Clearly, leadership is a complex concept. Surgeons should strive to adopt leadership qualities that provide the best outcomes for their patients, based on the following fundamental principles.
The first and most fundamental principle of leadership is to establish a vision that people can live up to, thus providing direction and purpose to the constituency. Creating a vision is a declaration of the near future that inspires and conjures motivation.8 A classic example of a powerful vision that held effective impact is President Kennedy’s declaration in 1961 that “… this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to the earth.” Following his declaration of this vision with a timeline to achieve it, the United Sates mounted a remarkable unified effort, and by the end of the decade, Neil Armstrong took his famous walk and the vision had been accomplished (Fig. 1-1).
Apollo 11 Lunar Module moon walk. Astronaut Edwin “Buzz” Aldrin walks by the footpad of the Apollo 11 Lunar Module, July 1969. (Reproduced with permission from AP Photo/NASA. © 2014 The Associated Press.)
On a daily basis, surgeons are driven by a powerful vision: the vision that our surgical care will improve patients’ lives. The great surgical pioneers, such as Hunter, Lister (Fig. 1-2), Halsted, von Langenbeck, Billroth, Kocher (Fig. 1-3), Carrel, Gibbon, Blalock, Wangensteen, Moore, Rhoads, Huggins, Murray, Kountz, Longmire, Starzl, and DeBakey (Fig. 1-4), each possessed visions that revolutionized the field of surgery. In the nineteenth century, Joseph Lister changed the practice of surgery with his application of Pasteur’s germ theory. He set a young boy’s open compound leg fracture, a condition with a 90% mortality rate at that time, using carbolic acid dressings and aseptic surgical technique. The boy recovered, and Lister gathered nine more patients. His famous publication on the use of aseptic technique introduced the modern era of sterile technique. Emil Theodor Kocher was the first to master the thyroidectomy, thought to be an impossible operation at the time, and went on to perform thousands of thyroidectomies with a mortality of less than 1%. He was awarded the Nobel Prize in Physiology or Medicine in 1909 for describing the thyroid’s physiologic role in metabolism. Michael E. DeBakey’s powerful vision led to the development of numerous groundbreaking procedures that helped pioneer the field of cardiovascular surgery. For example, envisioning an artificial artery for arterial bypass operations, Dr. DeBakey invented the Dacron graft, which has helped millions of patients suffering from vascular disease and enabled the development of endovascular surgery. Dr. Frederick Banting, the youngest recipient of the Nobel Prize in Physiology or Medicine, had a vision to discover the biochemical link between diabetes and glucose homeostasis. His vision and perseverance led to the discovery of insulin.9 In retrospect, the power and clarity of their visions were remarkable, and their willingness and dedication were inspiring. By studying their careers and accomplishments, surgical trainees can appreciate the potential impact of a well-developed vision.
Joseph Lister directing use of carbolic acid spray in one of his earliest antiseptic surgical operations, circa 1865. (Copyright Bettmann/Corbis/AP Images.)
Emil Theodor Kocher. (Courtesy of the National Library of Medicine.)
Michael E. DeBakey. (Reproduced with permission from AP Photo/David J. Phillip. © 2014 The Associated Press.)
Leaders must learn to develop visions to provide direction for their team. The vision can be as straightforward as providing quality of care or as lofty as defining a new field of surgery. One can start developing their vision by brainstorming the answers to two simple questions: “Which disease needs to be cured?” and “How can it be cured?”10 The answers represent a vision and should be recorded succinctly in a laboratory notebook or journal. Committing pen to paper enables the surgical trainee to define their vision in a manner that can be shared with others.
The Willingness Principle represents the active commitment of the leader toward their vision. A surgical leader must be willing to lead, commit to lifelong learning, communicate effectively, and resolve conflict.
A key characteristic of all great leaders is the willingness to serve as the leader. Dr. Martin Luther King, Jr., who championed the civil rights movement with a powerful vision of equality for all based on a commitment to nonviolent methods,11 did so at a time when his vocalization of this vision ensured harassment, imprisonment, and threats of violence against himself, his colleagues, and his family and friends (Fig. 1-5). King, a young, highly educated pastor, had the security of employment and family, yet was willing to accept enormous responsibility and personal risk and did so in order to lead a nation toward his vision of civil rights, for which he was awarded the Nobel Peace Prize in 1964. Steve Jobs, co-founder of Apple Inc., chose to remain in his position as chief executive officer (CEO) to pursue his vision of perfecting the personal computer at great personal expense. He described this experience as “… rough, really rough, the worst time in my life …. I would go to work at 7 a.m. and I’d get back at 9 at night, and the kids would be in bed. And I couldn’t speak, I literally couldn’t, I was so exhausted … . It got close to killing me.”12 Both individuals demonstrated a remarkable tenacity and devotion to their vision.
