Leadership in Surgery

Abstract

Many opportunities exist for surgeons to be leaders in healthcare. Leadership training should begin in medical school and continue throughout residency training and in clinical practice. Most leadership skills can be developed and refined through a variety of training programs. Formal programs that result in degrees can provide surgeons with special insight, experience, and skill sets. Leadership skills are used in everyday practice and are particularly valuable when shifting roles or taking on new positions, whether at your home institution or within national organizations. Ultimately, physician leaders are responsible for leading healthcare and will directly impact the quality of care delivered to our patients.

Objectives: (1) The reader should be able to list several leadership opportunities in academic surgery. (2) The reader should understand opportunities to further develop leadership skills as a resident and as an attending surgeon.

Medical school education focuses on the human body and the delivery of patient care. Coursework and hospital rotations prepare the student for residency training and beyond. Along the path, there is little (if any) training for the other “parts of the job”—running a business, motivating employees, developing an esprit de corps within a team, mentoring employees, negotiating deals, leveraging success, and learning from failures. In reality, when we become doctors, we become leaders yet most of us are not adequately prepared or trained to fill this role. Interestingly, the competitive nature of medical school admissions demands that applicants have proven leadership ability—whether captain of a tennis team, president of an undergraduate committee, developer of a free care clinic for underserved patients, first member of a family to attend college—but those pursuits tend to be sidelined by the rigors of medical school education and surgical residency. After 5 to 10 years of residency/fellowship training, surgeons are asked to resurrect those skills and begin to employ them again in their new role as a board certified surgeon. Running an operating room, a laboratory, coordinating an office, negotiating with hospital administrators, raising funds for research, and managing diverse personnel are daily activities. The presumption is that these tasks can be accomplished seamlessly as we transition to the next phase of our careers. The reality is that some find this easy or innate while most others struggle and often fail. Fortunately, these are skills that can be developed and refined.

What Is “Leadership?”

Leadership can be defined in innumerable ways. Ultimately, leadership is a process by which a person influences others to accomplish an objective and directs the organization in a way that makes it more cohesive and coherent. It is the ability and activity of leading a group of people or an organization. Leaders are held accountable for both success and failure.

Leadership involves

1. establishing a clear vision,

2. sharing that vision with others so that they will follow willingly,

3. providing the information, knowledge, and methods to realize that vision, and

4. coordinating and balancing the conflicting interests of all members and stakeholders (http://www.businessdictionary.com)

There exists plenty of controversy regarding the differences between leadership and management and whether either can be taught or if leadership can be learned and enhanced through coaching or mentoring. There are a myriad of conceptual models including great man, trait, behaviorist, participative leadership, situational, contingency, transactional and transformational, action-centered, adaptive, and emotional intelligence.¹ Bass's theory of leadership notes there are three basic ways to explain how people become leaders^{2 3 4}:

1. A crisis or important event may cause a person to rise to the occasion, which brings out extraordinary leadership qualities in an ordinary person. This is the Great Event or Great Man theory.

2. Some personality traits may lead people naturally into leadership roles. This is the Trait theory.

3. People can choose to become leaders. People can learn leadership skills. This is the Transformational or Process Leadership theory. It is the most widely accepted theory today.

Although leadership is learned, the skills and knowledge possessed by the leader can be influenced by his or her attributes or traits, such as beliefs, values, ethics, and character. Knowledge and skills contribute directly to the process of leadership, whereas the other attributes give the leader certain characteristics that make him or her unique. Thousands of books have been written on leadership, focusing on different philosophies and training programs. The goal of this article is neither to review all of these nor to summarize their teachings. Instead, the goal is to relate the concept of leadership to surgery and highlight opportunities where leadership positions exist and where leadership skills are important in transforming and defining such roles.

How to Improve Your Skills

Fortunately, there exists a wide array of opportunities to help build and develop leadership skills. Although there is some evidence to suggest various leadership skills are innate, it is widely accepted that these skills can be nurtured, developed, and improved.

Mentors

At the most simple level, one can establish a mentor–mentee relationship with a successful leader. This would be considered the more traditional and common approach. The mentor can be virtually anyone in the same or parallel organization but most commonly is a person who you interact with regularly and who you resonate with. Depending on your position and short-/long-term goals, this could be your division chief, department chair, or hospital Chief Executive Officer. There can be additional benefits from a mentoring relationship as when the mentor provides a unique perspective and imparts a diverse skill set, such as when the mentor is a hospital administrator or medical group head outside of surgery. These people may provide perspectives and opportunities that are either distinctive or originally considered beyond your reach. Such connections and relationships might serve you well in the future as you look to advance your career.

