless of theireducation, age, gender, social status, orrace. His language helped people let go ofoutdated ways of thinking and workingso they could “get on the same page” andcreate the necessary adaptive leadershipto tackle racial disharmony.

Thus, leaders play a critical role inshaping our meaning-making. Consider ateam of medical residents trying to figureout (make meaning of) a patient’s suddenonset of tachycardia. A differentialdiagnosis is developed and discussed inan attempt to make “common sense” ofthe findings. The various assessments,hunches, and insights are integratedusing language; without language, theresidents could not care for the patient.Language, notes Neuman,46 is what“ensures that an indeterminate signal willfind its appropriate conformation, ratherthan fall prey to an infinite regressionof … interpretations.” As so aptly statedby Wittgenstein,47 “The limits of mylanguage mean the limits of my world.”

Language, Context, andDistinctions

The word context refers to the space(domain) in which something—aproblem, a situation, a person—shows upor occurs for us. The notion of contextinvolves the fundamental juxtaposition oftwo entities: a situation (event) and whatsurrounds the event that is beingexamined; the latter provides theresources (cues) for the appropriateinterpretation of the event.48 Because notwo people draw on thesecontextualization cues in the same way,we each create different contextualframes; that is, we each “see” the worlddifferently. The relationship betweenevent and context is not unlike thatbetween “cultured cell” and “cellculture.” In our own lives, we are thecontext for “what happens” in our lives.Stuff happens in the context of me. I amthe space in which the events of my lifeoccur.49

In every conversation, language acts as a“behind the scenes” conversationalist thatmediates between speakers. It isseamlessly woven into the contextual

fabric of every organization, regulatingthe spoken and the unspoken, cloakingthe unsaid but conveyed, and defendingour lenses and filters. Leaders uselanguage to dynamically refashion thecontext that provides organization foraction within the conversation itself.48

Each additional linguistic move modifiesthe existing context and, in so doing,creates a new arena for subsequentinteraction. In other words, talk itselfconstitutes the main resource for theorganization of context. Malinowski50

argues that language becomes intelligibleonly when it is embedded within itscontext of situation; moreover, languageis “an indispensible element of concertedhuman action,” a meaning-makingvehicle that directs people to take steps toget things done.

Because our mental maps and frames ofreference are linguistically sculpted, theystrongly influence our contextualinterpretation. For example, Mike’sassertion that John can’t be trusted putslimits on the range of possibilities forhow Mike (and possibly others) dealswith John. On the other hand, languagecan be an undeniably potent resourcethat leaders use to create an insight thatchanges people’s thinking. Listen to thewords that Robert F. Kennedy51 spokeminutes after Martin Luther King, Jr.,was shot and killed on April 4, 1968:

In this difficult day, in this difficult timefor the United States, it is perhaps well toask what kind of a nation we are and whatdirection we want to move in. For thoseof you who are black … you can be filledwith bitterness, with hatred, and a desirefor revenge. We can move in thatdirection as a country, in greatpolarization— black people amongstblack, white people amongst white, filledwith hatred toward one another…. Or wecan make an effort, as Martin Luther Kingdid, to understand and to comprehend,and to replace that violence, that stain ofbloodshed that has spread across ourland, with an effort to understand withcompassion and love…. What we need inthe United States is not division; what weneed in the United States is not hatred;what we need in the United States is notviolence and lawlessness, but is love andwisdom and compassion toward oneanother, and a feeling of justice towardthose who still suffer within our country,whether they be white or whether they beblack.

In the context of what America wasfounded to stand for mostfundamentally, Kennedy’s speech helped

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angry people distinguish that retaliativeacts to King’s assassination made nosense. His speech inspired them to let goof old concepts (we’ll get even!) andlong-standing content (years of racialdisharmony) that were damaging. Thisdistinction helped people see newpossibilities for action. Kennedy created anew context from which new thinking,new behaviors, and new actions couldarise. His speech disclosed to people that,in spite of the tragic circumstances of thatnight, they could intentionally choose notto live a content-dictated life. They couldcreate a new context which could serve asa foundation for taking a stand for afuture that was not an extrapolation ofthe past. On a night where looting, arson,and rioting were widespread in dozens ofothers cities across the South, there wasnot a single act of vandalism inIndianapolis. The story illustrates thatwho we are and who we become areshaped by the linguistic contexts that wecreate and live inside of.

