Specific Competence of Surgical Leadership
Surgeons are uniquely prepared to assume leadership roles because of their position in the operating room (OR). Whether they aspire to the title or not, each and every surgeon is a leader, at least within their surgical team. Their clinical responsibilities offer a rich variety of interpretations that prepare them for a broader role in health care leadership. They deal directly with patients and their families, both in and out of the hospital setting, seeing a perspective that traditional health care administrative leaders rarely experience. They work alongside other direct providers of health care, in varied settings, at night, on weekends, as well as during the typical workday. They understand supply-chain management as something more than lines on a spreadsheet.
The Challenges for a Surgical Leader
Surgeons prefer to lead, not to be led. Surgical training has traditionally emphasized independence, self-reliance, and a well-defined hierarchy as is required in the OR. However, this approach does not work well outside the OR doors. With colleagues, nurses, staff, and patients, they must develop a collaborative approach. Surgeons are entrusted with the responsibility of being the ultimate decision maker in the OR. While great qualities in a surgeon in the OR, it hinders their interactions with others. They have near-absolute authority in the OR, but struggle when switching to a persuasive style while in committees and participating in administrative activities. Most surgeons do not realize they are intimidating to their patients and staff. With patients, a surgeon needs to be empathetic and a good listener. A surgeon needs to slow the pace of the discussion so that the patient can understand and accept the information they are receiving. As perfectionists, surgeons demand a high level of performance of themselves. This sets them up for exhaustion and burnout, becoming actively disengaged, going through the motions, but empty on the inside. Given the many challenges surgeons face, it is difficult for them to understand the leadership role, given its complex demands.
Although teams and all team members provide health care should be allowed input, the team leader makes decisions. The leader must accept the responsibility of making decisions in the presence of all situations. They will have to deal with conflicting opinions and advice from their team, yet they must accept that they will be held accountable for the performance of their team. The surgeon–leader cannot take credit for successes while blaming failures on the team. Good teamwork and excellent communication do not relieve the leader of this responsibility.
A surgeon often has a position of authority based on their titles or status in an organization that allows them to direct the actions of others. Leadership by this sort of mandate is termed “transactional leadership” and can be successful in accomplishing specific tasks. For example, a surgeon with transactional leadership skills can successfully lead a surgical team through an operation by requesting information and issuing directives. However, a leader will never win the hearts of the team in that manner. The team will not be committed and follow through unless they are empowered and feel they are truly heard. A transformational leader is one who inspires each team member to excel and to take action that supports the entire group. If the leader is successful in creating a genuine atmosphere of cooperation, less time will be spent giving orders and dealing with undercurrents of negativity. This atmosphere can be encouraged by taking the time to listen and understand the history behind its discussion. Blame should be avoided. This will allow the leader to understand the way an individual thinks and the group processes information to facilitate the introduction of change. While leadership style does not guarantee results, the leader’s style sets the stage for a great performance. At the same time, they should be genuine and transparent. This invites the team members to participate, creating an emotional connection. Leaders try to foster an environment where options are sought that meet everyone’s desires.
Conflict is pervasive, even in healthy, well-run organizations and is not inherently bad. Whether conflict binds an organization together or divides it into factions depends on whether it is constructive or destructive. A good leader needs to know that there are four essential truths about conflict. It is inevitable, it involves costs and risks, the strategies we develop to deal with the conflict can be more damaging than the conflict itself, and conflict can be permanent if not addressed. The leader must recognize the type of conflict that exists and deal with the conflict appropriately. Constructive discussion and debate can result in better decision making by forcing the leader to consider other ideas and perspectives. This dialog is especially helpful when the leader respects the knowledge and opinions of team members with education, experience, and perspective different from the leader’s. Honesty, respect, transparency, communication, and flexibility are all elements that a leader can use to foster cohesion while promoting individual opinion. The leader can create an environment that allows creative thinking, mutual problem solving, and negotiation. These are the hallmarks of a productive conflict. Conflict is viewed as an opportunity, instead of something to be avoided.