Institutional Programs

Many programs exist which focus on developing young talent within an institution. At UMassMemorial Medical Center and University of Massachusetts Medical School, there are several examples including the Strategic Leader Development Program, the Physician Leadership Development Program, and the Junior Faculty Development Program. Each of these programs chooses faculty who have shown early promise and interest in career advancement. The different programs focus on either academic or administrative career paths. They use the mentor relationship by engaging in-house leaders who share their insight and experience. Human resources support staff may conduct 360-degree reviews (a constructive process of providing leadership feedback elicited from managers, peers, and team members), Myers–Briggs evaluations (measurement of psychosocial preferences in how people perceive the world and make decisions), and serve as “coaches” to help navigate the process. Each of these programs focuses the efforts around a defined “action learning project” where the process of developing and completing this project by working with peers and colleagues is particularly educational. Often these programs include physicians and nonphysician administrators in an effort to allow collaboration and exposure to different ways of thinking about health care and the business of health care delivery. The process allows members of the group to learn from others problems and challenges in a safe, supportive, and facilitated environment. Formal presentations to hospital administrators provide face time and allow participants to hone presentation skills in a forum outside of traditional education or peer-reviewed environments. Participants in such programs demonstrate improved career satisfaction, retention in academic medicine, and attainment of administrative roles and/or higher academic rank.⁵

Leadership Courses

The American College of Surgeons (ACS) holds an annual 3-day leadership development program called Surgeons as leaders: from operating room to boardroom. This is a program open to practicing surgeons in private or academic practice who want to advance their skills in leading people, groups, and organizations. Leadership skills, as differentiated from management skills, are the focus of the course and keys in on issues such as navigating the operational and human aspects of change, cultivating commitment to a shared vision and goals, building teams, and developing strategies for leading up, down, and across the institutional environment. Another example of a course that is sponsored by surgical societies including the ACS and American Society of Colon and Rectal Surgeons is the 1-week long Leadership Program in Health Policy and Management at the Heller School for Social Policy and Management at Brandeis University.

Advanced Degrees

Physicians are motivated to obtain a dual degree for many reasons; for management positions in pharma industry, medical companies, and consulting firms, for entrepreneurial pursuits such as launching new device companies, or for increasing administrative responsibilities and the ability to communicate more clearly and effectively with hospital administrators. Formal training programs exist and degrees can be earned including masters in Health Care Administration and business administration (MBA). Although nearly impossible for a practicing surgeon to take a leave or sabbatical, executive MBA programs are offered specifically for practicing surgeons and are held online, at night, and on weekends. One must consider the cost of these postgraduate programs (upwards of $120,000) and alternatives for funding (scholarships, department subsidy, and personal investment). The personal and professional development learned through these programs help transform a surgeon into a skilled leader armed with the vernacular, experience, and resources that were not taught during traditional medical education. In addition, armed with this additional degree the surgeon is more welcomed into the world of hospital administration, now able to “speak the language” and offer insight that reflects their business acumen.

As a reflection of evolving interest and need, there are now more than 65 combined US programs where a MD and MBA are earned in a joint fashion before residency training. Other times a surgical resident will earn their MBA during a break in their residency training, traditionally considered “research time.” Of course, there are theoretical benefits to earning a MBA degree during medical school when one can incorporate the experiences gained during residency and early career. Actual experience on the job can help define your interest and skills, perhaps allowing the participant to not only bring a different perspective but immediately bring newly learned skills to practice “in real time” to a current role.

Positions of Leadership

There is an abundance of leadership positions within the medical environment. It remains fascinating that the appeal to become a surgeon can be quickly overcome by a new found enthusiasm and interest in the business side of medicine. Striking a balance between clinical practice and leadership roles can be challenging, particularly for a surgeon, due to the referral-based nature and unpredictability of the profession. At the same time, the surgeon holds a unique perspective related to their experience as an acute care provider coupled with an understanding of the intricacies of the business of medicine. Although “physician leaders” are integral to the success of our medical centers and health care systems, the framework of our health care organizations pose special leadership challenges.⁶ First, health care organizations are complex and are often divided in to silos. Second, surgeons are trained in ways that tend to conspire against collaboration. Third, the demands of training and performance compete for surgeon's attention to mastering leadership skills. Nonphysician administrators can never achieve a comprehensive understating of the patient–doctor relationship and how that relates to the business of health care. This key distinction is why physician leaders are so integral to the foundation of health care delivery and why we need to better prepare our trainees to hold positions that offer this inimitable perspective.

