Centenary collection

Surgical leadership
M. Rothmund
Faculty of Medicine, Philipps University, Baldingerstrasse, Marburg 35033, Germany (e-mail: rothmund.dekan@staff.uni-marburg.de)

Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9052

The importance of good surgical

leadership becomes evident when its
absence leads a department into difculty. Leadership may also be abused,
as evidenced recently in a German
liver transplant programme in which
patient data were manipulated to push
certain individuals to the top of the
waiting list; other patients received
liver transplants for questionable reasons. Both of these actions were done
to increase the number of transplant
procedures.
During the 19th and 20th centuries,
gifted men (no women) opened new
elds; cardiac and transplant surgery
are examples. These advances were
based on excellent surgical technique
and vision. Often these men wrote
memoirs, and sometimes they were
honoured by biographies authored by
others. These texts provide insight
into their thoughts on leadership, as
well as their approach to research
and teaching. Although many of these
great men had some real qualities of
leadership, it is unlikely that they had
all of the skills required of a leader in
the 21st century.
In the past, surgical leaders did not
instruct their juniors by assisting them
to conduct operations or by teaching
them formally during lectures. A
trainee would have observed the
master at work in the operating room
and listened to his wise words during
rounds. The leader acted mainly as a
role model in the contexts of patient
care, surgical science and teaching.
Rudolf Nissen wrote about this in
his autobiography, quoting William
Halsted: There are men who teach
best by not teaching at all1 .
2013 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd

Although the virtues of knowledge,

technical excellence, research ability
and teaching skill are far from obsolete, the ideal surgical leader of today
requires much more. Non-technical
matters, such as emotional competence, resilience and communication
skills, are essential additional competencies. Psychologists, as well as
business and industry professionals
tell us, perhaps fortunately, that most
of these non-technical or soft leadership skills are not innate natural
abilities they can be learned and
developed through education, observation and experience2 . Halvorsen
and colleagues3 have described the
basic principles of those essential
non-technical skills. They note that
the rst step is to recognize ones
own strengths and weaknesses, and to
learn about the two components of
leadership, namely self-management
and team management, the prerequisite for both being emotional intelligence. Goleman, a psychologist, has
described the four domains of emotional intelligence as self-awareness,
self-management, social awareness
and social skills4 . He has also classied
different leadership styles: authoritative, coaching, afliative, democratic,
pace-setting and commanding. Multiple leadership styles are necessary
for success, to be used according
to the specic circumstances of a
situation3,5 .
Almost all we know about team
management comes from the airline industry. Team building, situational awareness, brieng strategies,
stress management, and the need
to atten hierarchy (so that anyone
and everyone may speak out when

a problem arises) are considered to

be the cornerstones of team management. Surgeons have not been
good at this. They tend to have
difculty in recognizing when they
lack communication skills3 . In one
study 95 per cent of pilots, but only
55 per cent of surgeons, believed that
hierarchies interfered with optimal
team performance6 . Some 13 years
have passed since this work was published, and perhaps the recent introduction of standard theatre procedures and checklists run by junior
surgeons or circulating nurses have
improved things7 . It remains the case,
however, that any evaluation of soft
skills as part of the recruiting process for a surgical leader is rare.
Most institutions continue to seek the
technically well trained surgeon from
a prominent institution, who comes
with an impressive list of funding and
publications8 (Fig. 1).
The CanMEDS framework denes
seven roles of competence for physicians and surgeons9 . Most of the
non-technical skills mentioned above
are included in these roles. When it
comes to surgical leaders, these abilities and qualities are essential. In
addition, leaders are expected to communicate appropriately, not only with
patients and health professionals, but
also with the hospital administration,
politicians and surgical specialty organizations. Conict-solving strategies
are part of these skills. Listening to all
parties and taking their views seriously
is crucial, as is observing condentiality, when required. In Germany,
when surgical chairpersons fail and
have to step down from their position, this usually relates to inadequate
British Journal of Surgery 2013; 100: 577579

578

M. Rothmund

PRESENT
Understands the business of medicine
Emotional competence and resilience
Communication skills
Ability to deal with and resolve conflict
Tackles adaptive challenges
Builds alignment and effective team player
Success in developing others

PAST
National stature, visibility, recognition
Recruited from a prominent institution
Strong references and reputation
Track record in research/funding
Clinical competency
Appreciation for teaching
Gets along fairly well with others

Achievement-oriented abilities
Emphasis on what the
candidate had accomplished
personally

Fig. 1

Professionalism
Technical competence
Motivation
Innovation
Teamwork
Communication skills
Decision-making
Business acumen
Emotional competence
Resilience
Effective teaching

Learning/teaching-oriented abilities
Emphasis on the candidate's ability to
learn and help others

