Tuesday, March 29, 2016


                 There are many days when I examine my behavior during the day and ask: did I even come close to an enabling leader today or was did I act in a counterproductive manner? After, reading several papers on leadership this past month, I do not think I even come close to the pin (and maybe not on the putting green).
The group from Boston has produced yet another set of exceptional papers analyzing leadership styles in the Operating room and how these affect other individuals and the team. (1,2). Hopefully, I can review these with the authors in person, but until then this is what I took home from them:
The JASC paper assessed a range of leadership/teamsmanship styles via grading performance seen during video recording of five different surgeons comparing transactional and transformational leadership. The premise behind this study was that no prior studies assist us in understanding how one particular leadership style cultivates or inhibits specific team responses. In my observations of many surgeons, it appears that many of us tend to have a higher TRANSACTIONAL LEADERSHIP character (predominately goal or task focused with concentration more on rewards or failures) which overshadows any TRANSFORMATIONAL LEADERSHIP qualities (influenced on the collective mission and focus on inspiration and intellectual stimulation of our teammates). The question we all have had is there any detriment or attribute in displaying one style predominately over the other. In other words, does one style lead to reduced or improved safety? Does one style stymie or produce enhanced psychological safety- where our teammates feel encouraged to speak up when safety issues arise. To assess this, the Boston group used a previously described scoring system on leadership during an observation of intraoperative videos of five different surgeons.
      So did this group discover anything significant we can use in our own personal growth? They noted that the surgeons with high transformational scores tended to enter the room and immediately engage all the members of the team. The sense of a collective mission became apparent at the onset. Enthusiasm and support of others reigned during the entire case. It was clear that those in the room felt comfortable asking for clarification or alerting others about safety issues. Those with lower scores showed the least amount of engagement with others even during dire circumstances. More importantly was the discovery that one type of leadership style is NOT mutually exclusive of the other, but in fact typically additive. One can be a strong transactional leader (goal oriented) but also be a strong transformational leader (engaging).
      So I had to ask myself a question “for those of us who are clearly task oriented, is there any hope for us to become more team oriented?” I am sure I am not the only one out there who sees a situation as a task to be overcome and utilize our team as a set of tools to accomplish that task…OOOO I am sure that will not be viewed as politically correct. As I discussed last week, General Van Riper and I discussed the need to assure that team members actually know and understand what the objective is, during a mission or they may carry out a task either incorrectly or achieve the goal but at a cost that was not necessary. In the end that communication style will result in better morale. This study showed that you actually can be good at both and if you strive to be more translational in style, it should not negate your transactional methodologies, but will likely improve your ability to utilize the team to meet your objective.
      The other Boston study I mentioned assessed leadership behavior in terms of how the leader utilizes available team members (authoritative, explanatory, consultative, and delegative). They then assessed Junior Resident preferences to see which style meshed with their inherent learning preferences. As expected, us older surgeons were typically used to authoritative (autocratic) and some explanatory (explains their decisions to the team, but makes the decision) leadership during our training. We were typically told what was going to happen and grateful when the attendings explained why. The residents clearly indicate that they prefer consultative (team is consulted for an opinion) and delegative styles (the problem is put to the group and the majority wins) intraoperatively. I personally felt we were in a win-win situation when an attending asked my opinion on an approach I would prefer when managing an isolated aortic aneurysm with no distal occlusive disease (“hey I really want to do some properitoneal aortic approaches in case we have to operate on a patient with a frozen abdomen from prior surgical adhesions”). I had knowledge of differing approaches and felt it would be good to have this in my toolbox, just in case (which in fact it did several months later) so when my opinion appeared to be important I LEARNED THAT TECHNIQUE!
       But, does any of this really impact patient care? Well of course it does! Poor leadership, poor teamwork, unnecessary distractions, and a slew of other problems have been linked in multiple studies to poorer outcomes, increased stress on the team, and reduced morale. Once upon a time we could shirk our shoulders and say that we just did not have decent models that would fit in surgery or just say “well that’s easy for you to say! You don’t have to deal with the tough circumstances I have to!” but these studies are rapidly putting an end to that defense....... There are good models and while some circumstances are more stressful than others we can all adapt stress management strategies that include leadership approaches that foster teamwork, and improve morale but do not negatively impact patient care.
      Hopefully, the folks that have put these fantastic papers together have time in the near future to discuss them.


Hu YY, Henrickson Parker S, Lipsitz SR, Arriga AF, Peyre SE, Corso KA, Roth EM, Yule SJ, Greenberg CC. surgeon's leadership styles and team behavior in the Operating room. JACS 2016. 22(1):41-51.
Kissable-lee NA, Yule S, Pozner CN, Smink DS. Attending surgeons' leadership style in the operating room: comparing junior residents' experiences and preferences. JSE 2016. 73(1):40-44.

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