The Practicing Surgeon

Traditionally, the mark of a great surgeon relates to technical ability, knowledge, and diagnostic acumen while little focus was ever given to other management skills. Today, the nontechnical abilities such as communication and leadership skills ultimately translate into enhanced patient safety, experience, and outcomes. The day the surgeon starts their first job defines them as a leader, and this is particularly true for colorectal surgeon as they are immediately considered a specialist or expert.

The aristocratic, dominating surgeon of the past has been dethroned. Early in training, educators need to focus on creating leaders who are ready to seamlessly transition into staff positions where they build and lead teams while serving as mentors to the trainees. Unfortunately, management instruction and leadership development remains poor in our training programs. Simple interventions can prove useful.⁷ The operating room remains a well-controlled setting where the surgeon is irrefutably considered the leader and where many opportunities exist to transform the operating room into a rich, learning environment.⁸ With an ongoing shift toward disease-focused patient care, surgeons work more frequently as members of multidisciplinary teams and must learn to function and lead within that environment.

Laboratory

As a physician scientist, not only does one have to master the care of patients and their area of scientific study but in essence they have to run a small business. Grants have to be written with specific budgets, personnel have to be hired and managed, postdocs, residents, students have to be taught and mentored, and publications have to be written, edited, and published. Concurrently, patients have to be seen, followed and cared for, both in the inpatient and outpatient settings. Leadership skills and training are not only required but can prove the difference between a successful and failing laboratory. This is particularly germane today in the setting of limited available funding and increasing competition for resources. The complexities grow when considering the multifaceted interactions between a laboratory leader and the members of the medical center and medical school, who often present different priorities, interests, and challenges.

Section/Division Chief

Building and managing a colorectal surgery group can be exhilarating. The chief is responsible for developing the mission and vision of the division. Where will the division be in 1, 3, and 5 years? How will the division get there? What are the potential obstacles and who are the stakeholders who will help achieve success? How will all these happen working together as a cohesive team?

A division does not live in a vacuum but is a component of the greater department and, accordingly, the visions must be aligned. To start, a chairman who is not supportive of colorectal specialization will never allow your vision to be successful. A division that values achievement in clinical care, research, education, and community service will never realize success in a department or hospital system that values and rewards relative value units production alone. The chief must have the buy in of the team members and must possess the ability to motivate them to succeed. Rewards that include financial bonuses can be powerful but never discount the value of a healthy work environment where each member is encouraged to work toward their chosen piece of the master plan. With a supportive institution, a successful chief should be able to drive achievements in clinical care (comprehensive and innovative treatment options), research (presentations at regional and national meetings and peer-reviewed publications), education (mentoring general surgery residents and starting a colorectal residency training program), and community service (initiating a speaking panel for colorectal cancer prevention or a support group for inflammatory bowel disease patients). This role often involves the direction and direct reporting of support staff including division administrators, assistants, nurses, physician assistants, and medical assistants. Regular interactions include strategic planning and reporting to the department chair, medical group, and medical center administrators, as well as coordinated efforts with the marketing department, public relations, and nursing leaders.

Program Director

The role of Program Director (PD) is a unique one. The PD serves as a leader within a training program and develops the goals and personality of the program. Measured by resident experience, satisfaction, and ultimate fellowship/job placement, the PD maintains a position of authority over the members of the training program. Different from the division chief who manages colleagues, the PD is asked to motivate and discipline using a different set of tactics and approaches. In addition to this, the PD must organize the teachers who are responsible for training their students. This needs to happen in a relatively standardized fashion, focusing in on the 5-core competencies, while balancing a variety of independent teaching styles. Residency coordinators help with structure and documentation, and provide an additional level of supervision. The PD is responsible for the program coordinators, the residency participants, and the teaching staff while working hand in hand with the governing and credentialing bodies such as the ACGME. The focus remains on education and professional development and the end reward is the product—a board certified surgeon who is poised to become a leader. The PD role continues to evolve with the times, keeping up with a shifting demographic of surgical trainees, lifestyle issues, and increased trend toward subspecialization, all of which present new challenges.⁹

Department Chairman

The chairman is considered the ultimate leader of the surgical department. The chairman is responsible for providing oversight of the clinical divisions, the residency training program, and interacting with the other department chairs and hospital administrators as the advocate for the department. There is no question that the business-related fiduciary responsibilities of the chairman are well beyond any training that was offered in medical school and need to be on par with hospital administrators at all levels. This demands an understanding of operations, finance and accounting, human resources, strategic planning, reimbursement strategies, quality assessment, contract negotiation, and conflict resolution.

