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Surgery_Schwartz. Part IBasic ConsiderationsBrunicardi_Ch01_p0001-p0026.indd 129/01/19 10:58 AM Brunicardi_Ch01_p0001-p0026.indd 229/01/19 10:58 AMThis page intentionally left blank


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Surgery_Schwartz. Leadership in SurgeryStephen Markowiak, Hollis Merrick, Shiela Beroukhim, Jeremy J. Laukka, Amy Lightner, Munier Nazzal, Lee Hammerling, James R. Macho, and F. Charles Brunicardi 1chapterINTRODUCTIONThe field of surgery has evolved greatly from its roots, and sur-gical practice now requires the mastery of modern leadership principles and skills as much as the acquisition of medical knowledge and surgical technique. Historically, surgeons took sole responsibility for their patients and directed proceedings in the operating room with absolute authority, using a command-and-control style of leadership. Modern surgical practice has now evolved from single provider–based care toward a team-based approach, which requires collaborative leadership skills. Surgical care benefits from the collaboration of surgeons, anes-thesiologists, internists, radiologists, pathologists, radiation oncologists, nurses, pharmacists, social workers, therapists, hospital staff, and administrators. Occupying a


Surgery_Schwartz

Surgery_Schwartz. of surgeons, anes-thesiologists, internists, radiologists, pathologists, radiation oncologists, nurses, pharmacists, social workers, therapists, hospital staff, and administrators. Occupying a central role on the healthcare team, surgeons1 have the potential to improve patient outcomes, reduce medical errors, and improve patient satisfaction through their leadership of the multidisciplinary team. Thus, in the landscape of modern healthcare systems, it is imperative that surgical training programs include formal instruction on leadership principles and skills to cultivate their trainees’ leadership capabilities.Many medical and surgical communities, including residency training programs, acknowledge the need for improved physician leadership. Specifically, surveyed surgical residents felt a lack of confidence in multiple areas of leadership, particularly in conflict resolution.2 Surgical trainees identify leadership skills as important, but they report themselves as “not competent” or


Surgery_Schwartz

Surgery_Schwartz. a lack of confidence in multiple areas of leadership, particularly in conflict resolution.2 Surgical trainees identify leadership skills as important, but they report themselves as “not competent” or “minimally competent” in this regard.2,3 While a small number of surgical training programs have implemented 1formal curricula focused on teaching leadership principles, it is now imperative that all surgical training programs teach these important skills to their trainees.4,5 Interviews of academic chairpersons identified several critical leadership success factors,6 including mastery of visioning, communication, change management, emotional intelligence, team building, business skills, personnel management, and systems thinking. These chairpersons stated that the ability of emotional intelligence was “fundamental to their success and its absence the cause of their failures,” regardless of medical knowledge.6 Thus, residency programs need to include leadership training to prepare future


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Surgery_Schwartz. was “fundamental to their success and its absence the cause of their failures,” regardless of medical knowledge.6 Thus, residency programs need to include leadership training to prepare future surgeons for success in modern healthcare delivery.In the United States, the Accreditation Council for Graduate Medical Education (ACGME) has established six core competencies—patient care, medical knowledge, prac-tice-based learning and improvement, interpersonal and com-munication skills, professionalism, and systems-based practice (Table 1-1)4—that each contain principles of leadership. The ACGME has mandated the teaching of these core competencies but has not established a formal guide on how to teach the lead-ership skills described within the core competencies. Therefore, this chapter offers a review of fundamental principles of leader-ship and an introduction of the concept of a leadership training program for future surgeons.DEFINITIONS OF LEADERSHIPMany different definitions of


Surgery_Schwartz

Surgery_Schwartz. offers a review of fundamental principles of leader-ship and an introduction of the concept of a leadership training program for future surgeons.DEFINITIONS OF LEADERSHIPMany different definitions of leadership have been described. Former First Lady Rosalynn Carter once observed that “A leader takes people where they want to go. A great leader takes people Introduction 3Definitions of Leadership 3Levels of Leadership / 4Fundamental Principles of Leadership 4Vision / 5Generating Belief in Your Vision / 6Willingness / 7Time Management / 10Self-Care and Wellness / 11Recruitment / 11Creating a Culture of Empathy, Patient-Family-Centered Care, and Personalized Surgery / 11Why We Lead 11Choosing to Become a Leader / 11Leadership’s Effect on Healthcare Cost and Clinical Outcomes / 11The Importance of Diversity and Leadership 12Leadership Styles 12Formal Leadership Training Programs in Surgery 13History of Leadership Training and the Multifactor Leadership Questionnaire / 13Designing


