“Each of you is here because you serve in a leadership capacity at home. We want the benefit of all of your expertise,” said Patricia L. Turner, MD, FACS, Director, American College of Surgeons (ACS) Division of Member Services, in her opening comments at the sixth annual ACS Leadership & Advocacy Summit, May 6−9 in Washington, DC.
This year’s Leadership Summit drew 468 attendees—an 8 percent increase from 2016 and the highest number to date—representing all levels of ACS leadership, including Regents, Governors, Advisory Council members, Chapter Officers, Resident leaders, and other stakeholders.
This portion of the Leadership & Advocacy Summit—a paired meeting with a focus on both leadership enhancement and advocacy training—featured presentations covering a range of topics, including managing difficult people and conversations, leading from behind, volunteering “in your own backyard,” the state of ACS chapters and chapter success stories, overcoming burnout, leading health care systems, and understanding essential nontechnical skills in the operating room (OR).
Managing difficult people and conversations
“Overt bad behavior can be easier to handle as a leader than the more subtle negative behavior,” said Melina R. Kibbe, MD, FACS, Zack D. Owens Distinguished Professor and chair, department of surgery, University of North Carolina School of Medicine, Chapel Hill. Successfully managing difficult people, no matter how they exhibit negative behavior, is dependent upon a keen sense of self-awareness and self-regulation, Dr. Kibbe said. “Be open to your own emotional reaction—then modulate your emotions, because as a leader you can’t react emotionally.”
Dr. Kibbe described five different types of difficult people to manage, which include the following:
- Passive-aggressive: These individuals tend to “whisper” their dissent, are often sarcastic, and do not like being the center of attention. She suggests engaging passive-aggressive people openly and asking them to contribute in front of other team members.
- Chronic whiner: These individuals blame others for issues, which can disrupt teamwork. Dr. Kibbe advises leaders to underscore positive outcomes with concrete examples, while remaining realistic.
- People pleaser: Be careful when managing people who are always trying to please others. They tend to over-commit themselves and have a problem saying “no.”
- Unresponsive and disengaged: These individuals refuse to reveal their true motives and often use silence as an aggressive and controlling mechanism. Dr. Kibbe suggests asking disengaged team members open-ended questions and then waiting for their response.
- Hostile or disruptive: Address domineering or bullying staff members in a transparent and consistent manner, and try to determine the possible triggers for this behavior.
“Negative behavior in a health care environment is a serious patient care issue and jeopardizes patient safety because subordinates may be afraid to speak up,” Dr. Kibbe said. This behavior also affects patient engagement and can lead to an increase in patient complaints. She suggested surgeon leaders use the Vanderbilt Patient Advocacy Reporting System (PARS) or a similar tool to track and analyze patient complaints. “A very small number of physicians account for the majority of patient complaints,” Dr. Kibbe added, citing a Journal of the American Medical Association study of 645 physicians from 2002 that found that 9 percent of physicians account for half of all complaints.
“Disruptive and inappropriate behavior leads to patient safety concerns, high employee turnover, and greater malpractice risk,” Dr. Kibbe added. “The key to managing difficult people is emotional intelligence [EI] and establishing a culture of professionalism.”
Leading from behind
Leading from the front, also known as the command-and-control style, works well in urgent situations that arise in the OR. “But when you walk out of the OR, you need another set of leadership skills, also known as leading from behind,” said Patrick Hudson, MD, FACS, BCC, a surgeon and fellow of the National Anger Management Association. According to Dr. Hudson, leading from behind is rooted in collaborative and inclusive behavior. It is by no means passive. In fact, it is as active as leading from the front.
Dr. Hudson described the following four leading-from-behind strategies that can help surgeons motivate team members, help them function independently when necessary, and reduce stress levels:
- Avoid ego traps: Learn to balance self-confidence and self-assuredness with EI and team member needs.
- Empathy: “Confident leaders do not need to constantly prove themselves,” Dr. Hudson said. “Stop talking and actively listen.”
- Influence: “You need to learn to dance. Step one is tell, step two is ask. Tell them something, and then ask them a question. This is a classic coaching tool.”
- Self-management: “This is probably the most important skill. We need to be able to show [the team] that we can make mistakes and that we are willing to learn.”
Dr. Hudson noted that the leading-from-behind approach is derived from many sources, perhaps most notably from Nelson Mandela, who in his autobiography, Long Walk to Freedom, equates being a great leader with shepherds who traditionally lead their flock from behind the herd.
