Leadership in Surgical Residency

Abstract

Surgical training can be compared with a functioning military unit with chain of command, responsibility/accountability relationship, and graduated leadership assignments. Proficiency, commitment, communication, consistency, ownership, relationships, confidence, humility, feedback and evaluation, exemplary behavior, empathy, and humanity are all aspects of leadership. Leadership skills developed in the protected environment of residency are the basis for a successful career.

There are easily more than 1,000 definitions of leadership. Common to all definitions is the idea that “leadership is a process of influencing others.” When considering leadership, a common misconception is that any given organization is only, or at least primarily, led from the top. It perpetuates the belief that there is one single leader of an organization who sets the direction, goals, and standards for everyone. The immense role that subordinate leaders of any organization play in the success of the group is rarely acknowledged. While the president of a company approves the mission statement, it is incumbent to the leaders of the organizations subdivisions to translate that vision into a guide for the everyday actions of its members. Leadership in health care follows a similar pattern and occasionally does the leadership discussion addressing individuals in support positions or in training.

Similarly, the majority of the attention paid to leadership in the field of surgery is directed at the top. Leaders in the field of surgery tend to be known for pioneering new techniques or holding positions in surgical organizations. More emphasis is being applied to “potential leaders” in surgical specialties. The American College of Surgeons offers leadership courses which are aimed at practicing surgeons, faculty in academic surgery departments, or burgeoning hospital leaders. Much less has been written about leadership within surgical residency. As trainees, surgical residents could certainly benefit from structured education in the development of leadership skills.

As a second-year surgical resident, I am not expert on the application of leadership in surgical residency, nor an expert on the study of the leadership. My thoughts and opinions on the subject, while based on practice, were developed primarily from my military experience. Through 4 years as a cadet and 7 years 8 months and 18 days as an army officer, I served under a wide spectrum of leaders and served as a leader of anywhere from 12 to 150 soldiers at a time. Throughout those 12 years in uniform, regardless of the mission at hand, leadership and influencing others was a constant focus.

With more than 475,000 active duty soldiers, leadership and leader development are inherent in everything the army does. In the civilian world, “military style” leadership is thought to be solely authoritative and rank based; however, the reality is much more nuanced. By necessity, army leaders employ a full array of situational-based leadership tactics and styles. Although lawful orders must be followed, overuse of a dictatorial style at best gains simple, mindless compliance and at worst fosters resentment that limits a unit's effectiveness. Mission accomplishment, especially in combat, relies on subordinates not only following explicit orders but also fulfilling a host of implied and sometimes unexpected tasks to fulfill the commander's intent behind those orders. Having subordinate leaders who can translate the commander's overall goal to his or her soldiers and motivate them to accomplish it is the one of the key reasons the army is so devoted to leadership development.

The importance of subordinate leaders becomes obvious when you consider the hierarchical structure of the army and the concept of “span of control.” In the business world, “span of control” refers to the number of subordinates a supervisor has. ¹ While this number is variable in different contexts, in the army, the number is almost always three to four. A battalion of 450 soldiers is split into three operational companies (plus an administrative company). Each of those companies consists of four platoons. The platoons are made up of four squads, and those squads are generally made up of two to three fire teams of four soldiers each. Despite the fact that a battalion commander is responsible for all 450 soldiers, he or she primarily directs the four company commanders, who in turn direct their four platoon leaders, etc., all the way down to the fire team leaders individually leading three soldiers. This modular design is at once simple and essential. It is only through several layers of leadership that 450 (or more) individuals become a cohesive unit which able to accomplish any complex mission.

Surgical residency, in many ways, is based on a hierarchical command control system. I see many parallels between the world of surgical training and the army. As a medical student, one of the strongest impressions I had during my surgical clerkships was that the environment of a surgery residency felt so familiar. As someone who traded camouflage for scrubs, I saw a battalion commander (chair of surgery), company commander (program director), platoon leader (attending surgeon), and squads of residents led by a chief, and made up of a mid-level resident with one or two interns. I immediately felt comfortable with my place, took direction from the interns, and worked hard to contribute to the team. The hierarchical approach seemed to work well as daily tasks were divided along seniority lines and the reporting structure protected the least experienced members of the team.