Surgery_Schwartz

Surgery_Schwartz. of Diversity and Leadership 12Leadership Styles 12Formal Leadership Training Programs in Surgery 13History of Leadership Training and the Multifactor Leadership Questionnaire / 13Designing the Program / 14Practicing Leadership Skills and Assessing Leadership Formally With Objective Structured Clinical Examination (OSCE) and Simulation / 14Evaluation of Surgeon Performance / 16Mentoring and Development 18Mentoring / 18Modeling Leadership for Medical Students and the “Hidden Curriculum” / 18Tools to Measure Leadership Outcomes in Healthcare / 19Leadership Training for the Prospective Surgeon / 20Early Career Development and Establishing Oneself 20Senior Faculty Development: Transitioning to Departmental Leadership and Legacy Building 21Conclusion 21Brunicardi_Ch01_p0001-p0026.indd 329/01/19 10:58 AM 4Table 1-1Accreditation Council for Graduate Medical Education core competenciesCORE COMPETENCYDESCRIPTIONPatient careTo be able to provide compassionate and effective


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Surgery_Schwartz. 329/01/19 10:58 AM 4Table 1-1Accreditation Council for Graduate Medical Education core competenciesCORE COMPETENCYDESCRIPTIONPatient careTo be able to provide compassionate and effective healthcare in the modern-day healthcare environmentMedical knowledgeTo effectively apply current medical knowledge in patient care and to be able to use medical tools (i.e., PubMed) to stay current in medical educationPractice-based learning and improvementTo critically assimilate and evaluate information in a systematic manner to improve patient care practicesInterpersonal and communication skillsTo demonstrate sufficient communication skills that allow for efficient information exchange in physician-patient interactions and as a member of a healthcare teamProfessionalismTo demonstrate the principles of ethical behavior (i.e., informed consent, patient confidentiality) and integrity that promote the highest level of medical careSystems-based practiceTo acknowledge and understand that each


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Surgery_Schwartz. of ethical behavior (i.e., informed consent, patient confidentiality) and integrity that promote the highest level of medical careSystems-based practiceTo acknowledge and understand that each individual practice is part of a larger healthcare delivery system and to be able to use the system to support patient careKey Points1 Effective surgical leadership improves patient care, safety, and clinical outcomes.2 A fundamental principle of leadership is to provide a vision that people can live up to, thereby providing direction and purpose to the constituency.3 Surgical leaders have the willingness to lead through an active and passionate commitment to the vision.4 Surgical leaders have the willingness to commit to lifelong learning.5 Surgical leaders have the willingness to communicate effec-tively and resolve conflict.6 Surgical leaders must practice effective time management.7 Different leadership styles are tools to use based on the team dynamic.8 Surgical trainees can be taught


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Surgery_Schwartz. effec-tively and resolve conflict.6 Surgical leaders must practice effective time management.7 Different leadership styles are tools to use based on the team dynamic.8 Surgical trainees can be taught leadership principles in formal leadership training programs to enhance their ability to lead.9 Mentorship provides wisdom, guidance, and insight essen-tial for the successful development of a surgical leader.of business. In business, the processes of customer satisfaction, product development, and organization efficiency are the equiva-lent of patient satisfaction, medical advancement, and efficient delivery of care. Jim Collins, author of Good to Great, studied the success and leadership styles of Fortune 500 companies over a 30-year period. He found that leadership is strongly correlated with corporate success, and most importantly for our study, that leadership strength can be broken down by level and characteristic (See figure 1-1).8Of 11 particularly outstanding organizations


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Surgery_Schwartz. with corporate success, and most importantly for our study, that leadership strength can be broken down by level and characteristic (See figure 1-1).8Of 11 particularly outstanding organizations identified, great leadership was the single major defining characteristic that distinguished them from their peers. These organizations were led by what Collins called the “Level 5 Leader,” one whose per-sonal humility and professional will drove team success. Under this system of leadership study, surgeon-leaders begin at the bottom level and, through study, hard work, and professional development, advance to the ultimate level of leadership.8FUNDAMENTAL PRINCIPLES OF LEADERSHIPLeadership is a complex concept. Surgeons should strive to adopt leadership qualities that provide the best outcomes for their patients, based on the following fundamental principles: vision, willingness, time management, conflict resolution, where they don’t necessarily want to go, but where they ought to be.”


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Surgery_Schwartz. for their patients, based on the following fundamental principles: vision, willingness, time management, conflict resolution, where they don’t necessarily want to go, but where they ought to be.” Leadership does not always have to come from a position of authority. Former American president John Quincy Adams stated, “If your actions inspire others to dream more, learn more, do more, and become more, you are a leader.” Another defini-tion is that leadership is the process of using social influence to enlist the aid and support of others in a common task.7Levels of LeadershipWhen working toward organizational success, strong leader-ship is a critical component. The best study of the relationship between leadership skill and organizational success is in the field LEVEL 5 EXECUTIVEBuilds enduring greatnessthrough a paradoxical combinationof personal humility plus professional will.LEVEL 4 EFFECTIVE LEADERCatalyzes commitment to and vigorous pursuitof a clear and compelling vision;


