Surgical leadership across generations

Over the last decade, a transformation has occurred in surgery. With rapid technological advances, changes in reimbursement, and modifications to resident training programs, strong leadership is needed to ensure future success.

Changes in health care

The future of the U.S. health care system is powered by the vision of those leaders who thoroughly understand its past and have explored the dominant factors that have played an important role in the transformation of medicine throughout the twenty-first century.

While twentieth century medicine revolved around the treatment of disease, today’s focus is largely on preventive care. The emerging application of the sciences, such as genomics, proteomics, medical technologies, and informatics, has facilitated our understanding of the molecular and cellular events leading to disease. This new understanding should improve physicians’ ability to detect patients at risk and to potentially implement necessary preventive strategies.¹ With the advancement of treatment options, medicine has shifted from the management of acute disease to the management of chronic illnesses.^2,3 One out of every two adults—almost 133 million Americans—suffers from at least one chronic illness, and in 2020 this number is expected to grow to 157 million.⁴ A growing body of evidence shows that the rising rates of chronic disease are placing an unsustainable burden on the national economy, with health care spending expected to reach $4.2 trillion in 2016.⁵ The steady increase and growing ethnic diversity of the U.S. population, as well as the 78 million baby boomers becoming Medicare-eligible over the next 18 years, are creating an ever more compelling need to transition from an acute to a chronic care model.^6-9

As scientific knowledge accumulates, we realize that the etiology of disease is multifactorial. The interplay occurs between genes, infectious agents, environment, nutrition, behavior, and society. To solve the mystery of complex medical conditions, multi- and interdisciplinary research teams consisting of physicians, biologists, scientists, engineers, financial analysts, and other professionals are essential.¹⁰ A major barrier has been the lack of a common language among these multidisciplinary groups, the development of which would facilitate an effective and constructive dialogue. Surgeon leaders with the capability to effectively build and maintain multidisciplinary teams can set specific goals, find solutions, and translate such collaboration into effective health care delivery.¹¹

One major difference between the practice of medicine today and that of the twentieth century is that patients have greater and easier access to medical information and tend to evaluate health care providers in various ways.¹² The rise of social media, such as blogs and online social networks, has further fueled interest in the new “science of sentiment analysis,” a means of determining the attitude of an individual with respect to a specific topic or source.¹³ Access to care is considered a social right, and the patient plays an indirect, though crucial, role in any future renovations of medicine. Surgeons must safeguard patients’ ability to access appropriate care.

Physicians, hospitals, and university researchers may not generally be viewed as political entities, but when it comes to topics such as the highly debated Affordable Care Act, all three parties have certain advantages over government leaders. A 2009 poll of 1,009 national adults ages 18 and older found that nearly three-quarters (73 percent) of Americans trust physicians to take the lead in reforming the U.S. health care system.¹⁴ Whereas with great trust comes great responsibility, surgeons, residents, and researchers cannot further neglect our unsustainable health care system. To ensure that surgeons are able to influence the health policy development process, future medical education should incorporate formal training that allows for the development of competent physician leaders.

Advances in surgical training

Surgical training has undergone rapid changes in recent years. Beginning in 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated that residency training programs restrict duty hours and, thus, the 80-hour workweek was implemented. More recently, interns’ duty hours were further limited to a maximum of 16 consecutive hours. The goal of these work-hour restrictions is to improve patient safety by reducing resident fatigue. Since the implementation of these new restrictions, concerns have arisen regarding resident education and competency, especially in the setting of technological advancements in the treatment of surgical disease.