Volunteerism in your own backyard
“We train for long hours for many years, and why? To make a living, for sure, but there are lots of ways to make a living,” said Scott A. Leckman, MD, FACS, adjunct assistant professor of surgery, University of Utah School of Medicine, Salt Lake City. “We do this because we want to make a life-altering difference for others.”
In 2001, Dr. Leckman helped to lead the launch of the Health Access Project, a program that improves access to comprehensive health care for low-income and uninsured patients in Salt Lake County. Dr. Leckman described the challenges associated with recruiting the initial batch of surgeon participants.
“The first physician I talked to said, ‘No way, I already do too much free care,’ but he was talking about people who don’t pay their bills. I was talking about giving a gift to someone in need,” Dr. Leckman said. “I asked physicians to sign up for one patient per month. That wasn’t scary to anyone, and sign up they did. Patients are given a Health Access Project card, which looks like a standard health insurance card, and they wait in the same waiting rooms as other patients. When I operate on an Access patient, I am typically the only one in the room who is aware of this,” explained Dr. Leckman, who recruited the program’s first 300 physicians. Today, more than 600 physicians and nine hospitals in the county are providing free care to qualified individuals, totaling more than $22 million in donated health care.
In recognition of this effort, in 2014 Dr. Leckman received the ACS Surgical Volunteerism Domestic Award. He now serves on the Global Engagement Committee of Operation Giving Back (OGB), and chairs the Domestic Volunteerism Subcommittee.
“I don’t know what your destiny will be, but one thing I know—the only ones among you who will be really happy are those who will have sought and found how to serve,” said Dr. Leckman, ending his presentation with a quote from philosopher and physician Dr. Albert Schweitzer. “So, what can you do? Check the ACS OGB website for volunteer opportunities, but there are many more we don’t know about. Tell us what is going on in your community. If you don’t see anything in your area, be a leader and fill that need. If you ever hear your inner voice say, ‘Somebody should do something,’ remember, you are somebody.”
The state of the ACS chapters
After analyzing data from the 2016 Survey of ACS Domestic Chapters, which had a response rate of 82 percent, College leaders were able to determine strengths and opportunities for improvement in the following six categories:
- Member recruitment
- Chapter council/committee representation
- Financial health
- Communications
- Chapter meetings
- Advocacy
S. Rob Todd, MD, FACS, professor of surgery and chief, acute care surgery, Baylor College of Medicine, and chief, general surgery and trauma, Ben Taub Hospital, Houston, TX, presented details about the survey results, which will be disseminated to all chapters. Highlights are as follows:
- Of the respondents to the survey, 12 percent indicated a 10 percent increase in membership, while 18 percent noted a 10 percent decrease.
- The top revenue streams for the chapters include annual dues, meeting registration fees, exhibitor income, and income from investments and sponsorship income.
- Chapters report they most commonly communicate with their members quarterly, while others do it weekly, and others on an ad-hoc basis.
- Nearly half (49 percent) of the ACS chapters fail to engage in any social media platform.
- Approximately 89 percent of the chapters organized an annual chapter meeting in 2016, and 39 percent participate in ACS state lobby days.
“How do we act on the data? The ACS is committed to supporting the local chapters with new initiatives that are being implemented during the coming year, including promoting the value of chapter membership, increased marketing of chapter events, and continued support of chapter advocacy efforts,” Dr. Todd said.
Chapter success stories
Officers of the Connecticut Chapter, the North and South Texas Chapters, and the Georgia Society of the ACS (GSACS) shared their success stories in an effort to inspire other chapter leaders to boost member engagement and to improve their effectiveness.
Connecticut Chapter: Resident engagement
“Last year, four of our surgical residents attended the summit, and they really helped us determine what younger surgeons desire from the Connecticut Chapter,” said Kimberly A. Davis, MD, MBA, FACS, FCCM, President, Connecticut Chapter, and professor of surgery, Yale School of Medicine, New Haven. “Before the summit was over, plans were made to establish a Resident Council.” The Resident Council was formed in the summer of 2016 under an initiative led by the ex-officio resident member on the chapter board. The Resident Council is composed of one delegate from each residency program in Connecticut.
The Resident Council assumed responsibility for planning the resident panel at the chapter’s annual meeting, added a panel on legislative advocacy, hosted an American Board of Surgery In-Training Examination (also known as ABSITE) review session, and recruited resident participation for the 2017 Leadership & Advocacy Summit.
“What we realized is that tremendous success can come from the most unlikely source,” Dr. Davis said. “A little bit of mentoring goes a long way.”