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Surgery_Schwartz. enduring greatnessthrough a paradoxical combinationof personal humility plus professional will.LEVEL 4 EFFECTIVE LEADERCatalyzes commitment to and vigorous pursuitof a clear and compelling vision; stimulatesthe group to high performance standards.LEVEL 3 COMPETENT MANAGEROrganizes people and resources toward the effectiveand efficient pursuit of predetermined objectives.LEVEL 2 CONTRIBUTING TEAM MEMBERContributes to the achievement of groupobjectives; works effectively with others in a group setting.LEVEL 1 HIGHLY CAPABLE INDIVIDUALMakes productive contributions through talent, knowledge,skills, and good work habits.Figure 1-1. Levels of leadership as defined by Jim Collins in Good to Great. (Reproduced with permission from Collins J: Good to Great. Boston, MA: Harper Collins; 2011.)Brunicardi_Ch01_p0001-p0026.indd 429/01/19 10:58 AM 5LEADERSHIP IN SURGERYCHAPTER 1recruitment, and culture (See Table 1-2). Surgeon-leaders will develop a team of faculty, residents, and other


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Surgery_Schwartz. 429/01/19 10:58 AM 5LEADERSHIP IN SURGERYCHAPTER 1recruitment, and culture (See Table 1-2). Surgeon-leaders will develop a team of faculty, residents, and other healthcare per-sonnel who are aligned on mission, vision, and values. The team and leader must be willing to address complex problems with honest communication and well-developed conflict resolution skills. A culture must be established where faculty and staff will work towards the advancement of the medical arts and the greater good of society.9VisionThe first and most fundamental principle of leadership is to establish a vision that people can live up to, thus providing direction and purpose to the constituency. Creating a vision is a declaration of the near future that inspires and conjures motivation.10 A classic example of a powerful vision that held effective impact is President Kennedy’s declaration in 1961 that “. . . this nation should commit itself to achieving the goal, before this decade is out, of landing a


Surgery_Schwartz

Surgery_Schwartz. of a powerful vision that held effective impact is President Kennedy’s declaration in 1961 that “. . . this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to the earth.” Following his declaration of this vision with a timeline to achieve it, the United Sates mounted a remarkable unified effort, and by the end of the decade, Neil Armstrong took his famous walk and the vision had been accomplished (Fig. 1-2).On a daily basis, surgeons are driven by a powerful vision: the vision that our surgical care will improve patients’ lives. The great surgical pioneers, such as Hunter, Lister (Fig. 1-3), Halsted, von Langenbeck, Billroth, Kocher (Fig. 1-4), Carrel, Gibbon, Blalock, Wangensteen, Moore, Rhoads, Huggins, Murray, Kountz, Longmire, Starzl, and DeBakey (Fig. 1-5), each possessed a vision that revolutionized the field of surgery. In the 19th century, Joseph Lister changed the practice of surgery with his


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Surgery_Schwartz. Murray, Kountz, Longmire, Starzl, and DeBakey (Fig. 1-5), each possessed a vision that revolutionized the field of surgery. In the 19th century, Joseph Lister changed the practice of surgery with his application of Pasteur’s germ theory. He set a young boy’s open compound leg fracture, a condition with a 90% mortality 2Figure 1-2. Apollo 11 Lunar Module moon walk. Astronaut Edwin “Buzz” Aldrin walks by the footpad of the Apollo 11 Lunar Module, July 1969. (Reproduced with permission from AP Photo/NASA. © 2018 The Associated Press.)Figure 1-3. Joseph Lister directing use of carbolic acid spray in one of his earliest antiseptic surgical operations, circa 1865. (Used with permission from Getty Images.)rate at that time, using carbolic acid dressings and aseptic surgical technique. The boy recovered, and Lister gathered nine more patients. His famous publication on the use of aseptic technique introduced the modern era of sterile technique. Emil Theodor Kocher was the first to master the


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Surgery_Schwartz. and Lister gathered nine more patients. His famous publication on the use of aseptic technique introduced the modern era of sterile technique. Emil Theodor Kocher was the first to master the thyroidectomy, thought to be an impossible operation at the time, and went on to perform thousands of thyroidectomies with a mortality of less than 1%. He was awarded the Nobel Prize in Physiology or Medicine in 1909 for describing the thyroid’s physiologic role in metabolism. Michael E. DeBakey’s powerful vision led to the development of numerous groundbreaking procedures that helped pioneer the field of cardiovascular surgery. For example, envisioning an artificial artery for arterial bypass operations, Dr. DeBakey invented the Dacron graft, which has helped millions of patients suffering from vascular disease and enabled the development of endovascular surgery. Dr. Frederick Banting, the youngest recipient of the Nobel Prize in Physiology or Medicine, had a vision to discover the biochemical


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Surgery_Schwartz. disease and enabled the development of endovascular surgery. Dr. Frederick Banting, the youngest recipient of the Nobel Prize in Physiology or Medicine, had a vision to discover the biochemical link between diabetes and glucose homeostasis. His vision and perseverance led to the discovery of insulin.11 In retrospect, the power and clarity of their visions were remarkable, and their willingness and dedication were inspiring. By studying their careers and accomplishments, surgical trainees can be inspired by the potential impact of a well-developed vision.Table 1-2The fundamental principles of leadershipLEADERSHIP SKILLDESCRIPTION AND APPLICATION IN THE FIELD OF MEDICINEVisionThe act of establishing tangible goals of care for patients on both a daily basis as well as for long-term purposes.Effective communicationEstablishing an open, respectful, and nonjudgmental forum for communication among different members of the healthcare team and with the patient.Willingness to leadTaking on full