Traditional surgical resident education has occurred according to the model formalized by William S. Halsted, MD, FACS. The “see one, do one, teach one” paradigm guided surgical educators, and helped aspiring surgeons develop their technical skills. Although this model was successful in creating a highly skilled surgical workforce, it relied on a high volume of operative cases with progressive levels of responsibility that took years to amass. In the eyes of many experienced surgical educators, work-hour restrictions can essentially deprive the resident of such educational opportunities. This concern has been validated in a review of the ACGME Resident Statistic Summary that reported a decrease in total operative case volume and senior-level cases, with the number of junior-level cases remaining the same.¹⁵ Furthermore, in a survey of surgical trainees, a large subset of senior residents considered work-hour restrictions to be an educational barrier and expressed a desire to work longer hours.¹⁶

Training surgeons outside of the traditional Halsted model is not a novel concept. Since the early 1990s, with the advent of endovascular surgical techniques and continued progress in minimally invasive surgery, surgeons have spent time outside of the operating room (OR) and in simulation labs learning new and innovative techniques. The acceptance of surgical skills education outside of the OR has been widely accepted, and this is no more apparent than in the ACGME’s Residency Review Committee’s (RRC) requirements for surgical training programs, which recommend access to simulation centers. In fact, the Fundamentals of Laparoscopic Surgery is a Web-based educational module endorsed by the American College of Surgeons (ACS) and required for applicants to the American Board of Surgery (ABS).

As technology advances among the surgical subspecialties, components of specialty training may be excluded from the current curriculum of general surgery residency. Over the past two decades, the number of open, major vascular operations performed has significantly decreased and been replaced with minimally invasive techniques, such as endovascular aneurysm repair.¹⁷ As a consequence, fewer open vascular cases are trickling down from the fellow to the resident level, which ultimately takes away from the experience in basic surgical principles, such as gaining proximal and distal vascular control. Simulation and skills training (using cadaveric, animal, inanimate, or computer models) are ways to teach surgical residents not only the lifesaving skill of vascular control, but also to introduce vascular access and basic endovascular techniques.

The surgery training paradigm has certainly been altered to accommodate work-hour restrictions while still providing residents with the proper amount of exposure to surgical patients both in the clinic, emergency department, ward, intensive care unit, and OR. With the tendency toward specialization throughout all of medicine, a transition is already taking place, with integrated surgical training programs or early specialization programs. This movement has allowed for rapid progression via a shorter course of basic/early general surgery training with a more dedicated period of development in the desired specialty training program.

Academic surgical units play a fundamental role in the future of surgery and require effective leaders to maximize their impact. At the same time as the demand for surgical procedures is growing, financial resources are becoming more limited. The current changes make it imperative that modern surgical leaders acquire not only surgical skills, but also the ability to develop critical thinking, problem solving, and team-building skills. Leadership development must be incorporated early on into the resident curriculum, which will facilitate the creation of leaders who understand these changes and are effective surgical educators.

Leadership qualities

Various definitions of leadership exist, most of which emphasize the importance of influence. For example, John C. Maxwell, who has written extensively on the topic, has stated, “Leadership is influence—nothing more, nothing less.”¹⁸

Traditionally, leadership was judged largely on the basis of individual achievements. However, Wiley Souba, MD, FACS, and colleagues have asserted that great leaders have integrated their strengths in three fundamental areas: What they know, what they do, and who they are.¹⁹ This includes performance measures, such as knowledge, expertise, competence, action, results, accomplishments, and personal qualities and attributes.

In an interview with 10 female surgical leaders, 60 percent said the greatest challenges for leaders are obtaining buy-in, building consensus, and leading people through change.²⁰ Other challenges identified during the interview include the following: maintaining clinical skills, creating positive cultures, keeping communication open, avoiding burnout, recognizing and implementing ideas, dealing with difficult personalities, being a role model, managing funds, and making tough decisions.
Traditionally, the emphasis in surgical leadership was almost solely on technical and clinical expertise with minimal consideration given to management skills. A total of 258 leadership behaviors were observed over the course of 63 hours in a recent study.²¹ Surgeons most frequently showed the following behaviors: guiding and supporting (33 percent), communicating and coordinating (20 percent), and task management (15 percent). Most of these behaviors were directed to the room rather than at a specific team member. Surgeons demonstrated leadership qualities significantly more often during highly complex cases.

