Why is the Surgical Leader also a Manager?

Abstract

The surgeon acts as a manager in the operating room, ward, classroom, and in daily life to control time. Skills cross all boundaries of medicine with specific needs in each area. Without leadership skills the nonmedical aspect of practice becomes more difficult and can make the physician less successful. Learning to manage, therefore, becomes critical.

Several different factors have the potential to lead a medical student to a career in surgery. Some of us enjoy the concept of the mental and physical challenges of such a procedural specialty. Some are driven by the opportunity to directly intervene upon a patient and, in so doing, provide a cure to a disease process or malignancy. Others undoubtedly seek out the perceived prestige that comes with the title of surgeon. To the uninformed or uninitiated, though, there is an inaccurate assumption of the surgeon's role in the hospital environment. To be an excellent surgeon, one cannot function in isolation—rather, one must function as a manager in a variety of circumstances: the operating room (OR), the wards, and the classroom, to name a few. Such a topic could most likely fill a text on its own. Within the forthcoming pages, though, we will consider several varying managerial roles of the surgeon within each of these environments. What will ultimately come to light is that, contrary to popular belief, the surgeon's role as manager is far greater and more rigorous than his or her role as a medical professional.

The Operating Room

Far too often, the surgeon exists in a relative vacuum within the confines of the OR. The moment the safety time-out is complete and the scalpel descends upon the patient's skin, time seems to disappear until the final sutures or staples are secured. But this is not the reality, as every minute spent in the OR is tremendously expensive when one accounts for the room itself and the varied medical professionals aiding in the operative process, potentially incurring a cost of over one hundred dollars for each minute spent. This is not a burden that financially impacts the surgeon, of course, for neither the length of the procedure nor the cost of the associated equipment impacts the amount that the surgeon collects for his or her services. But it makes a dramatic impact on the cost of the procedure for the patient, the hospital, and society as a whole.

It is with such an understanding, then, that we begin to see the potential for a variety of roles that the surgeon might play in these circumstances. First, the surgeon must function as a personnel manager of the OR staff (even though these individuals are not directly under his or her employ), including the surgical technicians, nurses, and several resident physicians (at teaching facilities). Not only must the surgeon be aware of the roles each individual plays in the room, he or she must understand that this is an extraordinarily complex and dynamic environment based upon the specific people in the room: it is undeniably helpful to understand that a specific nurse is very effective in making sure necessary supplies are in the room but is very linear in thinking—in spite of the fact that the prep requires several minutes to dry, he or she is unwilling to perform that task if a surgeon's gown requires securing. As such, minutes that might be spent preparing for the operation while waiting for the chlorhexidine to dry are wasted as everyone stares at the clock, waiting the obligatory 3 minutes prior to draping out the operative field. Similarly, certain teams can turn over a room in a fraction of the time of others and, as such, a little extra motivation for the slower teams can dramatically improve OR efficiency. Sometimes this can even include requesting help from the charge nurse, residents, or medical students for an additional degree of oversight, or a rescheduling of one's own activities in between cases (such as interspersing bedside procedures or patient care rounds) based upon the expected turnover. Alternatively, a quick trip into the sterile core with the circulating nurse prior to scrubbing can alleviate certain difficulties by making sure that the necessary (or potentially necessary) supplies are already in the OR or that the nurse can easily identify their varied locations if it becomes necessary to leave the room. This must be a diplomatic effort, though, with the surgeon acting as a contributing and helpful member of the team rather than simply as a dictator or the often-referenced “captain of the ship”: words or actions perceived as hostile are more likely to slow efforts down than to speed them up. Perhaps the most important realization that begins to appear is the transition from what has traditionally been a physician-centered process to, ideally, a patient-centered one.

A sense of teamwork and of camaraderie is the ideal environment in the OR, and this must be nurtured by the attending surgeon. A certain degree of success in such a scenario requires a shared focus among the physicians, nurses, technicians, and other ancillary personnel (e.g., retractor holders, radiology technicians, patient-moving assistants, among others), but this can only occur if the attending staff encourage a team-oriented approach and demonstrate the respect deserved of any individual who does their job well (as well as the constructive and respectful motivation for those who require additional direction). This focus has come to the forefront in recent years with efforts to empower every member of the health care team to provide assistance where possible so as to improve patient care and outcomes, as well as the discretion to block progress to avoid patient harm. Far too often, surgeons have resisted various empowerment and patient safety efforts by arguing that such practices impair the ability of physicians to perform their tasks—not waiting for an alcohol-based skin prep to dry with the resultant potential for an intraoperative fire, skipping the preoperative time-out with the potential for wrong-site surgery, continuing to close the operative site in spite of an unreconciled instrument, or needle count with the potential for a retained surgical implement within the patient. And all of these potential situations happen far too frequently when the focus is on the individual surgeon rather than the safety of the patient.