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Surgery_Schwartz. communicationEstablishing an open, respectful, and nonjudgmental forum for communication among different members of the healthcare team and with the patient.Willingness to leadTaking on full responsibility for the care of patients and remaining ethical, professional, and committed despite the especially challenging rigors of joining the field of surgery.Willingness to learnA commitment to lifelong learning of the latest scientific, medical, and surgical updates to deliver optimized patient care.Conflict resolutionThe art of resolving conflicts in a peaceful and ethical manner in team settings.Brunicardi_Ch01_p0001-p0026.indd 529/01/19 10:58 AM 6BASIC CONSIDERATIONSPART IFigure 1-5. Michael E. DeBakey. (Reproduced with permission from AP Photo/David J. Phillip. © 2018 The Associated Press.)Generating Belief in Your VisionSurgical leaders with great visions will inevitably require help from colleagues, other healthcare professionals, scientists, administrators, patients, and


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Surgery_Schwartz. Press.)Generating Belief in Your VisionSurgical leaders with great visions will inevitably require help from colleagues, other healthcare professionals, scientists, administrators, patients, and nonmedical personnel. To get this help, surgical leaders must inspire their team and understand motivation. For the surgeon-leader, it is critical to know that people do not follow leaders because of what they do; people follow leaders because of why they do what they do. The people who help the leader execute the vision are motivated by the leader’s beliefs and attitudes more than the leader’s policy or agenda. This concept, based on Simon Sinek’s Start With Why, is rooted in understanding of the anatomy and function of the human brain.13 See figure 1-6.For example, take a surgeon-leader who wants to imple-ment a new perioperative checklist to reduce surgical errors. The “what” is very simple: a checklist to reduce errors. The operating room team may make a rational decision to adapt the


Surgery_Schwartz

Surgery_Schwartz. wants to imple-ment a new perioperative checklist to reduce surgical errors. The “what” is very simple: a checklist to reduce errors. The operating room team may make a rational decision to adapt the checklist; however, it is also possible that the checklist may be perceived as “another piece of paperwork” and rejected, or that the checklist may have its implementation fought, undermined, delayed, or ignored. A surgeon-leader who does not understand how people are motivated might argue rationally, telling the team that the checklist was created with great care, that all of the best evidence was incorporated in its creation, and that the checklist is short and efficient. This is the “how,” and once again it appeals to the rational and analytical side of the team. With these arguments, the surgeon-leader’s vision remains susceptible to rejection for many of the same reasons. A leader who understands how to motivate a team towards a vision will start with “why.” Before ever discussing


Surgery_Schwartz

Surgery_Schwartz. surgeon-leader’s vision remains susceptible to rejection for many of the same reasons. A leader who understands how to motivate a team towards a vision will start with “why.” Before ever discussing the checklist in detail with the team, the leader will speak of their shared mission to offer the best patient care possible, ask the team to imagine how they might want a family member treated, and emphasize that a careless error could lead to patient harm and embarrassment for the team. With these argu-ments, which constitute an emotional appeal to the team’s belief system, the leader can expect this vision for better patient care via a new surgical checklist to be adapted by the team. The team will be receptive to implementing a new checklist, not because they believe in the checklist as a tool, but because they believe in the surgeon-leader’s vision for optimizing patient care.There is a biological reason why this concept works. “Why,” “how,” and “what” are correlated to the functions


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Surgery_Schwartz. tool, but because they believe in the surgeon-leader’s vision for optimizing patient care.There is a biological reason why this concept works. “Why,” “how,” and “what” are correlated to the functions Figure 1-4. Emil Theodor Kocher. (Reproduced with permission from the National Library of Medicine.)Leaders must learn to develop a vision to provide direction for their team. The vision can be as straightforward as provid-ing quality of care or as lofty as defining a new field of sur-gery, such as atomic surgery and personalized medicine. One can start developing such vision by brainstorming the answers to two simple questions: “Which disease needs to be cured?” and “How can it be cured?”12 The answers represent a vision and should be recorded succinctly in a laboratory notebook or journal. Committing pen to paper enables the surgical trainee to define his or her vision in a manner that can be shared with others.WhatHowWhyNeocortexLimbic BrainWhen a leader's vision appeals to “why,” it


Surgery_Schwartz

Surgery_Schwartz. Committing pen to paper enables the surgical trainee to define his or her vision in a manner that can be shared with others.WhatHowWhyNeocortexLimbic BrainWhen a leader's vision appeals to “why,” it triggers an emotional response in the limbic brain and increases the likelihood that a vision will be embraced. Persuasion using “what” and “how” appeals to the neocortex and is more easily rejected.Figure 1-6. When leaders seek to generate belief in their vision, it is best to appeal to the team with “why” statements. (Data from Sinek S. Start with why: how great leaders inspire everyone to take action. London: Portfolio/Penguin; 2013.)Brunicardi_Ch01_p0001-p0026.indd 629/01/19 10:58 AM 7LEADERSHIP IN SURGERYCHAPTER 1of separate anatomical levels in the human brain. The neo-cortex is, evolutionarily, the newest area of our brains, and it is responsible for the analytical and rational thoughts and decisions that we make. It corresponds to the “what” and the “how.” When the


