Editor’s note: This article is based on the panel discussion The Pitfalls of Leadership in the Operating Room (OR), which took place during the 2011 Clinical Congress in San Francisco, CA. It is the first of a two-part series of articles based on that program.
The OR is a unique environment that, although often rewarding, can become exceedingly challenging for any surgeon. The successful completion of an operation depends on the execution of a series of steps—each of which may be dependent on equipment as well as on the coordinated efforts of the surgical team. It is the surgeon’s responsibility to lead the team. Although most surgeons recognize good leaders and appreciate the importance of leadership, knowing how to develop leadership skills may be less clear. Surgical atlases provide step-by-step guides to the technical aspects of performing an operation; however, nontechnical skills are not so easily broken down into components that can be practiced and mastered.
This article is intended to offer a reflection on leadership skills pertinent to the OR environment. Many of the suggestions here may appear to the reader to be based in the development of basic good manners and even-tempered behavior. While that deduction may be somewhat true, the stresses of the OR environment can override the best of manners and the kindliest of dispositions. The basic leadership skills presented here are intended to optimize the surgeon’s role by emphasizing the importance of the nontechnical performance aspects of operations.
Principles of surgical leadership
Basic principles of leadership transcend the OR and are important in all aspects of a surgeon’s professional life. The first step in building leadership skills is to recognize one’s own strengths and weaknesses. Leadership may be separated into two components: self-management and team management. Self-management begins with emotional intelligence. Emotional intelligence may be thought of as the ability to manage ourselves and our relationships.1 For some people, mastering one’s emotions and understanding how best to respond to others may come naturally. For others, it takes time and patience to become adept at these skills.
Psychologist Daniel Goleman, PhD, asserts that emotional intelligence consists of four domains:
- Self-awareness—the ability to read one’s own emotions and recognize their impact
- Self-management—the ability to control one’s emotions and impulses and adapt to changing circumstances
- Social awareness—the ability to sense, understand, and react to other people’s emotions
- Social skills—the ability to inspire others with a compelling vision and to help others develop by offering feedback and guidance
Communication is an essential social skill that requires both listening and sending clear messages, according to Dr. Goleman, and conflict resolution can also be defined as a social skill that includes reducing conflict and facilitating resolutions, as well as promoting cooperation among team members.1
In the book Primal Leadership, Dr. Goleman and colleagues describe six leadership styles: authoritative, coaching, affiliative, democratic, pacesetting, and commanding. Multiple leadership styles are necessary for success and should be used according to specific circumstances. The following is a list of leadership styles as described by Dr. Goleman and colleagues:
- An authoritative leader inspires people by focusing on long-term goals. By listening to others, the leader articulates goals for the group and builds support.
- Coaching, or mentoring, involves delegating responsibility to other individuals as appropriate to their role. An effective coaching leader helps individuals assess their own strengths and weaknesses and set their own performance goals. The coach guides others in finding additional information and resources.
- The affiliative leader create a safe, supportive environment that addresses other’s emotional needs. This style builds team harmony, boosts morale, and engenders loyalty. The affiliative leader typically offers ample positive feedback.
- A democratic leader obtains input from others in the group. Encouraging input from others stimulates new ideas and increases participation. The democratic style encourages buy-in and builds trust and respect.
- The leader who uses the pacesetting style sets high performance standards and exemplifies them. Weak performers are expected to improve or be prepared to be replaced. This style is most effective with a team of highly talented and motivated individuals. The risk of the pacesetting style is that it can compromise morale.
- The commanding leader articulates the goals of the group and expects immediate compliance. While input from others may be encouraged, the leader maintains the ultimate authority. This leadership style is effective in a crisis situation.2
Improving leadership skills starts with creating a mental image of the ideal leader one aspires to be. This involves reflecting on one’s core beliefs and priorities. The leader must ascertain how others perceive him or her. It requires self-reflection, listening skills, and the willingness to solicit and receive feedback. It may require resetting one’s self-perception. An aspiring leader must then compare the “ideal self” with the “real self” to recognize strengths and opportunities for improvement. The next steps involve setting goals to build on strengths and improve in areas where one needs to be more effective. Like the development of technical skills, the cultivation of leadership skills requires deliberate practice. Personal growth will be enhanced by fostering relationships that are trusting and supportive.2
Another essential component of leadership is team management. Much of what we understand about how teams function stems from studies of teamwork and communication among cockpit crew members. Detailed reviews of several aviation catastrophes revealed a common element: the crew’s failure to communicate and coordinate actions effectively. In response, airlines adopted a curriculum that included fostering skills such as team-building, situational awareness, briefing strategies, and stress management.3 A key principle of this training is the need to flatten the hierarchy so that each individual feels empowered to speak up when a question arises.