Dr. Martin Luther King, Jr. acknowledges the crowd at the Lincoln Memorial for his “I Have a Dream” speech during the March on Washington, D.C., August 28, 1963. (Reproduced with permission from AP Photo. © 2014 The Associated Press.)
Willingness to lead is a necessity in any individual who desires to become a surgeon. By entering into the surgical theater, a surgeon accepts the responsibility to care for and operate on patients despite the risks and burdens involved. They do so, believing fully in the improved quality of life that can be achieved. Surgeons must embrace the responsibility of leading surgical teams that care for their patients, as well as leading surgical trainees to become future surgeons. A tremendous sacrifice is required for the opportunity to learn patient care. Surgical trainees accept the hardships of residency with its accompanying steep learning curve, anxiety, long work hours, and time spent away from family and friends. The active, passionate commitment to excellent patient care reflects a natural willingness to lead based on altruism and a sense of duty toward those receiving care. Thus, to ensure delivery of the utmost level of care, surgical trainees should commit to developing and refining leadership skills. These skills include a commitment to lifelong learning, effective communication, and conflict resolution.
Surgeons and surgical trainees, as leaders, must possess willingness to commit to continuous learning. Modern surgery is an ever-changing field with dynamic and evolving healthcare systems and constant scientific discovery and innovation. Basic and translational science relating to surgical care is growing at an exponential rate. The sequencing of the human genome and the enormous advances in molecular biology and signaling pathways are leading to the transformation of personalized medicine and surgery in the twenty-first century (see Chap. 15).13 Performing prophylactic mastectomies with immediate reconstruction for BRCA1 mutations and thyroidectomies with thyroid hormone replacement for RET proto-oncogene mutations are two of many examples of genomic information guiding surgical care. Technologic advances in minimally invasive surgery and robotic surgery as well as electronic records and other information technologies are revolutionizing the craft of surgery. The expansion of minimally invasive and endovascular surgery over the past three decades required surgeons to retrain in new techniques using new skills and equipment. In this short time span, laparoscopy and endovascular operations are now recognized as the standard of care for many surgical diseases, resulting in shorter hospital stay, quicker recovery, and a kinder and gentler manner of practicing surgery. Remarkably, during the last century, the field of surgery has progressed at an exponential pace and will continue to do so with the advent of using genomic analyses to guide personalized surgery, which will transform the field of surgery this century. Therefore, surgical leadership training should emphasize and facilitate the continual pursuit of knowledge.
Fortunately, surgical organizations and societies provide surgeons and surgical trainees a means to acquire new knowledge on a continuous basis. There are numerous local, regional, national, and international meetings of surgical organizations that provide ongoing continuing medical education credits, also required for the renewal of most medical licenses. The American Board of Surgery requires all surgeons to complete meaningful continuing medical education to maintain certification.14 These societies and regulatory bodies enable surgeons and surgical trainees to commit to continual learning, and ensure their competence in a dynamic and rapidly growing field.
Surgeons and trainees now benefit from the rapid expansion of web-based education as well as mobile handheld technology. These are powerful tools to minimize nonproductive time in the hospital and make learning and reinforcement of medical knowledge accessible. Currently web-based resources provide quick access to a vast collection of surgical texts, literature, and surgical videos. Surgeons and trainees dedicated to continual learning should be well versed in the utilization of these information technologies to maximize their education. The next evolution of electronic surgical educational materials will likely include simulation training similar to laparoscopic and Da Vinci device training modules. The ACGME, acknowledging the importance of lifelong learning skills and modernization of information delivery and access methods, has included them as program requirements for residency accreditation.
To Communicate Effectively
The complexity of modern healthcare delivery systems requires a higher level and collaborative style of communication. Effective communication directly impacts patient care. In 2000, the U.S. Institute of Medicine published a work titled, To Err Is Human: Building a Safer Health System, which raised awareness concerning the magnitude of medical errors. This work showcased medical errors as the eighth leading cause of death in the United States with an estimated 100,000 deaths annually.15 Subsequent studies examining medical errors have identified communication errors as one of the most common causes of medical error.16,17 In fact, the Joint Commission identifies miscommunication as the leading cause of sentinel events. Information transfer and communication errors cause delays in patient care, waste surgeon and staff time, and cause serious adverse patient events.18 Effective communication between surgeons, nurses, ancillary staff, and patients is not only a crucial element to improved patient outcomes, but it also leads to less medical litigation.19,20,21 A strong correlation exists between communication and patient outcomes.