Many of our problems are revealed inconversations that communicate somesort of perpetual complaint (e.g., “Thingswill never change around here” or “Hewill always be a nonteam player” or “Ifwe had their resources we could be great,too”). For example, if my constantcomplaint is that my boss is amicromanager and an ineffective leader,my thoughts and behaviors in dealingwith him will be influenced by thatparticular way he occurs to me. I couldbecome irritated and judgmental and Imay disengage, but I might benefit bygetting to be “right” by keeping a mentallog of all the times he micromanages. Thedownside of this racket7 is that myeffectiveness at work may diminish andnegatively affect others.

My reality, however, could be different.Whether my boss is or isn’t amicromanager, a shift in context createsthe possibility for different results. Icould, for instance, change my context tosomething like, “He is very detail-oriented and likes to be involved indecision making. His leadership styledoesn’t make sense to me because thesituation occurs to me differently. Whatcan I do to support him so he can focuson our most pressing priorities?” Thisway of observing offers the opportunityfor a very different working relationship.It opens the door for a conversation toexplore roles and responsibilities. It

creates space for coaching. It generatespossibilities that were not availablebefore. If I do not change my context,one thing is sure: My present way ofdealing with my boss becomes my“default” future,7 which limits my waysof dealing with my boss. Each of us hasthe power to create our own context—atwork, at home, in every encounter andrelationship. Context is critical; it ispowerful; it is decisive.

Our interpretations— of people,situations, and conversations—arecolored by our experiences, memories,and beliefs. Where we get into trouble iswhen we treat our interpretations as facts,as objective reality. When that happens,situations and people “are what they are,”and we can’t change them. The best wecan do in this is/fixed reality is contriveand maneuver a bit here and there as wedeal with the all the problems at workthat we assume won’t change.5 Oncewe’ve locked in on the way we believe thefuture will be, we will fully align ourselveswith it in our thinking, speaking, andactions.

Thus, in confronting most any problem,

there’s a future that has already beenwritten about it. This future includespeople’s assumptions, hopes, fears,resignation, cynicism and “lessonslearned” through past experiences.Although this future is almost nevertalked about, it’s the context in whichpeople try to create change. These filtersand assumptions are called blind spotsbecause we can’t see that we have them.7

This creates a dilemma: Since I am in theclutch of my mental models (whichprevents me from observing impartiallywhat is actually there), I must free myselffrom their grasp or at least relax theirhold on me. How do I illuminate myblind spots and shift my contextual self’sindistinct way of observing so that whatoccurs to me is as close as possible towhat actually is? By making the indistinctmore distinct with distinctions.

Distinction is the basis of language andall logic. “Everything is made ofdistinction…. Every idea contains animplicit distinction between that which itindicates and that which it does notindicate.”52 Because contexts are usuallybackground phenomena, distinctionshelp reveal them. A language distinctioncreates a new way of understanding—anew lens, new frame of reference for

“seeing” the world we live in. Distinctionsare critical because they are the portal to“what we don’t know we don’t know.” Inthe act of distinguishing, we revealobstacles (e.g., invalid assumptions,outmoded beliefs) we can remove and, inso doing, make space for more effectiveleadership. For example, when I candistinguish that I don’t need to act“professorial” to prove myself and beliked by others, I am at liberty to give upthat behavior. In the absence of suchdistinctions, we live automatically intoour So-So (same ‘ol, same ‘ol) future, andnothing much changes.5

Language has always been with us, so wetake it for granted. Like the air webreathe, it’s just there. But it is the mostimportant faculty we have for gettingtraction in our lives. Language is theprimary vehicle we have for creatingleverage, for getting a purchase on and a“return” on life. To harness the power oflanguage, leaders must develop analertness to the unspoken butcommunicated, and they must create thesafety for people to say what they’ve beenthinking but have been unwilling to say.With time, people begin to see theconnection between their contextualthinking, their behaviors, and the resultsthey get. They begin to use language notjust as a descriptive, comparative tool butas one that invents. Zaffron and Logan7

write,

Future-based language … has the powerto create new futures, to craft vision andto eliminate the blinders that arepreventing people from seeingpossibilities. It doesn’t describe how asituation occurs; it transforms how itoccurs. It does this by rewriting thefuture.