Traditional and contemporary leadership characteristics2,8

communication with the administration and/or the chairpersons of other

departments within the institution.
As managers, surgical leaders
should be trained in organizational
tasking and in resource allocation;
they should understand the basics of
hospital and healthcare economy. In
recent years in Germany, almost all
surgeons who wish to be eligible for
the position of departmental chairperson have studied business administration. A Master of Business Administration degree makes them more
attractive to appointment committees than yet more efforts in research
and teaching, assuming an adequate
standard of these last two items and
a reasonable prociency in technical
surgery.
The role of a healthcare advocate
is an important one for surgical leaders. It is the leaders responsibility to
set standards within the department,
for instance in deciding whether the
volume of a difcult procedure is sufciently high to guarantee adequate
results, or whether to refer patients
needing complex major surgery to
a more specialist hospital. Training
and/or recruiting the best surgeon
2013 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd

available is another way of solving

such a problem.
Besides maintaining the requirements of a good scholar, surgical professionalism is an essential element of
leadership in surgery. Professionalism
means ongoing training, dened specialization, knowledge management
and team communication10 . Also of
importance are good social skills,
appropriate ethical standards and
honesty11 . Disastrous failures, such as
the one described at the beginning of
this article, should not happen if these
virtues are present in a leader.
In daily professional life, social
skills allow difcult problems to be
solved on the basis of common sense
and respect for individuals and groups
of healthcare professionals. Ethical
standards and honesty are prerequisites for any commitment to clinical
competence, for an atmosphere of
openness, for adequate patient safety
measures, for discussing ones own
errors and those of others, and for
resisting the (sometimes less than
ethical) challenges of hospital administrators. The economic pressure in
countries using a reimbursement system, with xed compensation on one
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side and the increasing expense for

hospital staff, energy, material and
devices on the other, can lead to problematic decisions. When leaders are
asked even coerced improperly to
increase the number of patients and
their case mix, and to perform more
and higher reimbursed procedures,
they must be prepared to resist.
Unnecessary procedures are unethical. Sadly, such resistance is not always
achieved.
A surgical leader, trained for the
traditional triathlon of operative skill,
research and teaching, is today inadequately prepared to run a department
successfully. The additional requirements described above are prerequisites if all the challenges of a complex
healthcare and hospital system are
to be met with condence. Indeed,
modern surgical leaders might better
be compared to decathletes. Although
styles of leadership may vary throughout the world British, Arabic and
Chinese leaders will behave in accord
with their native cultures the principles of modern leadership hold true
everywhere.
British Journal of Surgery 2013; 100: 577579

Surgical leadership

579

Yet there remains a place for

role models, whether their abilities be innate or acquired, or both.
Who else should teach young surgeons good surgery for example,
to dissect in the right anatomical plane and to stay calm in a
hazardous operative situation? Who
else should teach them even more
important the proper indications for
surgery? The words of the British surgeon Rodney Smith (Lord Smith of
Marlowe) still hold true: I can teach
you every operation within one year.
It takes me ve years to tell you when
to do it, but it takes you a lifetime
to learn when not to do it. And
nally, who else could teach how to
deal with the difcult patient or relatives, and how to care for the dying
patient?
Disclosure

The author declares no conict of

interest.

References
1 Nissen R. Helle Blatter Dunkle
Blatter. Deutsche Verlagsanstalt:
Stuttgart, 1969; 326.
2 Patel M, Warren O, Humphris P,
Kamran A, Hutan A, Rao C et al.
What does leadership in surgery
entail? Aust NZ J Surg 2010; 80:
876883.
3 Halvorsen AL, Walsh DS, Rikkers L.
Leadership skills in the OR. Part 1.
Communication helps surgeons avoid
pitfalls. Bull Am Coll Surg 2012; 97:
814.
4 Goleman D. Working with Emotional
Intelligence. Bantam Books: New York,
1998.
5 Goleman D, Boyatzis RE, McKee A.
Primal Leadership: Realizing the Power
of Emotional Intelligence. Harvard
Business School Press: Boston, 2002.
6 Sexton JB, Thomas EJ,
Helmreich RL. Error, stress and
teamwork in medicine and aviation:
cross sectional surveys. BMJ 2000;
320: 745749.
7 Haynes AB, Weiser TG, Berry WR,

10

11

Lipsitz SR, Breitzat A, Dellinger EP

et al.; Safe Surgery Saves Lives Study
Group. A surgical safety checklist to
reduce morbidity and mortality in a
global population. N Engl J Med 2009;
360: 491499.
Souba WW. The new leader: new
demands in a changing, turbulent
environment. J Am Coll Surg 2003;
197: 7987.
Royal College of Physicians and
Surgeons of Canada. The CanMEDS
Physician Competency Framework, 2010;
http://rcpsc.medical.org/canmeds/
index.php [accessed 11 November
2012].
McCulloch P. Surgical
professionalism in the 21st century.
Lancet 2006; 367: 177181.
Gruen RL, Watters DAK,
Hollands MJ. Surgical wisdom. Br J
Surg 2012; 99: 35.

BJS Special Issue on Emergency Surgery: Call for Papers

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2013 British Journal of Surgery Society Ltd

Published by John Wiley & Sons Ltd

www.bjs.co.uk

British Journal of Surgery 2013; 100: 577579