The importance of mentorship in the development of a surgical leader has been widely acknowledged. In a discussion of mentorship in the twenty-first century, Eva Singletary, MD, FACS, said a good mentor should listen, facilitate and provide networking experiences, share knowledge of the system, offer assistance as needed, teach by example, motivate, promote independence and balance, and rejoice in the success of their mentees.²² Even the traditional method of mentoring, in which the mentor served as technical expert, political strategist, role model, coach, and confidant, has given way to the mosaic model of mentoring, in which residents have multiple mentors, one for each sphere of their life and work, including clinical practice, research, personal life, communication, management skills, and so on.

The ACS was founded with the primary goal of improving the quality of care for the surgical patient by setting high standards for surgical education and practice. As an organization that has fostered and developed surgical leadership over the past century, its impact on surgery in America and around the globe has been tremendous. One of our young leaders, Patricia L. Turner, MD, FACS, Director of the ACS Division of Member Services, exemplifies the type of leader who has cultivated mentors on multiple levels in order to excel at both the professional and personal level (see photo).

Born and raised in Washington, DC, Dr. Turner said she “always wanted to be a surgeon, even as a young girl,” a sentiment not every physician may relate to. So, where does her passion and drive come from? Who was mentoring her at such a young age? As Dr. Turner’s career developed, many individuals provided guidance and contributed to her success. She cites L.D. Britt, MD, MPH, FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), immediate Past-President of the ACS, as the individual who has had the greatest effect on her career. Interestingly, she never attended Eastern Virginia Medical School, Norfolk, where Dr. Britt is the Edward Brickhouse Professor and Chair of surgery. She did not train there as a resident, and she has not directly worked for Dr. Britt. Their relationship actually began at a meeting for medical students, where she showed that same interest and zeal that many of us have seen in her. Over time, their relationship developed, and Dr. Turner was able to use his wisdom, experience, and guidance to make the necessary decisions to eventually become the surgical leader she is today.

Having the right mentors is only part of the leadership equation. Without the commitment, dedication, and a strong work ethic, Dr. Turner would not be where she is today. In fact, as a junior faculty member at the University of Maryland, Baltimore, Dr. Turner admitted that her academic productivity could have been better. In conversations with Dr. Britt, she began to provide him with various reasons why she had been less successful in her initial few years. Dr. Britt’s advice to her: “You can complain about your situation, but if you want to get promoted, the coin of the realm is delivering results.” Dr. Turner stated that this was probably the best single piece of advice she has been given with respect to her professional career.

Dr. Turner is as dedicated to her family as she is to the ACS. Her husband and two young daughters, Morgan Elizabeth (age 6), and Jessica Carmen (age 12), plan to join her in Chicago this year. Balancing our personal and professional lives is vital to long-term success.

Dr. Turner provides an excellent example of why it is important to find the right mentorship opportunities. Mentors will not do the work for their mentees, but they will provide them guidance in their chosen field. This relationship has been viewed with much gratitude among the mentees, who desire to “carry on the torch” of mentorship in their lives. As Ruth Whitman once said, “In every art, beginners must start with models of those who have practiced the same art before them.”²³

Theories of leadership

There are a wide range of theories regarding the development of skilled leaders. The “great man theory” postulated by Thomas Carlyle says that leaders are born and not made, and great leaders emerge when they are needed. The “trait theory” describes how traits of leadership are inherited, with successful leaders being endowed with the right combination of qualities.²⁴ In contrast, the “behavioral theory” is grounded in the notion that leaders can be groomed through proper teaching and observation.

Various types of leadership styles are often exhibited by leaders. Autocratic leaders exert high levels of power over their team members. Under this leadership style, there is a clear division between the leader and the followers. Few opportunities are available for making suggestions, even if applying these recommendations would be in the team’s or the organization’s best interest. The autocratic style of leadership often breeds resentment, which leads to high levels of absenteeism and staff turnover.
On the opposite end of the spectrum are transactional leaders, who tend to adapt to and thrive in challenging environments. They promote networking and encourage problem-solving and innovation. This form of leadership depends on some form of exchange—for example, productivity in return for rewards.