Note how HHS Secretary KathleenSebelius53 uses language to “rewrite thefuture” of global women’s health in herspeech at the Secretary General’sLuncheon on April 14, 2010:

Women and girls are particularlyvulnerable to ill health and arecomparatively underserved by healthservices…. We know that improving thehealth of women and girls frees upuntapped potential…. When women andgirls have access to health care, includingfamily planning and other reproductivehealth services, we see rapid and lastingprogress. When women are valued,educated, and enjoy legal and propertyrights and protection, and when theirreproductive rights are supported, theyhave smaller families, healthier children,

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and live longer lives…. Women the worldover are primarily responsible formanaging water, nutrition, householdresources, and accessing health servicesfor their families. When women receivethe care they need, their families,communities, and all of society benefit.When women are healthy and can maketheir own decisions about theirreproductive lives, the gains ripplethrough their entire community.

While context refers to the backgroundcircumstances relevant to a particularsituation, content refers to the specificconditions of the situation or problemthat is being addressed within thebackground of the larger context. Leadersin most organizations spend much oftheir time in the domain of content,where the issues are familiar, strategiesappear to be straightforward, andsolutions are seemingly apparent. Thisapproach is generally successful duringtimes of stability and predictability. Butin times of rapid change, whenuncertainty and disequilibrium areroutine, content-based information,while necessary, is insufficient fordecision making. During suchtumultuous times, context is asimportant as content in tackling complexproblems. All strategic planninginvariably depends on some capacity tosituate the issue in question within anappropriate context. As interlocutorsinteract, language enables them to makemeaning.

As a leader, if I can eliminate (orilluminate) my blind spots and biases sothat the way that any situation or person“shows up” for me is as close as possibleto the way it or that person actually is, thepossibility now exists for me, as a leader,to exercise leadership as effectively aspossible, in the most natural way for meand with the greatest degree of integrity,authenticity, and humanness. Leaders usethe power of language to create insightsthat nudge us to revise our frameworksand mental maps for viewing the worldaround us. Writer Kenneth Burke54

emphasizes that language doesn’t simply“reflect reality”; it also helps “selectreality” as well as “deflect reality.”

The story of the two cancer researchersillustrates the power of context. A fewyears ago, I was visiting a comprehensivecancer center and had the opportunity tomeet with several junior faculty. It wasgrant deadline time, so manyinvestigators were busy at work putting

the final touches on their proposals. Ihappened to be about 10 minutes earlyfor one of my appointments, so I strolleddown one of the adjacent halls. I walkedby one open door where a researcherappeared to be busy at work. Not wantingto disturb him but somewhat curious, Istopped and asked, “How are youdoing?” The investigator paused andlooked up, annoyed by my intrusion andsaid, “Can’t you see I’m writing a grant? Idon’t enjoy this work. And I know I’mgoing to get the shaft from the studysection. But my chairman insists that Iget funded.” I promptly apologized formy interruption and made my way backto my scheduled appointment.

A short time later I met with anotherresearcher who similarly was hard atwork. Her desk was covered withreprints, gels, figures, and otherimportant materials. “That looks likehard work,” I said, “and I bet it can bediscouraging knowing that the pay line isso unfavorable.” The relatively youngwoman stood up from her computer andreplied while sipping her coffee,

It is hard work and it requires lots ofdedication. I know it’s going to be manyhours before I finish this grant and Iknow the chances of getting fundedaren’t in my favor. But, it’s a labor oflove because I’m discovering a cure forcancer.