Now, as a resident, I realize the lines are not nearly as concrete, and although it took some time, I no longer stand at attention to present a patient on rounds. Despite the differences, many of the military leadership concepts apply. As a physician in training, even on day 1 of internship, you find yourself in a leadership position focused on the complex mission of taking care of patients, with little authority but much responsibility (and open to many demands of varying urgency). Just like a platoon or squad leader, “mission success” depends on your ability to give orders, clearly communicate the commander's intent (plan of care), ensure all treatment team members are on the same pace, and accept responsibility and accountability.

Although the stated goal of surgery residency is to develop technical skill and medical knowledge, the obligation to accept and develop leadership is present, whether or not it is implied or acknowledged. I believe this fact is vitally important to recognize early on so that you can begin to deliberately develop as a leader and achieve personal and professional success.

While there are thousands of surgical atlases and handbooks, I do not know of any tactical (resident) level surgery leadership guides. Below is a top 10 list I have adapted from a list of Timeless Principles of Leadership which has floated around in various army manuals since 1948. ² The list is by no means exhaustive, and I do not mean to imply that I have mastered all these items as a resident. Rather, my intent is to provide a starting point for fellow residents to consider and adapt as they progress through their training, and personalize as they assume the role of leading junior residents and students.

Principles of Surgical Resident Leadership are as follows:

1. Be proficient in the skills expected of you at your level . This is the first principle because competency should be number 1. Leaders set expectations, and the first expectation is that you live up to your own. This includes procedural, as well as cognitive. Only by immersing oneself in reading, listening, and practicing, can excellence be achieved? Holding oneself to the highest standard produces results.

2. Make a commitment to develop those on your team . This starts with a choice to view everyone involved in your patient's care as your team. ³ Allow your team to formulate (or at least suggest) the treatment plan. Take the time, whenever possible, to explain a management decision or thought process. This especially applies to the other residents on the team. In the army, much like residency, personnel rotate often and are promoted almost annually. The expected mindset is that you are always training your replacement. If you want the intern to be a good junior resident next year, make the time investment now. Delegation of responsibility is as much leadership as it is getting the work done. Picking the right person to manage a problem can grow both the “direction” and the “doer.” Choosing stretch objectives for team members grows the team as a whole.

3. Become a good communicator . In U.S. Army Ranger School, a leader is expected to name the task, explain the conditions of said task, and set the standards of completion. If a soldier failed to complete a task, a leader is expected to stop and consider, did I ensure they understood those three things. In the hospital, this will likely take the form of a conversation more than an operational briefing, but the principle still applies. The why, how, and what of every directive are keys to yielding excellent results. ⁴ Doing “your best” can only be interpreted in the backdrop of excellent communication.

4. Be consistent . Everyone craves consistency from their leader. Your team wants to know the expectations will not vary from day to day. Subordinates dread the experience of being scolded one day for “not being proactive,” only to be scolded another day for not notifying the boss prior to acting (responsibly). Nothing will dampen motivation, initiative, and sense of ownership more than an inconsistent leader. Always expect the maximum effort from yourself and, as a result, team members will have a clear example to follow. In this way, you develop influence.

5. Take ownership of your team . An army commander is expected to accept blame when the unit falls short and to spread the credit for its success. This trait builds serious trust from subordinates. A leader can delegate tasks but not the responsibility. The leader who understands this will have subordinates who work that much harder not to let them (or the team) down. A trustworthy leader can expect a higher level of alignment from the team. Positive response to the leader's vision is directly proportionate to the trust put in the leader. ⁵

6. Know your people and look after their welfare . “Mission first, people always” is an army dictum that sounds confusing. Stated simply, to have sustained success, you must take care of your people. Good patient care is the mission, and the residents around you are the people. Get to know one another on a personal level and check in when someone seems “off.” When possible, allow time to take care of (life) business. Empathy and social awareness are the keys to success in the area of leadership. Understanding the emotional state of the members of the team allows the leader to take care of the team on an individual basis.

