What Nobody Tells You About Leading Change in Academic Medicine

Change in academic medicine moves differently than it does in other sectors.

It is not slow because people don’t care. It is slow because the systems are old, the stakes are high, and the people inside them have learned often through painful experience that most initiatives arrive with urgency and leave without follow-through.

I’ve led change in institutions that were ready for it. And in institutions that weren't. The difference is not always what you’d expect.

The Memory of Systems

Institutions hold memory.

Not in any formal way, not in documents or policies or strategic plans. In the quiet, persistent knowledge that lives in the people who stayed when others left. In the eye-roll that happens when someone proposes something that was proposed before. In the way a coordinator answers a question about process not with what the policy says, but with what actually happens.

When I have walked into under-resourced GME offices, the first thing I’ve learned to read is that memory. What was tried before and didn’t land. Who was burned by the last change initiative. Which departments will say yes in the meeting and no in the follow-through.

That intelligence is not available in any orientation. You build it by listening before you lead. By asking questions you don’t already know the answers to. By understanding that the resistance you’re encountering is often not about you or your idea. It’s about everything that came before you.

The Loneliness of the Institutional Perspective

Here is something I didn’t expect when I moved into institutional-level GME work: how isolating it can be to hold the view from above.

Program directors have their residents. Coordinators have their programs. Department chairs have their faculty. Everyone has a clear constituency, a clear mission, a clear measure of success.

The institutional GME leader has all of them and none of them, not fully. Your jobs is to see across programs, which means no single program sees you as entirely theirs. Your job is to hold institutional priorities, which sometimes means delivering a message that program doesn’t want to hear. Your job is to build systems that benefit everyone, which means no one department gets everything it wants.

You are, by definition, in the middle. And the middle is not always a comfortable place.

What I’ve learned is that the loneliness of the institutional perspective is not a problem to be solved. It is a feature of the role. The goal is not to be everyone’s ally. It is to be trustworthy to everyone which is different, and harder, and more durable.

Change Without Authority

The most challenging version of this work and the one I know most personally is leading institutional change without full institutional authority.

When you are the only person in a GME office, or the only one in the room with experience across multiple institutions. When the DIO is present but clinical responsibilities consistently pull more attention that GME ones, leaving the operational work to someone without the positional authority to move it forward. When one program has been setting the institutional tone for years and sees little reason to change. When the person closest to the work has never worked anywhere else and so genuinely believes that what exists is what is possible, not recognizing that other institutions have moved further, faster, with better tools and more current approaches.

That last pattern is quieter than the others but just as real. It shows up in resistance to new platforms, new workflows, new systems- not from malice but from the limits of a single frame of reference. When the way things have always been done is the only way anyone is the room has ever seen the done, change doesn’t just require a good argument. It requires trust, patience, and the willingness to show rather than tell.

In those situations, the instinct to push harder. To make the case more forcefully. To escalate.

Sometimes that’s right. But more often, what actually moves things is something quieter. Building one relationship at a time. Solving one small problem visibly enough that people begin to trust your judgement. Making the work better in ways that don’t require anyone’s permission, then making those improvements visible to the people who do have authority.

Change without authority is not passive. It is strategic patience. It is understanding that trust is the only currency that actually works in institutions and that trust is built slowly, in small denominations, long before it becomes the thing that makes the bigger change possible.

What This Work Has Taught Me About Leadership

The leaders I’ve respected most in the field are not the ones who arrived with the best plans. They are the ones who stayed curious long enough to understand the institution they were actually in and not the one they imagined.

They were honest about what they didn’t know. They build coalitions before they needed them. They named the resistance without making enemies of the resisters. They understood that changing a system requires cooperation of the people inside it and that cooperation is not given, it is earned.

That kind of leadership is not flashy. It doesn’t make for compelling conference presentations. But it is what actually works.

And in graduate medical education where the stakes are the training of the next generation of physicians, working is not optional.

Closing Reflection

Nobody tell you how hard institutional change work is before you do it.

They tell you about the strategy. The frameworks. The stakeholder mapping. The communication plans.

They don’t tell you about the Tuesday morning when you’ve followed up for the fourth time and still don’t have the answer you need. When the system you’re trying to fix resists you in every direction at once. When you wonder whether the vision you’re holding is worth the friction it’s creating.

Those are moments that define whether a leader is actually leading or just administering.

I’ve had those moments. I expect to have more of them.

But I also seen what happens when the work takes hold. When a system starts functioning the way it was designed to. When a resident arrives on July 1 and everything is in place. When the institution becomes, in some small and measurable way, better than it was.

That’s what keeps me in this work.

And that’s enough.