The difference between these two cancerresearchers was not intrinsic orcircumstantial. As the story illustrates,the context we create can powerfullyinfluence the way we live and experienceour lives. Our effectiveness (andfulfillment) in life is not so much afunction of what we’re doing as it is afunction of the context inside of whatwe’re doing. The first scientist saw hiscircumstances—a seemingly hopelesssituation manifested as an outwardlydefeatist attitude—as determining hisexperience. His focus, so it seemed, wason content, and, perhaps he lived acontent-driven life. In contrast, thesecond researcher seemed to have moreof a context-orientation in living her life.Rather than see herself as a victim of hercircumstances—in this case, a lousy payline—she appeared to be more interestedin being the author of her own future.Her stand—for curing cancer—wasinspiring, to say the least.

Language, Change, andPerformance

Leading organizational change can beunderstood as a process that is managedand made sense of through language.“The language of change can be aliberating force or an analytical prison,”observe Pettigrew and colleagues.55

Language both enables and limits whatand how we think and the actions wetake. The word stroke, for example,means one thing in the context oftreating cerebrovascular disease butsomething quite different in the contextof playing tennis. Contextual languageshapes the way we “make sense” of healthcare. Parse56 stresses that words likedelivery system, consumer, provider, andcost-effectiveness reflect a business-modelcontext rather than a patient-centeredone. She writes,

To call health care pathways a deliverysystem is language that conjures an imageof a model with an assembly line ofefficiently moving products toconsumers…. These words with theirimages, sounds, and suggestions are soembedded in the health care languagethat they not only reflect but continue tofoster the idea that humans are objectswho must fit into a standard systemwhere uniqueness is ignored and personalmeaning is not honored.

Attention is the currency of the languageof leadership,32 and change requiresgetting people’s attention. Davenport andBeck57 report,

Overall, the factors most highly associatedwith getting attention in rank order, were:the message was personalized, it evokedan emotional response, it came from atrustworthy source or respected senderand it was concise.

Connecting with the audience in ameaningful way that captures their heartsand minds is a skill that leaders can andmust learn. Observe how PresidentObama personalizes his health carespeech to Congress on September 10,2009:

More and more Americans pay theirpremiums, only to discover that theirinsurance company has droppedtheir coverage when they get sick, orwon’t pay the full cost of care. It happensevery day. One man from Illinois lost hiscoverage in the middle of chemotherapybecause his insurer found that he hadn’treported gallstones that he didn’t evenknow about. They delayed his treatment,and he died because of it. Anotherwoman from Texas was about to get a

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double mastectomy when her insurancecompany canceled her policy because sheforgot to declare a case of acne. By thetime she had her insurance reinstated, herbreast cancer more than doubled in size.That is heart-breaking, it is wrong, and noone should be treated that way in theUnited States of America.58

While the language of leadership must beenergizing and engaging, it must alsoprompt cognitive shifts59 that jar peopleloose from their entrenched worldviews.While language is not the soledeterminant of what can be thought, itclearly influences what habitually doesget thought. Kegan and Lahey60 write,

All leaders are leading languagecommunities. Though every person, inany setting, has some opportunity toinfluence the nature of language, leadershave exponentially greater access andopportunity to shape, alter or ratifyexisting language rules…. The onlyquestion is what kind of language leaderswe will be.

Three language commitments—promises,complaints, and stories—each of whichinvolves a shift in speaking practices, canpositively influence organizationalperformance and morale in a short periodof time. The first—the promise—is asimple but powerful mechanism that cango a long way in getting things done. Sull61

points out that execution hinges on thequality of promises made and on theconsistency with which those commitmentsare honored. In this context, the objectiveof conversations for action is to weave aweb of commitments that ensurescoordinated action. The most effectivepromises are public (to avoid special deals),actively negotiated, voluntary, explicit, andlinked to institutional priorities. Leadersare, above all, their word.