7. Inspire confidence . This is more than just having self-confidence. The Army's Jumpmaster school trains personnel to lead groups of soldiers through airborne (parachute) operations. A jumpmaster has tremendous responsibility for preparing, inspecting, and leading soldiers through all steps of jumping from a military aircraft. The training appropriately focuses on the technical skills required of a Jumpmaster; however, one key component in the evaluation of Jumpmaster candidates is the ability to “inspire confidence in the jumper.” A successful Jumpmaster must inspire the confidence it takes to jump from a “perfectly good” airplane, often at night, attached to cumbersome military gear, relying on parachutes whose design has changed little since World War II. I first began to see surgery's corollary to this concept while going through informed consent with patients; telling them all the ways in which the procedure could be dangerous while trying to still inspire the confidence requisite for the patient to go through with the surgery. This concept applies more broadly, though, to any “jumper” (colleague or subordinate) whom a surgery resident must convince to follow her lead in the operating room, trauma bay, or at the bedside. Inspiring confidence is the direct result of competence, consistency, and trustworthiness. Whether inspiring confidence in a team member or patient, the surgeon must have all three of the above traits. Skills can be developed to portray, these in a very short encounter with a patient but must be backed up by action.

8. Retain humility . As your confidence grows, guard against arrogance. Conceit makes you appear less approachable and turns others away. Speaking from personal experience here, the “hero to zero” phenomenon exists. The leader should always be the “ideal” team player. Lencioni describes humility, hunger, and adaptability as the characteristics needed. Humility is the premier trait.

9. Seek and give feedback . It is difficult to improve upon weakness that you do not see. Asking for feedback from colleagues above and below your level can point out those blind spots. At the same time, make a habit of giving feedback (positive and negative) to those below you. This goes back to principle 2, to develop people on your team. Receiving and asking for feedback is also a learned skill. It is a sign of self-awareness and self-management when this becomes an ingrained habit. Selecting the team member who can give good feedback is also a skill.

10. Be the example . I kept this one for the end because it is one of the most challenging. You cannot realistically hold others to a higher standard than you hold for yourself. As others see you strive to improve yourself, you are automatically influencing them to grow. ⁶ Admitting that continuous improvement and learning is important to you will inspire the team to grow.

11. Remember that you (and those around you) are human . Despite all earnest efforts to fulfill principles 1 to 10, there will be times when you and those residents around you will fall short. Do your best not to dwell on the failure; however, absorb the lesson and let the emotion go. Forgive yourself, forgive others, and move on. In this way, a positive psychological approach can prevent burnout and self-doubt. A growth mindset is a skill that can be developed. ⁷ Managing team failure and personal failure in a positive way is the basis of resilience. Once you see the opportunity to improve, which underlies every failure, you begin the path to resilience and thus limit the negative influence of burnout.

If you are still reading this, thank you. I understand if you think this list seems too lofty or unrealistic. We as residents already feel task saturated with patient care, learning how to operate, and reading/studying all within the 80-hour duty week. I am certain, though, that striving to live up to these principles will only push you to become a better surgeon. Teaching a skill, walking an intern through a procedure, or explaining the “whys” takes more time than just doing it yourself, at least at first. Think of that time like an investment. The devotion of extra time upfront, teaching and supervising juniors, will free up more time as those subordinates become increasingly more proficient and assume leadership attributes themselves.

So why, aside from personal improvement, does this matter? A commitment to leadership, to the process of influencing others, has a lasting impact. A critical mass of resident leaders can transform a training program's culture. And I personally believe a culture of resident leadership is the key to maintaining (appropriate) resident autonomy.

It is tempting to look at residency as the “final hurdle.” If we can just “make it” through these tough years, it will be alright. Unfortunately, that belief is short-sighted and ignores the fact that decisions become more complicated at each level in the future (practice setting, fellowship, partner selection, etc.). Maturity in surgery brings with it more complex patient care, full accountability for mistakes or poor outcomes, more critical scrutiny of behavior and performance, larger areas of responsibility with limited guidance, and no end in sight (the rotation lasts more than 2 months). It is important for us to remember that leadership skills begin with self-awareness and self-management and results in social awareness and relationship management based on empathy. Therefore, by learning leadership skills in the protected environment of residency, we develop skills that underscore our success and enhance the opportunities that we face to truly enjoy a meaningful and exciting career.