Similar to the transactional leadership style, transformational leaders focus on collaboration and working toward and promoting an ideal. Leaders work toward a common goal with followers and invest in their development.

The current emphasis in surgical leadership has shifted from the traditional autocratic and transactional styles to a more transformational model.²⁴ Thomas Lee, MD, recently published an article addressing the traditional approaches to leadership in medicine.²⁵ According to Dr. Lee, physicians see themselves as heroic lone healers, and working in teams can be challenging. However, under the transformational model, building effective teams is a key part of being a successful leader. In contrast to traditional leaders who try to maximize revenue under existing revenue systems, new generation leaders focus on measures, such as outcomes and performance improvement processes. Development of health care systems that are patient-centered is now considered a touchstone toward improving quality of care.

Traditionally, hospital departments were organized around the physician. The culture of health care organizations has been moving away from these silos to the development of units where a variety of specialty physicians care for a particular patient population (such as heart patients) under one roof—called “collocation.” Due to the fact that the practice of medicine is highly evidence-based, performance measures or outcome assessment plays a key role in referrals and potentially physician reimbursement. The surgeon-leader must be well-versed in these developments and possess not only basic leadership qualities, but also sound financial management skills and the ability to collaborate with multidisciplinary team members.

The contrast between clinical care and organizational leadership has been described as a difference in cultures.²⁶ Medical culture is largely characterized by autonomous decision making, a reactive approach to problem solving, and a focus on individuals within the context of their biological, psychosocial, and sociological environments. The administrative focus is typically proactive, systems-oriented, and collective, and it is in sharp contrast to physicians’ focus on helping individual patients one at a time.

Leadership development

The transformational change necessary for physicians to develop business and leadership skills can be supported and encouraged in a leadership development program that includes a specific curriculum design, program monitoring, and opportunities to apply new skills in practice.²⁶ Peter Büchler and colleagues demonstrated how implementation of business management concepts changes workflow management and surgical training, and they emphasize the importance of introducing a business skills curriculum into medical education and postgraduate surgical career development.²⁷ Leadership courses in surgery also assist in the development of these skills, and examples of these courses include the College’s Residents as Teachers and Leaders course and the Surgeons as Leaders course, as well as the career development programs that the Association of Women Surgeons sponsors.

Conclusion

With rapid changes occurring in the nation’s health care system, the need for strong surgeon leaders has never been greater. The essential qualities and requirements for such leadership have changed. Although excellent clinical knowledge, technical skills, and strength of character are still the hallmarks of surgical leadership, current leaders also require administrative and management skills. Incorporation of early formal leadership training during both medical school and the residency period is necessary to produce capable leaders who can guide surgery through these changing times.

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Disclaimers
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the U.S. Department of the Navy, U.S. Department of Defense, or the U.S. government.

Dr. Grabo states: “I am a military service member. This work was prepared as part of my official duties. Title 17, USC, §105 provides that ‘Copyright protection under this title is not available for any work of the U.S. Government.’ Title 17, USC, §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.”