The second, the complaint, is one of themost common negative behaviorsobserved in many organizations. Asenergy-depleting as complaints andcomplainers can be, they do have a silverlining. People do not complain aboutwhat they don’t care about. Inside thecomplaint, there is a value that is notbeing honored, which accounts for thedisplacement of energy and passion. Inother words,

the language of complaint essentially tellsus, and others, what it is we can’t stand.The language of commitment tells us(and possibly others) what it is we standfor. Without having our complaints takenaway and without giving them up,

transforming language enables us to makea shift from experiencing ourselves asprimarily disappointed, complaining,wishing, critical people to experiencingourselves as committed people who holdparticular convictions about what is mostvaluable, most precious and mostdeserving of being promoted ordefended.60

When we make this distinction ourthinking becomes open to change,creating the opportunity to amend ourspeaking from the language of complaintto the language of personalaccountability.

Finally, because organizations arenetworks of conversations, the nature ofthose storied interactions determines thefuture. Herein dwells the third languagecommitment, stories. Ford62 stresses thatorganizations are

constituted in and by conversations….Producing and managing change involvesshifting that network of conversations byintentionally bringing into existence andsustaining “new” conversations whilecompleting (and removing) currentconversations.

A major cause of organizational inertialives in the background stories andconversations that reinforce the mentalmodels, organizational routines andrelationships, and underlying valuesthat determine future behavior.62,63

Said otherwise, problematic behaviorsare embedded, retained, andmaintained in collective stories64 suchthat an organization’s future canbecome an extrapolation of its past.Creating a new future begins withdisclosing the unspoken so people canlet go of their counterproductiveconversations and stories so there’sroom for new, more constructivenarratives to be woven into the culturalfabric. In essence, the “clearing out” ofantiquated and obsolete worldviews, anexercise aided by distinctions, createsthe space for new ways of thinking anddoing. This process, and the self-discipline involved, is the linguisticanalogue and ontological equivalent ofcleaning out your attic.

Language and TransformativeLearning

We each come to the table with a set offixed and unchallenged assumptions thatunconsciously lead us to listen to what wehear in predetermined ways. When

someone starts to say something, muchof the time we already have an opinion ofwhat it will mean. This automatic,reflexive listening acts as a filter thatscreens out what does not fit with ourmental maps. It limits possibilities fornew learning and for organizationaltransformation. Our backgroundlistening says, “You are this way and youwon’t change,” or “We don’t do thingsthat way around here.” Language ismerely a medium for labeling things thatare already there. Today is just anotherversion of yesterday, and much of whatwill happen tomorrow is already given.

Accordingly, effective leaders listen insuch a way that they recreate forthemselves what is being said, such thatthe speaker is left with the experience that“what is” for the listener is a replicationof “what is” for the speaker. Boje andcolleagues65 stress that

we do not just report and describe withlanguage; we also create with it. And whatwe create in language “uses us” in that itprovides a point of view (a context)within which we “know” reality andorient our actions.

At a meeting of the promotions andtenure committee, for example, memberscreate their own unique context thatinfluences the way they engage with oneanother. That context affects the way theymake sense out of dossiers, how theyvote, and what they say and don’t say.How the promotions and tenurecommittee chair’s linguistic cues areinterpreted affects her effectiveness andthe degree to which her language “sticks”or gives texts “staying power.”66

Transformative learning involvesrevising our ingrained, often rigidframes of reference through criticallyself-reflecting on the assumptions onwhich our interpretations, beliefs, andhabits of mind are based.67 Studies byDeborah Tannen,68 professor oflinguistics at Georgetown University,suggest that men and women approachconversations and transformativelearning differently. While men aremore competitive, seeking status andjockeying for position, women valueconsensus, experiencing the world as asupportive network of relationships.Women tend to look for win–wins andencourage broad input. Transparencycoupled with openness to new ideas iskey to building trust, especially at a

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time when unpredictability is the rulerather than the exception. As writer andhumorist Gelett Burgess69 said, “If inthe last few years you haven’t discardeda major opinion or acquired a new one,check your pulse. You may be dead.”