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Surgery_Schwartz. is, evolutionarily, the newest area of our brains, and it is responsible for the analytical and rational thoughts and decisions that we make. It corresponds to the “what” and the “how.” When the surgeon-leader in the previous example started with the checklist and its rational arguments, the leader was appealing to their team’s neocortex, and the vision was rejected. However, when the surgeon started with the “why,” the vision for better patient care was emotionally accepted by the team, who became receptive to the checklist as a tool for achieving the vision.13Surgery is a field that requires extraordinary dedication and great personal sacrifice. The very nature of vision—steps forward into a better future—implies that change and difficult work will be required of the leader. See figure 1-7. For this reason, surgeon-leaders should establish visions about which they are deeply pas-sionate and committed so that when obstacles are encountered the leader has the strength of will to


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Surgery_Schwartz. 1-7. For this reason, surgeon-leaders should establish visions about which they are deeply pas-sionate and committed so that when obstacles are encountered the leader has the strength of will to progress forward. Leaders should be selective about which options they pursue. Each oppor-tunity and idea requires great effort to execute; ultimately only a few can be brought to completion. Therefore, leaders should understand what drives their organization’s economic engine: the ideas and opportunities that will bring patients better care, bring the organization more patients, and create new treatments, etc. Thousands of hospitals, companies, innovators, and physicians are addressing many of the same problems in healthcare, such as growing burdens of chronic disease, an aging population, and ris-ing health costs. The best opportunities lie where talent and ability align, so leaders and organizations should be cognizant of choos-ing projects for which they have the potential to be the “best


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Surgery_Schwartz. health costs. The best opportunities lie where talent and ability align, so leaders and organizations should be cognizant of choos-ing projects for which they have the potential to be the “best in the world” at doing. Once the vision is set and the project is chosen, it is up to the leader to generate momentum.Momentum is either a cumulative effect of continuous steps towards improvement or, alternatively, in the negative sense, movements towards failure or stagnation. The “flywheel effect,” depicted in Fig. 1-8, demonstrates the building of momentum with (a) initial steps forward, (b) an accumulation of visible results, (c) realignment of the team in the new direc-tion (accounting for new information and data), and then (d) an accumulation of momentum followed by more steps forward. Careful attention to the aforementioned principles is essential in building a successful surgical career, department, or division.8The Flywheel Effect of Building and


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Surgery_Schwartz. followed by more steps forward. Careful attention to the aforementioned principles is essential in building a successful surgical career, department, or division.8The Flywheel Effect of Building and SustainingMomentumStepsforwardVisibleresultsMomentumbuildsThe Teamaligns andadjustsFigure 1-8. The “flywheel effect.” (Data from Collins J: Good to Great. Boston, MA: Harper Collins; 2011.)WHAT YOU ARE DEEPLYPASSIONATE ABOUTWHAT DRIVESYOURECONOMICENGINEWHAT YOU CANBE THE BEST INTHE WORLD ATFigure 1-7. Leaders should be selective about where they expend their efforts, as demonstrated by Jim Collins in “Good to Great.” (Reproduced with permission from Collins J: Good to Great. Boston, MA: Harper Collins; 2011.)WillingnessThe Willingness Principle represents the active commitment of the leader toward his or her vision. To do so, a surgical leader must be willing to lead, commit to lifelong learning, communi-cate effectively, and resolve conflict.To Lead. A key characteristic of all great


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Surgery_Schwartz. toward his or her vision. To do so, a surgical leader must be willing to lead, commit to lifelong learning, communi-cate effectively, and resolve conflict.To Lead. A key characteristic of all great leaders is the will-ingness to serve as the leader. Dr. Martin Luther King Jr, who championed the civil rights movement with a powerful vision of equality for all based on a commitment to nonviolent methods,14 did so at a time when his vocalization of this vision ensured harassment, imprisonment, and threats of violence against him-self, his colleagues, and his family and friends (Fig. 1-9). King, a young, highly educated pastor, had the security of employ-ment and family, yet was willing to accept enormous respon-sibility and personal risk and did so in order to lead a nation toward his vision of civil rights, for which he was awarded the Nobel Peace Prize in 1964.Willingness to lead is a necessity in any individual who desires to become a surgeon. By entering into the surgical the-ater, a


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Surgery_Schwartz. of civil rights, for which he was awarded the Nobel Peace Prize in 1964.Willingness to lead is a necessity in any individual who desires to become a surgeon. By entering into the surgical the-ater, a surgeon accepts the responsibility to care for and operate on patients, despite the risks and burdens involved. They do so, believing fully in the improved quality of life that can be achieved. Surgeons must embrace the responsibility of leading surgical teams that care for their patients, as well as leading sur-gical trainees to become future surgeons. A tremendous sacrifice is required for the opportunity to learn patient care. Surgical trainees accept the hardships of residency with its accompanying steep learning curve, anxiety, long work hours, and time spent away from family and friends. The active, passionate commit-ment to excellent patient care reflects a natural willingness to lead based on altruism and a sense of duty toward those receiving care. Thus, to ensure delivery of the