Throughout the media at present we see similar examples of such poor managerial choices, be they in the public sector or private enterprise. On a daily basis, we see news stories describing corporate executives choosing to dramatically increase the price of a medication or ignoring worker safety measures so as to maximize profits, politicians succumbing to pressure from their larger donors or their political base rather than representing their constituents, or more individual circumstances of people neglecting the humanity of others for their own benefit. The #MeToo movement against sexual assault and harassment is yet another contemporary example.

Managers choose short-term profit or personal gain, but they do so at tremendous cost to their organizations and their personnel. Hubris is far too frequent in individuals with a significant power differential between themselves and those whom they manage, whether that differential is the result of education, economics, or social standing—in the case of a surgeon, all three tend to be the case. We, as a surgical community, repeatedly ignore the concerns and feelings of those in the room because our surgical culture has allowed us the pride to believe, all too frequently, that we are infallible. Unsurprisingly, such attitudes eventually lead to disastrous results—for the surgeon it is frequently medicolegal or monetary, but for the patient it is potentially life-altering (if not life-ending). The surgical leader, then, must recognize that their own behaviors, their personal interactions, and their integrity all affect the process of patient care.

Still within the confines of the OR, the surgeon must reflect upon the quality, cost, and efficacy of the equipment that he or she uses on a daily basis. In this era of corporatization of hospitals and of medicine itself, the equipment provided by the hospital is frequently selected based upon pricing and contractual obligations rather than necessarily on the quality of the product. This is not to suggest that a focus on cost is necessarily a bad thing, and our discussion will return to that very point shortly—rather, the surgeon must weigh the potential benefits of a specific piece of equipment against the cost thereof, balancing economic considerations with his or her comfort with a specific item versus a similar product from a competitor. Sometimes the difference is great enough that one must step forward and argue the point, especially when patient safety is a concern, but more frequently product preference relates more to surgeon comfort or (sadly) the aggressiveness with which the product is marketed, rather than any relative patient benefit. The American health care system distances both the patient and the physician from the cost of virtually every aspect of medicine, and it is to our detriment: were we to spend time understanding the costs of the services we provide and the equipment with which we provide them, perhaps we could reconsider aspects within that service and determine whether it is worth the expense of a surgical robotic interface rather than traditional laparoscopy, or a long-acting anesthetic that increases the cost of a procedure by several standard deviations. How often do we, as a surgical community, order a hemoglobin and hematocrit rather than one or the other? Given the interchangeability of the two numbers, is it worth the patient's money to pay for two tests instead of one? (Rarely is there a discount for the patient—rather, we obtain redundant data at twice the cost.) Similarly, we frequently fail to consider whether the various tests that we obtain are changing management or simply increasing the cost to all players within the world of medical economics.

Undoubtedly, neither the cheapest nor the most expensive is likely to be the best, but without an understanding of that facet of care it is impossible to arrive at a truly educated decision. With an understanding of these factors, as well as a reasonable price list for any given procedure, we find that the surgeon may also manage their cost to the hospital and to the patient. Such considerations are not frequently on the minds of most surgeons, but the surgical leader benefits the patient, the hospital, and the health care system when they step back and consider the larger picture.

The Wards

So, too, does the surgeon have the opportunity to beneficially impact the care of his or her patients outside the OR by taking a larger view. Compare two drastically different iterations of surgical practice as an example, which we might describe as the surgical technician and the surgical health care provider for the purposes of differentiation. The former is exactly how many medical specialties may see the role of the surgeon—when a procedure is necessary, the surgeon is the individual whom you consult to perform the said procedure, but their services do not extend beyond that role of technician. In some cases, such an approach is the result of institutional practice patterns—the hospital might require that all patients are admitted to a medical service and, in such an environment, all surgeons function as consultants. In others, the practice arises from the surgeons themselves in that, postoperatively, they delegate the vast majority of care to advanced practitioners or other services rather than continuing to guide that care themselves. This delegation, though, has detrimental consequences from the standpoint of cost- and personnel-efficiency: not every patient requires a board-certified internist to manage their care and the inclusion of another specialty necessarily costs the patient more in terms of physician fees; additionally, such a practice does not necessarily improve patient outcomes. Coordination of care in areas where a surgeon lacks expertise or comfort is understandable, but the addition of more providers to allow the surgeon to shirk postoperative care seems to be more often the case, unfortunately.