To facilitate transformative learning,leaders must help others become aware ofand critical of their own and others’ tacitassumptions and unarticulatedpresuppositions. Learning is a socialprocess, and effective discourse dependson how well the leader can create asituation in which

those participating have full information;are free from coercion; have equalopportunity to assume the various rolesof discourse … are empathic and open toother perspectives; are willing to listenand to search for common ground or asynthesis of different points of view; andcan make a tentative best judgment toguide action.67

It is not about imposing some particularpoint of view but rather about becomingmore amenable to new ways ofperceiving, interpreting, and acting in theworld.

Language and Our Future

Our intelligence has created for us acurious conundrum. In using ourremarkable language-endowed brain todiscover new biotechnologies, design newdrugs, and develop greater comforts inlife, some of our fellow human beingshave ended up with the short straw.Yesterday’s solutions have created today’sproblems. For all our intellectualhorsepower, we seem to solve fewerproblems and create more complex ones.Jonas Salk once said, “If all the insects onearth disappeared, within 50 years all lifeon earth would disappear. If all humansdisappeared, within 50 years all specieswould flourish as never before.”70

Tolle71 describes the dangers of relyingsolely on intellectualism to solve ourproblems:

I was convinced that all the answers to thedilemmas of human existence could befound through the intellect…. I didn’trealize that thinking without awareness isthe main dilemma of human existence.

Can we use the intelligence that got uswhere we are today more intelligentlygoing forward? Indeed, the clock isticking, and we’re well into the fourth

quarter. A fascinating 2003 book by J.F.Richard72 suggests we have 20 to 30 yearsto “turn things around” on earth. Thatwas seven years ago.

The single biggest leadership challengefor the world today is getting peoplewith contrasting values, competingpriorities, diverse backgrounds, anddifferent worldviews to embracediversity and work together.5 It is adilemma that is only accentuated in aworld that’s flat. Tackling thisseemingly intractable challenge willrequire world-class leadership exercisedby world-class leaders who lead world-class conversations. Inside of thisdialogue, leadership must begin on theinside, where each of us forges thefoundation for living our lives.Language constitutes that foundation,infusing it with integrity and our word.In granting us access to ourselves andto the world, language is the gateway totransformation.

“You can always count on Americans todo the right thing after they’ve exhaustedevery other alternative,” WinstonChurchill once said. That we’veexhausted every other option appears tobe our current situation in health care—at least that’s the way it occurs to manypeople. But can we “talk” our way out ofour current dilemma? Seriously, we must.Bickerton9 argues that each of theproperties that distinguish humanintelligence and consciousness from thatof other animals can be shown to derivedirectly from properties of language. Henotes,

It is this power to transform imaginationinto fact that distinguishes humanbehavior from that of our ancestralspecies, and indeed from that of all otherspecies. It is exactly what enables us tochange our behavior, or invent vastranges of new behavior, practicallyovernight, with no concomitant geneticchanges.

Indeed, this very property of language—its ability to bring forth, out of theunspoken realm, innovative ideas andpossibilities—will determine the kind ofhealth care system we will create and willshape the future of our world. Languageis the most underused resource leadershave at their fingertips.5 We must takeadvantage of that opportunity, and wemust do it as a community. “Nothinghappens without personaltransformation,” wrote quality guru W.

Edwards Deming.73 The only safe spaceto allow for this transformation is alearning community.74

In a 2002 interview,75 developmentalpsychologist and Harvard professorRobert Kegan raises the evocativequestion: What order of consciousnesswill allow human beings to respondtransformationally to the demands of apluralistic postmodern culture?“Transformation,” notes Kegan, “is aprocess by which each living piece, orpart, is, in a certain way, betterrecognizing its true nature. It is what weare called to do, what the universe needsof us.” Sadly, our attachment to the keymeasures of looking good and measuringup in our culture hinders the personaljourney of transformation andcontributes to the sense ofmeaninglessness that many peopleexperience today.5,76,77 Fundamentalquestions such as, “What role do I play intransforming our health care system?”and “What does it mean to live moreconsciously as a human being?” tend tobe ignored. Consciousness, assertsMorwood,78 expresses and experiencesitself through selflessness, by servingothers.