Establishing a collaborative atmosphere is important since communication errors leading to medical mishaps are not simply failures to transmit information. Communication errors “are far more complex and relate to hierarchical differences, concerns with upward influence, conflicting roles and role ambiguity, and interpersonal power and conflict.”17,22 Errors frequently originate from perceived limited channels of communication and hostile, critical environments. To overcome these barriers, surgeons and surgical trainees should learn to communicate in an open, universally understood manner and remain receptive to any team member’s concerns. A survey of physicians, nurses, and ancillary staff identified effective communication as a key element of a successful leader.23 As leaders, surgeons and surgical trainees who facilitate an open, effective, collaborative style of communication reduce errors and enhance patient care. A prime example is that successful communication of daily goals of patient care from the team leader improves patient outcomes. In one recent study, the modest act of explicitly stating daily goals in a standardized fashion significantly reduced patient length of intensive care unit stay and increased resident and nurse understanding of goals of care.24 Implementing standardized daily team briefings in the wards and preoperative units led to improvements in staff turnover rates, employee satisfaction, and prevention of wrong site surgery.22 In cardiac surgery, improving communication in the operating room and transition to the postanesthesia care unit was an area identified to decrease risk for adverse outcomes.25 Behaviors associated with ineffective communication, including absence from the operating room when needed, playing loud music, making inappropriate comments, and talking to others in a raised voice or a condescending tone, were identified as patient hazards; conversely, behaviors associated with effective collaborative communication, such as time outs, repeat backs, callouts, and confirmations, resulted in improved patient outcomes.
One model to ensure open communication is through standardization of established protocols. A commonly accepted protocol is the “Time Out” that is now required in the modern operating room. During the Time Out protocol, all team members introduce themselves and state a body of critical information needed to safely complete the intended operation. This same standardization can be taught outside the operating room. Within the Kaiser system, certain phrases have been given a universal meaning: “I need you now” by members of the team is an understood level of urgency and generates a prompt physician response 100% of the time.22 As mentioned earlier, standardized forms can be useful tools in ensuring universally understood communication during sign-out. The beneficial effect of standardized communication further demonstrates how effective communication can improve patient care and is considered a vital leadership skill.
Great leaders are able to achieve their vision through their ability to resolve conflict. During the pursuit of any vision, numerous conflicts arise on a daily basis; numerous conflicts arise on a daily basis when surgeons and surgical trainees provide high-quality care. Therefore, the techniques for conflict resolution are essential for surgical leaders.
To properly use conflict resolution techniques, it is important for the surgeon and surgical trainee to always remain objective and seek personal flexibility and self-awareness. The gulf between self-perception and the perception of others can be profound; in a study of cooperation and collaboration among operating room staff, the quality of their own collaboration was rated at 80% by surgeons, yet was rated at only 48% by operating room nurses.26 Systematic inclusion of modern conflict resolution methods that incorporate the views of all members of a multidisciplinary team help maintain objectivity. Reflection is often overlooked in surgical residency training but is a critical component of learning conflict resolution skills. Introspection allows the surgeon to understand the impact of his or her actions and biases. Objectivity is the basis of effective conflict resolution, which can improve satisfaction among team members and help deliver optimal patient care.
Modern conflict resolution techniques are based on objectivity, willingness to listen, and pursuit of principle-based solutions.27 For example, an effective style of conflict resolution is the utilization of the “abundance mentality” model, which attempts to achieve a solution that benefits all involved and is based on core values of the organization, as opposed to the utilization of the traditional fault-finding model, which identifies sides as right or wrong.28 Application of the abundance mentality in surgery elevates the conflict above the affected parties and focuses on the higher unifying goal of improved patient care. Morbidity and mortality (M&M) conferences are managed in this style and have the purpose of practice improvement and improving overall quality of care within the system, as opposed to placing guilt or blame on the surgeon or surgical trainees for the complication being reviewed. The traditional style of command-and-control technique based on fear and intimidation is no longer welcome in any healthcare system and can lead to sanctions, lawsuits, and removal of hospital privileges or position of leadership.
Another intuitive method that can help surgical trainees learn to resolve conflict is the “history and physical” model of conflict resolution. This model is based on the seven steps of caring for a surgical patient that are well known to the surgical trainee.29 (1) The “history” is the equivalent of gathering subjective information from involved parties with appropriate empathy and listening. (2) The “laboratory/studies” are the equivalent of collecting objective data to validate the subjective information. (3) A “differential diagnosis” is formed of possible root causes of the conflict. (4) The “assessment/plan” is developed in the best interest of all involved parties. The plan, including risks and benefits, is openly discussed in a compassionate style of communication. (5) “Preoperative preparation” includes the acquisition of appropriate consultations for clearances, consideration of equipment and supplies needed for implementation, and the “informed consent” from the involved parties. (6) The “operation” is the actual implementation of the agreed-upon plan, including a time-out. (7) “Postoperative care” involves communicating the operative outcome, regular postoperative follow-up, and the correction of any complications that arise. This seven-step method is an example of an objective, respectful method of conflict resolution. Practicing different styles of conflict resolution and effective communication in front of the entire group of surgical trainees attending the leadership training program is an effective means of teaching conflict resolution techniques.