North and South Texas Chapters: Collaboration is key
“It took us three years to set the stage for a closer relationship between the North and South Texas Chapters that would lead to sustained collaboration and joint ventures,” said Sharmila D. Dissanaike, MD, FACS, FCCM, Immediate Past-President, North Texas Chapter, and professor and Peter C. Canizaro Chair, department of surgery, Texas Tech University Health Sciences Center, Lubbock. Dr. Dissanaike said the primary goals of the collaboration were to offer a combined annual meeting and to unify advocacy efforts at the state level.
“This idea to have a combined meeting started at the 2014 Leadership & Advocacy Summit,” added Tien C. Ko, MD, FACS, Immediate Past-President, South Texas Chapter, and Jack H. Mayfield, MD, Distinguished Professor in Surgery, University of Texas Health Science Center, Houston. “We set some ground rules: there was to be 50-50 partnership in everything, including planning, fund raising, profit and loss sharing.” Other ground rules for the collaboration included dividing responsibilities between the two administrative staffs, centralizing fundraising efforts, combining program committees to develop sessions and invite speakers, and allowing medical students and surgery residents who were presenters at the annual meeting to participate free of charge.
This kind of collaboration between the two Texas chapters, the first in nearly a decade, was made possible after identifying leaders from each chapter and was facilitated through in-person planning meetings at the ACS Clinical Congress, the Leadership & Advocacy Summit, and Texas Surgical Society meetings.
“We realized that a combined meeting is a great way to synergize political lobbying efforts to energize individual chapters,” Dr. Ko said. He noted that a successful joint venture of this scale requires equal partnership and added that both the North and South Texas Chapters intend to have a joint meeting approximately every four years.
GSACS: Stop the Bleed
“Our first annual Trauma Awareness Day in Georgia is our success in a nutshell—and it took us a long time to get there,” said Dennis Ashley, MD, FACS, President-Elect, GSACS, and Milford B. Hatcher Professor and Chair of Surgery, Mercer University School of Medicine, Navicent Health, Macon, GA. The GSACS has participated in the ACS Lobby Day Grant program since its inception, according to Dr. Ashley, and when the College instituted a Lobby Day pilot program this year with a larger stipend of $15,000, the GSACS made it a goal to use the additional funds to institute a Stop the Bleed® program.
Before applying for the larger pilot project grant, the GSACS secured buy-in and support from the Georgia Trauma Foundation, the Georgia Committee on Trauma, and the Georgia Trauma Commission, ultimately forming the Georgia Trauma Awareness Day Coalition in October 2016. “‘Stop the Bleed’ was our battle cry,” Dr. Ashley said.
On February 7, the GSACS, other coalition members, trauma surgeons, and advocates from around the state met at the Georgia State Capitol to train legislators in Stop the Bleed techniques. The coalition also asked legislators to allocate $1 million from the state’s Super Speeder fund to place bleeding controls kits in all Georgia schools and to train teachers and staff about hemorrhage control tactics. (The Super Speeder fund is composed of monies collected from violators of Georgia’s Super Speeder Law, which fines drivers $200 for speeding more than 75 miles per hour (mph) on two-lane roads or more than 85 mph on any road within the state.)
More than 300 legislators, staff, and visitors were trained in Stop the Bleed techniques during Georgia’s inaugural Trauma Awareness Day, with surgeons in their white coats leading the program. As a result of this effort, three large trauma stations were installed at the Georgia State Capitol, and the $1 million in additional funds were appropriated to the Georgia Trauma Commission.
Overcoming burnout
“Work-related burnout is a triad composed of emotional exhaustion, depersonalization or a dehumanized perception of others, and dissatisfaction with job-related accomplishments,” said Krista L. Kaups, MD, MSc, FACS, professor of clinical surgery, department of surgery, University of California–San Francisco, Fresno. “Burnout refers specifically to one’s relationship to work, unlike depression, and is seen in occupations with a high level of personal involvement and interactions with others,” she said, citing a 2008 ACS survey in which 40 percent of 7,905 respondents met the criteria for burnout. According to the survey, surgeons tend to experience two components of the burnout triad—emotional exhaustion and depersonalization—but generally maintain a sense of personal accomplishment.
“Physician burnout has been shown to influence quality of care, patient safety, physician turnover, and patient satisfaction. What is the alternative to burnout? Having well-being as a goal,” Dr. Kaups said. “We now have a tool on the College’s website called the Physician Well-Being Index, which is available on the ACS website. This self-assessment tool is easy to complete and anonymous.” Available to all U.S. Fellows and Associate Fellows in active practice, as well as surgical residents and fellows, this validated screening mechanism helps users identify areas of risk in comparison with their peers across the U.S.