How do we get there in a world that’s notjust flat but also confused and irritable?Can language be the driver ofconstructive change? Kegan asks,

What does it actually mean to live it or toexperience it, as opposed to just talkingabout it? Do we have the language tospeak about [transformation]?…Language has all these constraints builtinto it … [that] may make it impossibleto talk about these notions of union andoneness.75

Going forward, do we let language use usor do we use language? What kinds ofconversations might help us get the shiprighted? British mathematician andphilosopher Alfred North Whitehead79

writes, “The mentality of mankind andthe language of mankind created eachother.” Will we let our mentality beshaped by the language of complaints,excuses, entitlement, and what-have-you-done-for-me-lately? Or, will we choosethe language of commitment, teamwork,caring, and personal responsibility? Thelanguage we choose will be the architectof our future.

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Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

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Teaching and Learning MomentsLet’s Be Clear

In addition to the usual information,such as procedures, logins, EMRoperations, security passcards, andevaluation paperwork, covered on thefirst day of residency, my colleaguesand I at the family medicine teachingclinic also want our residents to learnabout our culture. And so the newchief resident, my codirector, and Igathered together a group of 20 or soorientation-weary R1s on their firstday.

I began, “This time of year is always abit poignant. We’ve just said goodbyeto our outgoing residents who havespent the past two years with us.We’re excited to be starting newrelationships with you. Over the years,we’ve found that about 20% of ourgraduating residents are lovely humanbeings, fantastic physicians, and greatcolleagues. You’ll meet some of theseindividuals because we ask them toreturn as locums and, occasionally, asjunior faculty. The majority of ourgrads, about 75% or so, are alsogreat people, and we enjoy workingwith them. They make very goodfamily physicians, and we keep intouch.”

I paused for a second, noticing thatseveral people were doing the math intheir heads.

“Frankly, because of the frustrationand hostility they cause, we can’t waitfor the remaining five percent to leave.This orientation is to tell you what youneed to know so that you don’t findyourself in that five percent.”

There was a long pause. Many of theresidents stared at us in open shock;several mouths hung open. Then therewas a round of nervous laughter. Forthe next 30 minutes, we shared howwe hoped our residents would behave,as well as a few instances in which ourresidents strayed into “The FivePercent” in the past.

Despite our shocking revelation, “TheFive Percent” of residents is, in reality,a much smaller percentage of thegroup. And although we encounterresidents who need remediation foracademic and personal problems, theyaren’t the ones who incite any degreeof animus. The ones who stick out inour minds are the residents who seemdifficult—they complain, they creatework for others, and they see patientsas the enemy. In my experience, it’svery difficult to address this pattern ofbehavior early enough so the residentmay learn from his or her mistakewithout the incident being tooemotional. Because of the deepfrustration, even anger, these patterns

of behavior can bring about inpreceptors and peers, residentsexhibiting these behaviors are oftensimply avoided. Or we focus insteadexclusively on their cognitiveevaluations because addressing howtheir attitudes and coping strategiesaffect others makes us uncomfortable.Finally, since we so often assume thatothers know what we expect of them(isn’t it obvious?), our frustration isdoubled when we see learners behavein ways that seem so deliberatelyannoying or concerning.

This year’s R1s have begun theirrotation with a heightened awarenessthat their behavior really does impactother people and that first impressionson the team are important. Severalhave met with us, saying “I don’t wantto be in that five percent.” Best of all,if we do see something troubling, wehave an easy way to introduce ourconcerns and start an early andcorrective conversation. But I suspectwe won’t need to because they stillremember what we said at orientationand won’t easily forget their shock atour honesty.

Cathy Risdon, MD, DMan

Dr. Risdon is associate professor and David Braleyand Nancy Gordon Chair in Family Medicine,McMaster University, Hamilton, Ontario, Canada.

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