The surgical health care provider functions differently. Within the construct of evidence-based practice and a multidisciplinary environment, there are a variety of nonphysician service lines to aid in patient management. With assistance from registered dieticians and clinical pharmacists, as well as physical and occupational therapists or speech and language pathologists, a collegial approach to patient care can provide all the necessary services for any given patient. These professionals can aid in any number of clinical circumstances when incorporated into daily practice—the concept of intensivist multidisciplinary rounds is an excellent example of this concept—if allowed to practice within their fields of expertise. An internist is not necessarily required to aid in blood pressure management if a constructive dialogue occurs between surgeon and pharmacist. A nephrologist may not be necessary if a patient has appropriate urine output and is clearing effectively. A hepatologist consult is not required for any aberrant liver function tests. By maintaining one's skill within the medical realm, listening to nonphysician colleagues and their recommendations for optimization of care in their disciplines, and selectively involving other service lines for the benefit of the patient, we as surgical health care providers once again have the opportunity to reduce cost while simultaneously providing better care. We, as a health care manager of each of our patients, can improve patient outcomes if we continue to practice medicine (and not just surgery) and use the resources available to us in those areas with which we may no longer have the most current knowledge. Completely relinquishing the medical care of our surgical patient is not the answer, just as arrogantly managing all health care ourselves is equally likely to have poor outcomes—a recognition of our own strengths and limitations, as well as the strengths and limitations of those around us, lead to optimal patient care.

The Classroom

The surgeon has always filled the role of medical educator, as well, whether for students, residents, advanced practice professionals (APPs), or others. Frequently, though, surgeons lack an understanding of educational principles and learning theory to provide the optimal experience for their students. The medical student and resident experience is far-too-frequently one of pimping and potential public humiliation, with focus on minutiae or specific literature rather than the broader critical thinking skills that are so important to the proper practice of medicine. Such a focus on eponyms and trite facts results in a misunderstanding of what we do—any good medical student can tell their examiner that ultrasound is the gold standard for diagnosis of cholelithiasis, cholecystitis, and other iterations of acute biliary disease, but this is so ingrained in them that they frequently refuse to consider an already-obtained computed tomography scan as adequate imaging in the right clinical setting because we have not taught them to step back and assess the larger picture. Nor do we tend to provide an opportunity for contemplation, which also leads to that regurgitated and thoughtless answer. We are teaching medical trivia rather than the practice of the art of medicine.

Within the realm of education, though, we have the ability to modify our own actions to emphasize the critical thinking so important to clinical medicine. We have the opportunity to create a learning environment that actually favors education. This requires a certain degree of sacrifice—we cannot direct the educational environment as we tend to do in the OR. Optimal education requires time for a considered response, for the student to synthesize their knowledge base with the problem at hand and to formulate a solution. If we give only a moment's pause for our student to respond before answering our own question, we have already failed as surgical educators. We must manage both the student's expectations and our own, understanding that in the nonclinical venue is the perfect environment for time and thought. It is this process, a foundation in common sense and critical thinking, that truly establishes the surgical educator. And it is a focus on the decision-making process of clinical practice—the understanding of what is clinically important and what is not—that provides lasting benefit for the student, regardless of their level of training or their chosen specialty. After all, no obstetrician or family practice physician will ever need to know the borders of Calot's triangle in their daily practice. But the ability to differentiate ascending cholangitis from simple choledocholithiasis and the urgency required for the requisite surgical consultation, is a different matter.

It is here where the surgical leader can break from tradition. First, we must recognize the fact that not every medical student is going to be a surgeon. Second, we must realize that not every medical student wants to be a surgeon. Whether a student is meant to spend a few months or the rest of their career within the surgical environs is neither here nor there: the difference is whether or not we—as a surgeon and as an educator—can meet the student where they are and provide them with both the best experience possible and the most useful knowledge for them to carry out of the experience to aid their future practice and their future patients. The result of such an approach requires more effort from each of us: we must meet the student where they are, rather than expecting them to meet us entirely in our venue. But a good manager understands their team, understands that each and every member of their team has the potential to succeed. We must understand their beginnings, their motivations, and use that as the foundation for their education.