Surgery and aviation are similar in their potential for high stress, time pressures, dependence on properly functioning equipment, and a historically rigid hierarchy. In a 2000 survey comparing attitudes and performance of cockpit crews and OR teams, expert observers rated surgery team performance inferior to that of cockpit crews. The perceptions of poor teamwork were shared among the nonsurgeon OR team members. In contrast, the surgeon’s perception of the teamwork and communication was disproportionately high. This finding is important because the study demonstrated that surgeons may not recognize when their communication skills are lacking. Additionally, when questioned about factors that contribute to team performance, 95 percent of pilots and only 55 percent of surgeons rejected hierarchies.4
Failures in teamwork and communication have been correlated with increased surgical errors and flow disruptions.5 Institutions that have implemented a formal team-training curriculum for OR personnel have increased efficiency, reduced errors, and improved staff satisfaction. Using adaptations of the aviation industry’s crew resource management program, the Department of Veterans Affairs initiated a medical team training program aimed at minimizing risk and improving patient safety.6,7 Risk-adjusted surgical morbidity declined 15 percent at the 74 hospitals with the medical team training program, compared with a decline of 10 percent in the 34 control hospitals. Other institutions have observed similar improved clinical outcomes after introduction of a team training curriculum.8,9
Airline pilots use a preflight checklist to facilitate communication. The purpose of the checklist is to convey information so that each pilot has a shared understanding of the situation and to ensure that no detail is overlooked. Implementation of a preoperative briefing using a checklist facilitates the sharing of information by empowering junior members to speak up and training senior members to listen. The use of a preoperative briefing has been shown to improve team performance in the OR. DeFontes and colleagues reported fewer errors, improved staff satisfaction, and decreased nurse turnover.10 Subsequent studies have reported improved culture and efficiency after implementation of a preoperative briefing.11,12 While these tools may initially seem artificial or contrived, they may be of great value when introduced intelligently and when supported consistently.
Leadership during crises
Firefighting is a long-standing, respected profession dedicated to managing crises and casualties on a daily basis, often at risk of great personal harm. Surgeons can learn much about the skills required for handling intraoperative crisis from a sentinel event that occurred on August 5, 1949, and went on to revolutionize the way firefighters are trained to handle disaster. The following is a description of that event.
A seemingly routine forest fire was spotted in Montana’s Helena National Forest at Mann Gulch, and 15 randomly selected members of the recently developed “smokejumpers” parachuted in for containment. Their assigned leader, Wag Dodge, was considered a good fireman, but was a “man of few words” and tended to quietly go about his business, assuming others would follow his stride.
On arrival, Mr. Dodge’s initial take was that the fire was routine, and he proceeded to eat dinner. The rest of the team took their cues from him and a relaxed atmosphere, including the taking of photographs, was established as they began digging trenches to control the fire.
Shortly thereafter, Mr. Dodge sensed the fire was changing and ordered the men to head downhill into the gulch toward the river, his intended escape route. Partway down the hill his tenor changed a second time. He suddenly ordered his men to drop their tools and run. To his inexperienced team, this was extraordinarily confusing, as he was ordering them to drop the very instruments they used to fight fire. They hesitated until they saw the fire rapidly rise above a hidden ridge, cutting them off from the escape route. By the time they started running back up hill (some with tools still in hand), the fire was moving at breakneck speed. Mr. Dodge then confused them again. He stopped running, took out a match, and started burning the ground around him. He yelled for the team to do the same and join him on the burned grass. Again, this made no sense to the crew. There was a raging fire gaining on them and he was lighting a second fire. Their leader had lost credibility, and none of the team followed his command.
Of the 14 crew, two survived by sliding into a rocky crevice, and 12 died, unable to outrun the flames. Mr. Dodge also survived. By setting the area of grass around him on fire, he eliminated the fuel source for the approaching forest fire—the first documented use of an “escape fire.” He laid down in the center of this burned grass, and the raging fire passed around him, leaving Dodge unharmed.13,14
The tragedy at Mann Gulch holds tremendous learning potential for the surgeon on many fronts. First, even the seemingly routine can quickly become catastrophic through errors in analysis and critical decision making. Secondly, the true intraoperative crisis creates an environment requiring advanced technical, communication, and leadership skills. And finally, team dynamics play a fundamental role in the successful management of emergencies.