Although chairman traditionally “learned on the job,” the current trend is to seek supplemental training that better prepares the chairman to develop business plans, read and understand financial reports, understand the system-wide implications of proposals, engage insurance companies on contracting, and envision a world of accountable care organizations. In the past, surgeons were chosen for chairman positions based on traditional academic and clinical success rather than leadership skills. Their skill sets often had little to do with the skill sets that they needed to be successful chairman, such as emotional intelligence, change management, team building, and systems thinking. This transition can be facilitated by advanced degrees and many chairs now prepare for the role by obtaining additional training in the form of an MBA. Chairmen may attempt to communicate these methodologies to their department by hosting department retreats, often with the expertise of an outside facilitator who engages the participants in a manner that is engaging and empowering.

Chairmen of the 21st century recognize that their job can be as much about talent management as it is about strategy. The management and supervision of surgeons are difficult tasks as surgeons value autonomy and are products of long, hierarchical training programs that have rewarded and graded based on personal/individual performance. Chairmen are now more willing to elicit the recommendations of their constituents and empower them to be part of the design and implementation plan. Team building has replaced hierarchical departments while regular constructive feedback has replaced finger pointing. With a diverse workforce and new challenges including work-life balance, today's chairmen must be multitalented and armed with advanced leadership skills.

National Societies (Including the American Society of Colon and Rectal Surgeons, American College of Surgeons, Society of American Gastrointestinal Endoscopic Surgeons, and Society for Surgery of the Alimentary Tract)

National societies provide great opportunity for leadership and career advancement. Serving on committees and later leading committees allows the academic surgeon an occasion to create and develop programs under the auspices of a national organization. These large organizations have resources and abilities to impact major change. They can provide opportunities such as traveling fellowships and development programs. Participation also allows interactions and collaboration with other national and international leaders who would otherwise rarely be accessible. Often times success within these organizations provide opportunities for roles in other efforts such as Journal boards, educational organizations such as the residency review committee, National Board of Examiners, among others.

Hospital Administration: Chief Medical Officer, Hospital President, Medical Group President, Chief Operating Officer, Chief Executive Officer, Chancellor, Dean

These positions require individuals with proven track records and a special gift for leadership. There is so much riding on these leaders that the wrong appointment can be detrimental to an entire institution. Such leaders should have proven success either in similar positions elsewhere or in challenging positions at the same institutions. They are responsible for establishing a long-term vision and strategy, creating a climate of trust, and developing a positive culture. There is typically something special that sets them apart—they are skilled communicators, natural motivators, charismatic, and true visionaries. Of course, politics enter the equation to a certain degree as various constituents can support their initiatives and vision, sometimes in a quid pro quo fashion. This can be more apparent at public and nonprofit institutions. Most of the time, the demands of these jobs require a full commitment and complete surrender of clinical responsibilities. The jobs are just too big to be done part time. This is one reason why it is rare for a surgeon, particularly a young surgeon, to leave the clinical arena as surgery tends to be their first love. These leaders can have a major impact on the climate or “the feel” of an organization, which is powerful enough to even impact the culture of an institution.

Conclusion

Surgeons are leaders poised to take advantage of the many leadership opportunities within health care. These positions provide surgeons with outlets for their interests outside of traditional patient care. Some people are born with leadership skills and others develop them over time. Programs exist to either expose or enhance such leadership skills. It is clear that this process should begin early and that medical students and residents should be prepared for leadership roles as we develop a pipeline of “physician leaders” moving forward. The ACS has initiated a program for residents called Residents as Teachers and Leaders as a means of helping residents master critical and nonclinical skills related to leading a team and teaching. For some, primary roles may shift or direct a career away from patient care. For others, a balance between clinical and administrative careers may be fulfilled in a defined role. Regardless, setting goals and working toward attaining these goals within the construct of a team are the mark of all successful leaders.