We must also approach the education of residents in such a fashion. The transition from medical school to residency is far less dramatic today than it was 20 years ago, as both resident and student autonomy has lessened. Appropriately, much greater supervision is provided to junior residents today—unfortunately, this has led to a more cavalier approach to early resident education. Every physician ultimately learns the lesson that their decision-making has the potential to harm if they make their decisions injudiciously, but the pendulum has swung such that this realization occurs far later into residency today than in decades past. It is far too easy to fade into the background and to complete dictated tasks today, rather than refine their critical decision-making pathways and processes—as such, it is seems more likely for a resident to be taught how a specific surgeon likes to care for the patient rather than how the patient should be cared for . ¹

The surgical leader must understand, then, that the most important part of a resident's early education is the ability to identify the truly sick patient and understand the interventions necessary to stabilize that patient. This does not revolve around an electronic medical record but rather the face-to-face interaction with their patients. The surgical leader must be able to model such behavior, as well as to grasp that there is rarely a single correct way to complete a clinical task while on rounds: whether a trainee chooses to bolus normal saline or lactated Ringer's is usually of little consequence; what is important is the recognition that the patient is volume depleted and an intervention is required. This lends itself, then, to a more Socratic mode of questioning of the resident—if normal saline was chosen, when might the trainee use a different crystalloid? When might colloid be of benefit? At what point is a Foley catheter necessary to monitor ins and outs, or a central line for central venous pressure? The surgeon who issues edicts as to the correct answer is doing no justice to the resident, for they are depriving their student of the ability to practice clinical decisions and formulate their own algorithms for patient care. The surgical leader allows their trainee to manage such decisions themselves, guiding them, correcting course when necessary, and allowing them to reflect on their own decision-making processes. It is here where true education can take place, and with these foundations it is possible to truly succeed in our role as surgical educators.

The Clock

The conclusion to which any reasonable person must come at this point is that there is not enough time, especially in a world of electronic medical records, to complete every task within the allotted hours of the workday. And so we must find a way to pack more into the hours of the day. To achieve more in less time, to manage time itself, is one of the necessary tasks of a surgical leader. ² This is a significant challenge for surgeons everywhere, though it is a framework with which managers around the world are familiar—it is the concept of delegation and of shared responsibility, as well as an understanding (to a certain degree) of medicolegal risk. As referenced previously, we function in a health care environment where others can shoulder some of the burden of patient care, if we let them. In certain hospitals, this falls to the residents, if we provide them the guidance and autonomy necessary to both further their education as well as to alleviate our burden. In others, the responsibility (when shared) falls to physician assistants and nurse practitioners. In either case, though, it is the role of the surgeon manager to ask for the input of others and to allow his or her fellow health care professionals to provide the assistance for which they were trained. Unquestionably, the ability to provide (relatively) autonomous care benefits the APP as it allows them to do what they were trained to do and provides a significant degree of satisfaction as a result. Such an environment also provides significant benefit for the surgeon in that such delegable tasks can markedly decrease the workload of the surgeon while simultaneously satisfying the APPs. Suddenly, the surgeon has found more hours in the day.

So, too, must we accept that there are decisions that are better made by larger entities than the individual. The surgeon should not be responsible for making the decision as to when a Foley catheter or central venous line should be removed—these are delegable tasks. Our focus should be, just as it should be within the educational environment, on the critical thinking that is truly the defining characteristic of modern medicine and modern medical education. The role of the physician or surgeon is not to dictate every aspect of care, for it is highly likely that evidence-based practice will frequently disagree with the practice of any specific surgeon. Rather, the role of the surgeon is to critically identify those situations where deviation from the evidence-based guideline is warranted. Again, the role of the surgical leader is not to micromanage. It is to understand where management is necessary to redirect a course or to deviate from a protocol. By doing so, we provide ourselves an opportunity to focus on more of what truly matters, rather than to exert control wherever possible. Let others demonstrate their strengths whenever possible, and let the surgical leader interfere only when course correction is required. ³

Any physician can identify that there are not nearly enough hours in the day to do everything we are asked to do. Some time can be reclaimed in the fashion listed above, but we must all recognize that we must sometimes say no. We must recognize that our colleagues are frequently just as capable, as we ourselves are for a committee appointment, a book chapter, or a presentation. For it is only with such efforts that have the opportunity to focus our attention on what truly matters: our lives outside of the confines of the hospital. We live in a world in which we push ourselves far more aggressively than others do, and often such drive is to the detriment of the friends and family who support us. We deprive ourselves of too many experiences, too many moments, and too many joys because of our sense of obligation and duty. Such an approach is not entirely wrong, for someone must take care of the injured and infirm. But this is a burden that can be shared.

Ultimately, what we must manage is ourselves. We must control our emotions. We must control our expectations. We must make an active choice to participate in a medical environment that allows all of those who work in the patient care environment to do their best for the patient. This allows each provider the autonomy to do their job, provide guidance or supervision for others should they require it, with the knowledge that everything we do is for the benefit of the patients for whom we care. The surgical leader understands that success is determined by managing a team and by letting each team member excel within their environment. ⁴ By doing so, we model the behavior that allows both providers and patients to thrive in an environment which has the potential to be as fulfilling as it is frustrating. And the better we manage, the more fulfilling it will be.