In retrospect, Mr. Dodge erroneously set a casual tone at the Mann Gulch fire, which was difficult to overcome once the situation changed. In addition, he communicated poorly, particularly considering that he had never worked with the team he was about to lead. He could not realistically have expected others to follow him in the confusion of the crisis, and yet he did. How often do surgeons find themselves in similar positions?
A true OR crisis is unexpected, constitutes a threat to the patient, and necessitates critical steps be taken in a short time frame.15 Difference in expected pathology, problems with equipment or technology, and errors of communication can all conspire to create a surgical crisis. Rarely is a lack of intelligence or malfeasance on the part of the surgical professional the cause of the problem. Studies of critical decision making in medicine and other industries suggest other factors, often unknown, at play. For example, the “sunk cost effect” is the tendency to make decisions based on what has already been invested in an endeavor.16 We already scheduled the OR time, the patient and his caregiver already took the day off of work, or the instruments and implant have already been opened, but the patient is found to have a wet cough when seen in preoperative holding by anesthesia. Are we proceeding because it is the right thing to do for the patient or because of the time, money, and effort already invested in the case?
Surgeons may also fall victim to biases, such as the anchoring bias, which involves a failure to adjust to changes in the initial assessment. In instances involving the confirmation bias, surgeons filter the data available to support continuing the current management and exclude data that promotes a change. In cases of an availability bias, an individual’s most recent experience becomes the basis for decision making without recourse to a more comprehensive data review, which might include similar, if less recent, events.17 Of course, not all biases are bad. In fact, some biases may help health care professionals recover from unfamiliar critical situations.13 Nevertheless, it is important to become aware of prevailing biases, dysfunctional references, and confounding circumstances when complications and other problems are reviewed. Errors in leadership should be identified, characterized, and studied in order to encourage improved decision making in the future.
As educator Michael Roberto said, “We want to believe that the failure of others is due to lack of intelligence or skill because we want to convince ourselves that we would succeed at a similar endeavor despite the obvious risks, when, in fact, most of the mistakes are cognitive traps, independent of intellect or expertise.”13
Effective communication is key
As leaders, surgeons need to set the tone in the OR. We need to strike a balance between being so serious that we all are on edge and so relaxed that focus is lost. Communication is critical and should occur preoperatively, intraoperatively, and postoperatively.18 An amazing amount of crisis prevention can be accomplished by discussing the preoperative plan with the team. For example, anesthesia can have the right lines, medications, and backup plans in place, and nurses can pull additional equipment for the just-in-case scenarios. Perhaps most importantly, residents and assistants can better understand how to help the surgeon in a way that averts trouble before it starts.
Communication during a crisis requires a unique skill set, and outcomes may be dependent on it. It is important for health care professionals to learn to escalate urgency without increasing emotion. Communication should be precise and focused, but not laconic. It may be useful to deploy communications tools, such as SBAR, which stands for discussion of the situation, background, assessment, and recommendation.19 It is often a good idea to soften language by saying “I need” or “we need,” instead of the more accusatory “you need.”20 Using polite speech—including saying “please” and “thank you”—is also helpful.
One should avoid creating a hostile atmosphere. Never hurl accusations in the heat of the moment or insult others. Exaggeration, imprecation, and the use of inflammatory language serve no function. In contrasts, calls for help—including to nurses, anesthesiologists, technical support, and even to another experienced surgeon—for assistance, advice, and support, are always worth considering. Crises are often best managed with good help and good counsel.
Delegating in times of crisis also requires leadership skills. It is essential for the surgeon to assign tasks thoughtfully. For example, sending a circulating nurse out of the room to get something an anesthesia tech could obtain may not be the best use of resources.
When team members disagree on how to handle the crisis, the surgeon must quickly assess the discordant perspectives and make a decision on how to proceed, ideally in a non-judgmental way. If the disagreement is between the surgeon and another team member, it is important for the surgeon to hear the other perspective, acknowledge it, and understand the intent, even if the surgeon decides to ask all to “fly in formation.” Afterward, it is important to ask for feedback, and provide it constructively to others both during and after the crisis.20
The American College of Surgeons’ closed claims study found 19.8 percent of sentinel events were due largely to communication errors. Likewise, The Joint Commission has identified communication failure as a common contributing factor to operative and postoperative sentinel events.21 The importance of constant, effective communication cannot be overemphasized, as details and data obvious to the surgeon may not be visible or obvious to other personnel.
The tragedy at Mann Gulch provided the impetus to revolutionize the way forest fires are fought and, more importantly, how firefighters are trained. Standards for decision making and communication were created, team training was initiated, and mortality rates in wildfires diminished markedly.