Surgery_Schwartz

Surgery_Schwartz. The active, passionate commit-ment to excellent patient care reflects a natural willingness to lead based on altruism and a sense of duty toward those receiving care. Thus, to ensure delivery of the utmost level of care, surgical trainees should commit to developing and refining leadership skills. These skills include a commitment to lifelong learn-ing, effective communication, and conflict resolution.To Learn. Surgeons and surgical trainees, as leaders, must possess willingness to commit to continuous learning. Modern surgery is an ever-changing field with dynamic and evolving healthcare systems and constant scientific discovery and inno-vation. Basic and translational science relating to surgical care is growing at an exponential rate. The sequencing of the human 3Brunicardi_Ch01_p0001-p0026.indd 729/01/19 10:58 AM 8BASIC CONSIDERATIONSPART Igenome and the enormous advances in molecular biology and signaling pathways are leading to the transformation of pre-cision medicine and


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Surgery_Schwartz. 729/01/19 10:58 AM 8BASIC CONSIDERATIONSPART Igenome and the enormous advances in molecular biology and signaling pathways are leading to the transformation of pre-cision medicine and personalized surgery in the 21st century (see Chapter 15).15 Performing prophylactic mastectomies with immediate reconstruction for BRCA1 mutations and thyroidecto-mies with thyroid hormone replacement for RET proto-oncogene mutations are two of many examples of genomic information guiding surgical care. Technologic advances in minimally inva-sive surgery and robotic surgery as well as electronic records and other information technologies are revolutionizing the craft of surgery. The expansion of minimally invasive and endovas-cular surgery over the past three decades required surgeons to retrain in new techniques using new skills and equipment. In this short time span, laparoscopy and endovascular operations are now recognized as the standard of care for many surgical diseases, resulting in shorter


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Surgery_Schwartz. techniques using new skills and equipment. In this short time span, laparoscopy and endovascular operations are now recognized as the standard of care for many surgical diseases, resulting in shorter hospital stay, quicker recovery, and a kinder and gentler manner of practicing surgery. Remarkably, during the last century, the field of surgery has progressed at an exponential pace and will continue to do so with the advent of using genomic analyses to engineer cancer cells with molecular imaging agents that will guide personalized surgery, which will transform the field of surgery during this century. Therefore, surgical leadership training should emphasize and facilitate the continual pursuit of knowledge.Willingness to learn encompasses the surgeon’s commit-ment to lifelong learning. This has been exemplified by the surgeons of the past several decades who have dedicated their peak practicing years to perfecting minimally invasive surgical Figure 1-9. Dr. Martin Luther King Jr


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Surgery_Schwartz. This has been exemplified by the surgeons of the past several decades who have dedicated their peak practicing years to perfecting minimally invasive surgical Figure 1-9. Dr. Martin Luther King Jr acknowledges the crowd at the Lincoln Memorial for his “I Have a Dream” speech during the March on Washington, D.C., August 28, 1963. (Reproduced with permission from AP Photo. © 2018 The Associated Press.)techniques, including the use of robotic surgery. The field con-tinues to advance, offering many advantages to patients includ-ing faster recovery, sometimes decreased pain depending on procedure type, and shorter hospital stays.16-18Fortunately, surgical organizations and societies provide surgeons and surgical trainees a means to acquire new knowl-edge on a continuous basis. There are numerous local, regional, national, and international meetings of surgical organizations that provide ongoing continuing medical education credits, also required for the renewal of most medical licenses.


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Surgery_Schwartz. local, regional, national, and international meetings of surgical organizations that provide ongoing continuing medical education credits, also required for the renewal of most medical licenses. The American Board of Surgery requires all surgeons to complete meaningful continuing medical education to maintain certification.19 These societies and regulatory bodies enable surgeons and surgical trainees to commit to continual learning and ensure their competence in a dynamic and rapidly growing field.Surgeons and trainees now benefit from the rapid expan-sion of web-based education as well as mobile handheld tech-nology. These are powerful tools to minimize nonproductive time in the hospital and make learning and reinforcement of medical knowledge accessible. Currently web-based resources provide quick access to a vast collection of surgical texts, lit-erature, and surgical videos. Surgeons and trainees dedicated to continual learning should be well versed in the utilization of these


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Surgery_Schwartz. provide quick access to a vast collection of surgical texts, lit-erature, and surgical videos. Surgeons and trainees dedicated to continual learning should be well versed in the utilization of these information technologies to maximize their education. The next evolution of electronic surgical educational materials will likely include simulation training similar to laparoscopic and Da Vinci device training modules. The ACGME, acknowl-edging the importance of lifelong learning skills and moderniza-tion of information delivery and access methods, has included them as program requirements for residency accreditation.To Communicate Effectively. The complexity of modern healthcare delivery systems requires a higher level and collab-orative style of communication. Effective communication directly impacts patient care. In 2000, the U.S. Institute of Medi-cine published To Err Is Human: Building a Safer Health System, which raised awareness concerning the magnitude of medical errors. This