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References

1. Snyderman R, Langheier J. Prospective health care: The second transformation of medicine. Genome Biol. 2006;7(2):104.
2. Partnership for Solutions. Chronic conditions: Making the case for ongoing care. A Project of Johns Hopkins University and The Robert Wood Johnson Foundation. September 2004. Available at: http://www.partnershipforsolutions.org/DMS/files/chronicbook2004.pdf. Accessed March 11, 2012.
3. Snyderman R, Williams RS. Prospective medicine: The next health care transformation. Acad Med. 2003;78(11):1079-1084.
4. Bodenheimer T, Chen E, Bennett HD. Confronting the growing burden of chronic disease: Can the U.S. health care workforce do the job? Health Aff (Millwood). 2009;28(1):64-74.
5. Trunkey DD. Health care reform: What went wrong. Ann Surg. 2010;252(3):417-425.
6. U.S. Census Bureau. Available at: http://www.google.com/publicdata/explore?ds=kf7tgg1uo9ude_&met_y=population&tdim=true&fdim_y=country:US&dl=en&hl=en&q=us+population – !ctype=l&strail=false&bcs=d&nselm=h&met_y=population&fdim_y=country:US&scale_y=lin&ind_y=false&rdim=country&idim=country:US&ifdim=country&tdim=true&hl=en&dl=en. Accessed Mar. 11, 2012
7. Wilensky GR. Directions for bipartisan medicare reform. N Engl J Med. 2012;366:1071-1073.
8. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: Translating evidence into action. Health Aff (Millwood). 2001;20(6):64-78.
9. American College of Physicians. The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care. A report from the American College of Physicians. January 30, 2006. Available at http://www.acponline.org/advocacy/events/state_of_healthcare/statehc06_1.pdf. Accessed Mar. 11, 2012.
10. Center for Integration of Medicine and Innovative Technology. Available at: http://www.cimit.org/. Accessed: March 11, 2012.
11. Surgeons as leaders: From operating room to boardroom. Available at: http://www.facs.org/education/surgeonsasleaders.html. Accessed March 11, 2012.
12. Siegrist RB Jr. The drive toward measuring the quality of performance of physicians. MedGenMed. 2006;8(2):86.
13. Siegrist RB Jr. The Relationship between Patient Satisfaction and Quality and Insights from the New Science of Sentiment Analysis. Paper presented at the 59th Annual Meeting of the Massachusetts Chapter of the American College of Surgeons. 2011; Boston, MA.
14. Saad L. On healthcare, Americans trust physicians over politicians. Gallup, Inc. Available at: http://www.gallup.com/poll/120890/Healthcare-Americans-Trust-Physicians-Politicians.aspx. Accessed March 11, 2012.
15. Kairys JC, McGuire K, Crawford AG, Yeo CJ. Cumulative operative experience is decreasing during general surgery residency: A worrisome trend for surgical trainees? J Am Coll Surg. 2008;206:804-811.
16. Moalem J, Salzman P, Ruan DT, Cherr GS, Freiburg CB, Farkas RL, Brewster L, James TA. Should all duty hours be the same? Results of a national survey of surgical trainees. J Am Coll Surg. 2009;209(1):47-54.
17. Grabo DJ, DiMuzio PD, Kairys JC, McIlhenny SE, Crawford AG, Yeo CJ. Have endovascular procedures negatively impacted general surgery training? Ann Surg. 2007;246(3):472-477.
18. Maxwell JC. Developing the Leader Within You, 2nd ed. Thomas Nelson; 2000.
19. Souba WW. Leadership and strategic alignment—getting people on board and engaged. J Surg Res. 2001;96:144–151.
20. Kass RB, Souba WW, Thorndyke LE. Challenges confronting female surgical leaders: Overcoming the barriers. J Surg Res. 2006;132:179–187.
21. Parker SH, Yule S, Flin R, McKinley A. Surgeons’ leadership in the operating room: An observational study. Am J Surg. 2011; Dec 16 [Epub ahead of print].
22. Singletary SE. Mentoring surgeons for the 21st century. Ann Surg Oncol. 2005;12:848–860.
23. Whitman R. Becoming a Poet. Boston, MA: The Writer, Inc; 1982.
24. Patel VM, Warren O, Humphris P, Ahmed K, Ashrafian H, Rao C, Athanasiou T, Darzi A. What does leadership in surgery entail? ANZ J Surg. 2010;80(12):876-883.
25. Lee T. Turning doctors into leaders. Harvard Business Review. 2010;4:50-58.
26. McAlearney AS, McAlearney AS, Fisher D, Heiser K, Robbins D, Kelleher K. Developing effective physician leaders: Changing cultures and transforming organizations. Hosp Top. 2005;83:11-18.
27. Büchler P, Martin D, Knaebel HP, Büchler MW. Leadership characteristics and business management in modern academic surgery. Langenbecks Arch Surg. 2006;391(2):149-156.