While team training for surgical teams remains in its early stages, it holds tremendous potential for improving outcomes. The details differ, but the principles remain the same. Individual surgeons have the opportunity and the responsibility to guide other team members to adopt practices that optimize team performance. Changes in how we assess critical decision making, how we communicate through crises, and how we prepare as surgical teams all hold potential for improving patient safety.
Fundamental leadership skills include listening, sharing information, and supporting an esprit de corps. Effective listening is an active process that requires focus and deep attention. One must remain attuned to body language and tone that may communicate unspoken meaning. Listening with respect includes not interrupting and maintaining eye contact.
It is the responsibility of a leader to gather, note, and articulate the goals of a group and provide information that allows all team members to have a shared understanding. An effective leader establishes an environment in which other team members are motivated, feel a responsibility to the entire team, and feel comfortable speaking up to share relevant information. Establishing trust and respect will promote optimal teamwork during the daily routine as well as during critical moments.
Good leaders praise in public and deal with misbehavior in private. They make the effort to learn the names of individuals with whom they are working. Finally, one of the most important responsibilities of the leader is to say, “Thank you.”
The authors acknowledge Teo Forcht Dagi, MD, FACS, for guidance and editorial assistance in the development of this article.
- Goleman D. Working With Emotional Intelligence. New York, NY: Bantam Books; 1998.
- Goleman D, Boyatzis RE, McKee A. Primal Leadership: Realizing the Power of Emotional Intelligence. Boston, MA: Harvard Business School Press; 2002.
- Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. Int J Aviat Psychol. 1999;9(1):19-32.
- Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: Cross sectional surveys. Brit Med J. 2000;320(7237):745-749.
- Weigmann DA, El Nardissi AW, Dearani JA, Daly RC, Sundt TM. Disruptions in surgical flow and their relationship to surgical errors: An exploratory investigation. Surgery. 2007;142(5):658-665.
- Neily J, Mills PD, Young-Xu, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700.
- Sundar E, Sundar S, Pawlowski J, Blum R, Feinstein D, Pratt S. Crew resource management and team training. Anesthesiol Clin. 2007;25(2):283-300.
- Armour Forse R, Bramble JD, McQuillan R. Team training can improve operating room performance. Surgery. 2011;150(4):771-778.
- Young-Xu Y, Neily J, Mills PD, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP. Association between implementation of a medical team training program and surgical mortality. Arch Surg. 2011;146(12):1368-1373.
- DeFontes J, Surbida S. Preoperative Safety Briefing Project. The Permanente J. 2004;8(2):21-27.
- Hurlbert SN, Garrett J. Improving operating room safety. Patient Saf Surg. 2009;3(1):25.
- Nundy S, Mukherjee A, Sexton JB, Pronovost PJ, Knight A, Rowen LC, Duncan M, Syin D, Makary MA. Impact of preoperative briefings on operating room delays: A preliminary report. Arch Surg. 2008;143(11):1068-1072.
- Roberto MA. The Art Of Critical Decision Making. The Great Courses. Chantilly, VA: Teaching Co.; 2009.
- Rothermel R. Mann Gulch Fire: A Race That Couldn’t Be Won. U.S. Department of Agriculture. General Technical Report INT-299. 1993. Available at: http://www.fs.fed.us/rm/pubs_int/int_gtr299.pdf. Accessed February 28, 2012.
- St. Pierre M, Hofinger G, Bueschaper C (eds). Crisis Management in Acute Care Setting: Human Factors and Team Psychology in a High Stakes Environment. New York, NY: Springer; 2008.
- Beach LR, Connolly T. The Psychology of Decision Making: People in Organizations. Thousand Oaks, CA: Sage Publications; 2005.
- O’Reilly KB. Diagnostic errors: Why they happen. Am Med News. Available at http://www.ama-assn.org/amednews/2010/12/06/prsa1206.htm. Accessed March 16, 2012.
- Griffen FD. ACS closed claims study reveals critical failures to communicate. Bull Am Coll Surg. 2007;92(1):11-16.
- Institute for Healthcare Improvement. SBAR Technique for Communication. Available at: http://wwww.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx. Accessed November 29, 2011.
- Conflict Research Consortium. Respectful Communication. Available at: http://www.colorado.edu/conflict/peace/treatment/civilcom.htm/. Accessed November 11, 2011.
- The Joint Commission. Sentinel Event. Available at http://www.jointcommission.org/sentinel_event.aspx. Accessed March 16, 2012.