Communication is the primary tool of a successful leader. On important topics, it is incumbent on the leader to be articulate, clear, and compelling. Their influence, power, and credibility come from their ability to communicate. Research has identified the primary skills of an effective communicator. They are set out in the LARSQ model: Listening, Awareness of Emotions, Reframing, Summarizing, and Questions. These are not set in a particular order, but rather should move among each other freely. In a significant or critical conversation, it is important for a leader to listen on multiple levels. The message, body language, and tone of voice all convey meaning. You cannot interrupt or over-talk the other side. They need an opportunity to get their entire message out. Two techniques that enhance listening include pausing and the echo statement. Pausing before speaking allows the other conversant time to process what they have said to make sure the statement is complete and accurate. Echo statements reflect that you have heard what has been said and focuses on a particular aspect needing clarification. Good listening skills assure that the leader can get feedback that is necessary for success.
Vision, Strategy, Tactics, and Goals
One of the major tasks of a leader is to provide a compelling vision, an overarching idea. Vision gives people a sense of belonging. It provides them with a professional identity, attracts commitment, and produces an emotional investment. A leader implements vision by developing strategy that focuses on specific outcomes that move the organization in the direction of the vision. Strategy begins with sorting through the available choices and prioritizing resources. Through clarification, it is possible to set direction. Deficits will become apparent and a leader will want to find new solutions to compensate for those shortfalls. For example, the vision of a hospital is to become a world class health care delivery system. Strategies might include expanding facilities, improving patient satisfaction, giving the highest quality of care, shortening length of hospital stay with minimal readmissions, decreased mortality, and a reduction in the overall costs of health care. Tactics are specific behaviors that support the strategy with the aim to achieve success. Tactics for improving patient satisfaction may include reduced waiting time, spending more time with patients, taking time to communicate in a manner that the patient understands, responding faster to patient calls, etc. These tactics will then allow a leader to develop quantitative goals. Patient satisfaction can be measured. The surgical leader can then construct goals around each tactic, such as increasing satisfaction in specific areas. This information allows a surgical leader to identify barriers and they can take steps to remedy problem areas. This analysis helps a leader find the weakest links in their strategies as they continue toward achieving the vision.
The world of health care is in continuous change. The intense rate of political, technical, and administrative change may outpace an individual’s and institution’s ability to adapt. Twenty-first century health care leaders face contradictory demands. They must navigate between competing forces. Leaders must traverse a track record of success with the ability to admit error. They also must maintain visionary ideas with pragmatic results. Individual accountability should be encouraged, while at the same time facilitating teamwork. Most leaders do not understand the change process. There are practical and psychological aspects to change. From an institutional perspective, we know that when 5% of the group begins to change, it affects the entire group. When 20% of a group embraces change, the change is unstoppable.
Succession Planning and Continuous Learning
An often-overlooked area of leadership is planning for human capital movement. As health care professionals retire, take leaves of absences, and move locations, turmoil can erupt in the vacuum. Leaders should regularly be engaging in activities to foster a seamless passing of institutional knowledge to the next generation. They also should seek to maintain continuity to the organization. Ways to accomplish this include senior leaders actively exposing younger colleagues to critical decisions, problem solving, increased authority, and change management. Leaders should identify promising future leaders, give early feedback for areas of improvement, and direct them toward available upward career tracks. Mentoring and coaching help prepare the younger colleagues for the challenges the institution is facing. Teaching success at all levels of leadership helps create sustainable high performance.
The Surgical Personality
Surgical stereotypes are remnants of the days of pre-anaesthesia surgery and include impulsivity, narcissism, authoritativeness, decisiveness, and thinking hierarchically. Medical students hold these stereotypes of surgeons early in their medical training. As Pearl Katz says in the The Scalpel’s Edge: ‘Each generation perpetuates the culture and passes it on by recruiting surgical residents who appear to resemble them and training these residents to emulate their thinking and behaviour.’ The culture of surgery has evolved, and certain behaviours are rightly no longer seen as acceptable, Non-technical skills such as leadership and communication have become incorporated into surgical training. Wen Shen, Associate Professor of Clinical Surgery at University of California San Francisco, argues that this has gone too far: ‘Putting likeability before surgical outcomes is like judging a restaurant by the waiters and ignoring the food,’ I would argue that operative and communication skills are indivisible, An aggressive surgeon is a threat to patient safety if colleagues are frightened to speak up for fear of a colleague shouting or, worse, throwing instruments. Conversely, a flattened hierarchy promotes patient safety.