It is important for leaders to practice effective time management. Time is the most precious resource, as it cannot be bought, saved, or stored. Thus, management of time is essential for a productive and balanced life for those in the organization. The effective use of one’s time is best done through a formal time management program to improve one’s ability to lead by setting priorities and making choices to achieve goals. The efficient use of one’s time helps to improve both productivity and quality of life.
It is important for surgeons and surgical trainees to learn and use a formal time management program. There are ever-increasing demands placed on surgeons and surgical trainees to deliver the highest quality care in highly regulated environments. Furthermore, strict regulations on limitation of work hours demand surgical trainees learn patient care in a limited amount of time.30 All told, these demands are enormously stressful and can lead to burnout, drug and alcohol abuse, and poor performance.30 A time-motion study of general surgery trainees analyzed residents’ self-reported time logs to determine resident time expenditure on educational/service-related activities (Fig. 1-6).31 Surprisingly, senior residents were noted to spend 13.5% of their time on low-service, low-educational value activities. This time, properly managed, could be used to either reduce work hours or improve educational efficiency in the context of new work hour restrictions. It is therefore critical that time be used wisely on effectively achieving one’s goals.
Surgery resident time-motion study. H & P = history and physical examination.
Parkinson’s law, proposed in 1955 by the U.K. political analyst and historian Cyril Northcote Parkinson, states that work expands to fill the time available for its completion, thus leading individuals to spend the majority of their time on insignificant tasks.32 Pareto’s 80/20 principle states that 80% of goals are achieved by 20% of effort and that achieving the final 20% requires 80% of their effort. Therefore, proper planning of undertaking any goal needs to include an analysis of how much effort will be needed to complete the task.32 Formal time management programs help surgeons and surgical trainees better understand how their time is spent, enabling them to increase productivity and achieve a better balanced lifestyle.
Various time allocation techniques have been described.32 A frequently used basic technique is the “prioritized list,” also known as the ABC technique. Individuals list and assign relative values to their tasks. The use of the lists and categories serves solely as a reminder, thus falling short of aiding the user in allocating time wisely. Another technique is the “time management matrix technique.”28 This technique plots activities on two axes: importance and urgency, yielding four quadrants (Fig. 1-7). Congruous with the Pareto’s 80/20 principle and Parkinson’s law, the time management matrix technique channels efforts into quadrant II (important but nonurgent) activities. The activities in this quadrant are high yield and include planning, creative activity, building relationships, and maintaining productivity. Too often, surgeons spend a majority of their time attending to quadrant I (important and urgent) tasks. Quadrant I tasks include emergencies and unplanned or disorganized situations that require intensive and often inefficient effort. While most surgeons and surgical trainees have to deal with emergencies, they often develop the habit of inappropriately assigning activities into quadrant I; excess time spent on quadrant I tasks leads to stress or burnout for the surgeon and distracts from long-term goals. Efficient time management allows surgeons and surgical trainees to be proactive about shifting energy from quadrant I tasks to quadrant II, emphasizing preplanning and creativity over always attending to the most salient issue at hand, depending on the importance and not the urgency.
Time management. (From Covey S. The Seven Habits of Highly Effective People. New York: Simon & Schuster; 1989.)
Finally, “the six areas of interest” is an alternative effective time management model that can help surgeons and surgical trainees achieve their goals, live a better balanced lifestyle, and improve the quality of their lives.32 The process begins by performing a time-motion study in which the activities of 6-hour increments of time over a routine week are chronicled. At the end of the week, the list of activities is analyzed to determine how the 168 hours in 1 week have been spent. The surgical trainee then selects six broad categories of areas of interest (i.e., family, clinical care, education, health, community service, hobbies, etc.), and sets a single activity goal in each category every day and monitors whether those goals are achieved. This technique is straightforward and improves one’s quality of life by setting and achieving a balanced set of goals of personal interest, while eliminating time-wasting activities.
A formal time management program is essential for modern leadership. The practice and use of time management strategies can help surgeons and surgical trainees achieve and maintain their goals of excellent clinical care for their patients, while maintaining a more balanced lifestyle.