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Surgery_Schwartz. impacts patient care. In 2000, the U.S. Institute of Medi-cine published To Err Is Human: Building a Safer Health System, which raised awareness concerning the magnitude of medical errors. This work showcased medical errors as the eighth leading cause of death in the United States with an estimated 100,000 deaths annually.20 Subsequent studies examining medical errors have identified communication errors as one of the most com-mon causes of medical error.21-23 In fact, the Joint Commission identifies miscommunication as the leading cause of sentinel events. Information transfer and communication errors cause delays in patient care, waste surgeon and staff time, and cause serious adverse patient events.23 Effective communication among surgeons, nurses, ancillary staff, and patients is not only a crucial element to improved patient outcomes, but it also leads to less medical litigation.24-26 A strong correlation exists between communication and patient outcomes.Establishing a


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Surgery_Schwartz. is not only a crucial element to improved patient outcomes, but it also leads to less medical litigation.24-26 A strong correlation exists between communication and patient outcomes.Establishing a collaborative atmosphere is important since communication errors leading to medical mishaps are not simply failures to transmit information. Communication errors “are far more complex and relate to hierarchical differences, concerns with upward influence, conflicting roles and role ambiguity, and interpersonal power and conflict.”22,27-29 Errors frequently originate from perceived limited channels of com-munication and hostile, critical environments. To overcome these barriers, surgeons and surgical trainees should learn to communicate in an open, universally understood manner and remain receptive to any team member’s concerns. A survey of physicians, nurses, and ancillary staff identified effective communication as a key element of a successful leader.30 As


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Surgery_Schwartz. manner and remain receptive to any team member’s concerns. A survey of physicians, nurses, and ancillary staff identified effective communication as a key element of a successful leader.30 As 45Brunicardi_Ch01_p0001-p0026.indd 829/01/19 10:58 AM 9LEADERSHIP IN SURGERYCHAPTER 1leaders, surgeons, and surgical trainees who facilitate an open, effective, and collaborative style of communication can reduce errors and enhance patient care. A prime example is that suc-cessful communication of daily goals of patient care from the team leader improves patient outcomes. In one recent study, the modest act of explicitly stating daily goals in a standard-ized fashion significantly reduced patient length of intensive care unit stay and increased resident and nurse understanding of goals of care.31 Implementing standardized daily team briefings in the wards and preoperative units led to improvements in staff turnover rates, employee satisfaction, and prevention of wrong-site surgery.27 In


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Surgery_Schwartz. Implementing standardized daily team briefings in the wards and preoperative units led to improvements in staff turnover rates, employee satisfaction, and prevention of wrong-site surgery.27 In cardiac surgery, improving communication in the operating room and transition to the postanesthesia care unit was an area identified to decrease risk for adverse outcomes.32 Behaviors associated with ineffective communication, including absence from the operating room when needed, playing loud music, making inappropriate comments, and talking to others in a raised voice or a condescending tone, were identified as patient hazards; conversely, behaviors associated with effec-tive collaborative communication, such as leading the time-out process and closed-loop communication technique, resulted in improved patient outcomes.One model to ensure open communication is through standardization of established protocols. A commonly accepted protocol is the “time out” that is now required in the modern


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Surgery_Schwartz. improved patient outcomes.One model to ensure open communication is through standardization of established protocols. A commonly accepted protocol is the “time out” that is now required in the modern operating room. During the time-out protocol, all team mem-bers introduce themselves and state a body of critical informa-tion needed to safely complete the intended operation. This same standardization can be taught outside the operating room. Within the Kaiser system, certain phrases have been given a uni-versal meaning: “I need you now” by members of the team is an understood level of urgency and generates a prompt physician response 100% of the time.27 As mentioned earlier, standardized forms can be useful tools in ensuring universally understood communication during sign-out. The beneficial effect of stan-dardized team communication further demonstrates how effec-tive communication can improve patient care and is considered a vital leadership skill.Effective communication with


Surgery_Schwartz

Surgery_Schwartz. effect of stan-dardized team communication further demonstrates how effec-tive communication can improve patient care and is considered a vital leadership skill.Effective communication with patients in the mod-ern era, necessitates understanding that many patients access health information via the internet and that patients are often ill equipped to evaluate the individual source.33,34 Discrepancies exist between surgeon’s self-perceived ability to communicate and patient’s actual satisfaction. A patient’s perceived interac-tion with their physician has an enormous impact on patient health outcomes, malpractice, and financial reimbursement;35-40 specifically, the association between poor doctor–patient com-munication and a patient’s perception that their doctor does not care about them. Good bedside manner has been shown to decrease litigation even in situations of error or undesirable out-come.39-40 Physicians who demonstrate concern, actively know their patients, and share


