From the outside, leadership can look like freedom—calling the shots, setting the direction, being “in charge.” On the inside, it feels a lot more like carrying weight that no one else sees. Take a look at my blog from the April 19, 2022, edition of Sifted, “Transitioning to Leadership.”
If you’ve been leading a small O&P practice—or you’re stepping into more responsibility—you already know this: Leadership isn’t free. It costs you time, energy, peace of mind, and sometimes even relationships. Most of us didn’t chase leadership for its own sake; we said yes because we believed we could make a difference for patients, staff, and our community. Over time, though, we discover that leadership is as much about what we’re willing to carry as what we’re trying to accomplish.
I once heard Georgia football coach Kirby Smart talk about the cost of leadership, and his three points show up over and over again in small O&P practices: You will have to make hard decisions that negatively affect people you care about, you will be disliked despite doing what’s best for the most, and you will be misunderstood and won’t always get the chance to defend yourself.
- You’ll make painful calls that affect people you care about.
Small practices often feel like families. We’ve watched techs and practitioners grow in their careers, meet spouses, and raise kids. So when you have to make a decision—a performance correction, a schedule change, changing someone’s role, or even letting someone go—it’s personal.
But this is one of the unavoidable costs of leading. Sometimes protecting the mission of the business means discomfort for an individual. The practice exists to serve patients safely and sustainably, to stay compliant with payers, and to provide stable jobs—and that requires hard choices, even when they sting.
How to handle it well:
- Take a step back and separate emotion from purpose. You can care deeply and still act decisively.
- Be honest and kind, but avoid sugarcoating. Most people handle clarity better than uncertainty.
- Remind yourself that protecting the health of the business protects every patient and employee who depends on it.
Leadership isn’t about avoiding pain—it’s about choosing the pain that moves everyone forward.
- You won’t always be liked, even when you’re doing what’s best overall.
New leaders often assume, “If I’m fair and transparent, people will respect my decisions.” Many will—but not all. Some will interpret your decisions only through the lens of how they’re affected personally.
Maybe you tighten documentation standards to reduce denials, enforce scheduling discipline to keep patients flowing, or promote one clinician and not another. Even when you communicate well, you can’t lead and keep everyone happy at the same time.
When you’re the villain of the week:
- Stay rooted in your values, your mission, and your clinical and compliance standards. Don’t chase approval with reactive decisions.
- Listen carefully to concerns, but resist overexplaining. Clarity doesn’t always equal agreement.
- Keep a small circle of trusted peers or mentors outside your practice who can give you perspective and remind you you’re not crazy.
A seasoned leader once told me, “If everyone likes me, I’m probably not leading.” Popularity fades; earned respect lasts.
- You’ll be misunderstood and you won’t always get to explain yourself.
Sometimes you simply can’t set the record straight. Maybe you’re working through a personnel issue you legally can’t discuss or navigating an audit or payer dispute that you’re not free to unpack for the whole team. It’s lonely, and it often feels unfair—but it comes with the chair.
In a small O&P practice, word travels quickly. One misunderstood decision can ripple through the team by lunch. The temptation is to justify and over-justify. But part of leadership is holding your tongue and letting your consistency and integrity do the talking over time.
When you feel misunderstood:
- Ground yourself in the bigger mission and your obligations to patients, payers, and regulators—you answer to more than hallway opinions.
- Keep doing consistent, transparent work everywhere you can be open; trust often rebuilds faster than your fears predict.
- Circle back later when it’s appropriate and safe to share more context; silence forever isn’t the goal, timing is.
You can’t control the story people tell about you, but you can control how you live it. Over time, your track record becomes your defense.
Counting—and Accepting—the Cost
The costs of leadership can sound heavy because they are. But they’re also what make leadership meaningful. You can only lead well if you’ve accepted that being “the one who decides” also means being “the one who carries the weight.”
To make that cost sustainable:
- Set realistic expectations. You’re not trying to be everyone’s friend; you’re trying to build a healthy, ethical, patient-centered, compliant business.
- Invest in your inner circle. Don’t carry it alone—connect with peers in other practices, your office manager, owners’ groups, or a mentor who understands healthcare.
- Use your compass. Before consequential decisions, check your mission, vision, and values (MVV) as a litmus test. If your decision aligns there, you’ll sleep better, even when others don’t like it.
- Practice self-compassion. You will get some calls wrong. Leadership is iterative; it’s about course correction, humility, and persistence more than perfection.
Over time, the costs don’t disappear, but they start to feel less like burdens and more like tuition for becoming a leader worth following. The O&P owners who build stable, respected practices over decades don’t brag about being popular—they talk about trust earned, standards upheld, and the people who grew under their watch, even those who eventually left.
That’s the paradox of leadership: The cost is real, but so is the return. You trade some comfort for influence, some certainty for integrity, and being liked for being respected. In a small O&P practice—where the stakes are patients’ mobility, safety, and dignity—that’s a trade worth making every time.
A Question for You and Your Team
The next time you’re facing a hard call, ask yourself and your emerging leaders, “What cost am I willing to pay here—comfort, popularity, or clarity—to do what’s truly best for our patients and our practice?”
Scott Williamson, MBA, CAE (ret), is the president of Quality Outcomes and the executive director of education and events for OPIE Software. He can be contacted at scott.williamson@opiesoftware.com.