“We know that work-life balance, although often discussed and evaluated, is a myth. Work-life integration might be a better term,” Dr. Kaups said, adding that resilient people who excel at work-life integration share the following characteristics:
- A staunch acceptance of reality
- A deep belief—often buttressed by strongly held values—that life is meaningful
- An uncanny ability to improvise
Leading health care systems
“Hospitals with the most clinician involvement in management roles performed 50 percent higher on indicators of performance, such as effectiveness of overall management, performance management, and leadership, in contrast to hospitals with little clinical leadership,” said Bhagwan Satiani, MD, MBA, FACS, FACHE, professor of clinical surgery, division of vascular diseases and surgery; medical director, noninvasive vascular laboratory; and director, Faculty Leadership Institute at Wexner Medical Center, The Ohio State University College of Medicine, Columbus.
According to Dr. Satiani, leadership in health care is no different from management roles in other fields, although he underscored the importance of leadership training for preparing physician leaders to take on these roles in the future. Traditionally, physician leaders of hospital systems were appointed as a reward for their technical skills and loyalty to the organization, and sometimes because there weren’t any other competent individuals to fill these positions. In an effort to develop competent physician leaders, Dr. Satiani and colleagues created the Faculty Leadership Institute in 2013. The 12-month program is based on a curriculum composed of leadership competency training, strategic planning, financial management, team building, health care law, and change management.
The Faculty Leadership Institute’s program has resulted in enhanced continuity of leadership; the ability to identify faculty for committee work and leadership roles; higher retention of faculty, particularly junior faculty members; and, ultimately, improved patient care.
“I think the time for accidental leaders is done,” Dr. Satiani. “[Leadership roles] are not for everyone. But developing a pipeline for future leaders by investing in training and mentorship is important. If you’re not leading, you will be led.”
Mastering nontechnical skills for surgeons
“Nontechnical skills are critical for safety, longevity, and resilience in high reliability organizations and are related to surgical performance,” said Steven Yule, PhD, assistant professor of surgery, Harvard Medical School, and director of education and research, STRATUS Center for Medical Simulation, Brigham and Women’s Hospital, Boston, MA. “Surgeons are integrating lessons from other high reliability industries to improve operative performance,” he said, citing the explosion on the Piper Alpha oil platform in the North Sea in 1987 and the Space Shuttle Columbia disaster in 2003 as examples of what can happen when faulty decision making and an ill-defined safety culture are present.
“Error is normal,” Dr. Yule said. “Good team skills and communication strategies can help capture them before they result in patient harm.” Patient outcomes can be improved through nontechnical skills and team training, he noted.
Nontechnical skills for surgeons include proficiency in leadership, decision making, assertiveness, and team management. The Non-Technical Skills for Surgeons (NOTSS) program, which instructs surgeons on how to enhance these skills in the OR, was developed in Scotland in 2006 at the University of Aberdeen with support from the Royal College of Surgeons of Edinburgh. Dr. Yule was a part of this development team, and today he is part of the Non-Technical Skills Lab at Brigham and Women’s Hospital and Harvard Medical School.
In 2014, the NOTSS became part of the American Board of Surgery’s SCORE (Surgical Council on Resident Education) national curriculum for surgical training.
ACS update: Dr. Hoyt
“What do we have to do to meet the demands of an uncertain time? We need to operate at the speed of health care system change,” said ACS Executive Director David B. Hoyt, MD, FACS, in his closing remarks at the Leadership Summit. He summarized the organizational and financial strengths of the College, including programs and advocacy initiatives that support surgeons and help them stay informed at the local and national level.
Dr. Hoyt also provided an update on Optimal Resources for Surgical Quality and Safety, which officially debuted at the ACS Quality and Safety Conference in New York, NY, last month. The manual is intended to help health care institutions improve quality processes and outcomes. “The quality manual deals with the infrastructure that is needed to have a successful quality program in a hospital, including regulatory requirements, application of registry and outcomes data, and education and training. It also covers what the individual surgeon has to do to improve quality improvement, including the role of mentoring and coaching,” said Dr. Hoyt.
Dr. Hoyt updated attendees on other key College initiatives, including the resources available to navigate the Quality Payment Program; and the QuintilesIMS project, which will seamlessly link ACS clinical databases under a single platform, beginning with the recently released next-generation ACS Surgeon Specific Registry (SSR) featuring new SSR reports that he said are “more actionable, [have] faster generation, more interactive, and with better data visualization.”
“At this year’s summit, we’ve learned how to implement change leadership and how to measure and use emotional intelligence,” said Dr. Hoyt. “The beautiful thing about [these competencies] is that they are learnable skills.”
The next ACS Leadership & Advocacy Summit will take place May 19−22, 2018, in Washington, DC.