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Surgery_Schwartz. them. Good bedside manner has been shown to decrease litigation even in situations of error or undesirable out-come.39-40 Physicians who demonstrate concern, actively know their patients, and share responsibility for decision-making are more likely to be trusted by their patients.26,41,42 Strong doctor–patient relationships and effective communication skills have been incentivized by the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services through their Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Clinical and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) programs, which measure patient satisfaction.43To Resolve Conflict. Great leaders are able to achieve their vision through their ability to resolve conflict. Delivery of modern surgical care is complex; numerous conflicts arise on a daily basis when surgeons and surgical trainees provide high-quality care. Therefore, the techniques for


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Surgery_Schwartz. resolve conflict. Delivery of modern surgical care is complex; numerous conflicts arise on a daily basis when surgeons and surgical trainees provide high-quality care. Therefore, the techniques for conflict resolution are essential for surgical leaders.To properly use conflict resolution techniques, it is impor-tant for the surgeon and surgical trainee to always remain objec-tive and seek personal flexibility and self-awareness. The gulf between self-perception and the perception of others can be profound; in a study of cooperation and collaboration among operating room staff, the quality of their own collaboration was rated at 80% by surgeons, yet was rated at only 48% by oper-ating room nurses.44 Systematic inclusion of modern conflict resolution methods that incorporate the views of all members of a multidisciplinary team help maintain objectivity. Reflection is often overlooked in surgical residency training, but it is a critical component of learning conflict resolution skills.


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Surgery_Schwartz. members of a multidisciplinary team help maintain objectivity. Reflection is often overlooked in surgical residency training, but it is a critical component of learning conflict resolution skills. Introspection allows the surgeon to understand the impact of his or her actions and biases. Objectivity is the basis of effective conflict resolu-tion, which can improve satisfaction among team members and help deliver optimal patient care.Modern conflict resolution techniques are based on objec-tivity, willingness to listen, and pursuit of principle-based solu-tions.45 For example, an effective style of conflict resolution is the utilization of the “abundance mentality” model, which attempts to achieve a solution that benefits all involved and is based on core values of the organization, as opposed to the uti-lization of the traditional fault-finding model, which identifies sides as right or wrong.46 Application of the abundance mental-ity in surgery elevates the conflict above the affected


Surgery_Schwartz

Surgery_Schwartz. to the uti-lization of the traditional fault-finding model, which identifies sides as right or wrong.46 Application of the abundance mental-ity in surgery elevates the conflict above the affected parties and focuses on the higher unifying goal of improved patient care. “Quality Improvement” (previously or alternatively “Morbidity and Mortality”) conferences are managed in this style and have the purpose of practice improvement and improving overall quality of care within the system, as opposed to placing guilt or blame on the surgeon or surgical trainees for the complication being reviewed. The traditional style of command-and-control technique based on fear and intimidation is no longer welcome in any healthcare system and can lead to sanctions, lawsuits, and removal of hospital privileges or position of leadership.Another intuitive method that can help surgical trainees learn to resolve conflict is the “history and physical” model of conflict resolution. This model is based on the


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Surgery_Schwartz. or position of leadership.Another intuitive method that can help surgical trainees learn to resolve conflict is the “history and physical” model of conflict resolution. This model is based on the seven steps of caring for a surgical patient that are well known to the surgical trainee47: (a) the “history” is the equivalent of gathering subjec-tive information from involved parties with appropriate empa-thy and listening; (b) the “laboratory/studies” are the equivalent of collecting objective data to validate the subjective informa-tion; (c) a “differential diagnosis” is formed out of possible root causes of the conflict; (d) the “assessment/plan” is developed in the best interest of all involved parties; the plan, including risks and benefits, is openly discussed in a compassionate style of com-munication; (e) “preoperative preparation” includes the acquisi-tion of appropriate consultations for clearances, consideration of equipment and supplies needed for implementation, and the


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Surgery_Schwartz. of com-munication; (e) “preoperative preparation” includes the acquisi-tion of appropriate consultations for clearances, consideration of equipment and supplies needed for implementation, and the “informed consent” from the involved parties; (f) the “operation” is the actual implementation of the agreed-upon plan, including a time-out; (g) and “postoperative care” involves communicat-ing the operative outcome, regular postoperative follow-up, and the correction of any complications that arise. This seven-step method is an example of an objective, respectful method of con-flict resolution.47 Practicing different styles of conflict resolu-tion and effective communication in front of the entire group of Brunicardi_Ch01_p0001-p0026.indd 929/01/19 10:58 AM 10BASIC CONSIDERATIONSPART Isurgical trainees attending the leadership training program is an effective means of teaching conflict resolution techniques.Time ManagementIt is important for leaders to practice effective time


Surgery_Schwartz

Surgery_Schwartz. trainees attending the leadership training program is an effective means of teaching conflict resolution techniques.Time ManagementIt is important for leaders to practice effective time management. Time is the most precious resource, as it cannot be bought, saved, or stored. Thus, management of time is essential for a productive and balanced life for those in the organization. The effective use of one’s time is best done through a formal time management program to improve one’s ability to lead by setting priorities and making choices to achieve goals. The efficient use of one’s time helps to improve both productivity and quality of life.48-50It is important for surgeons and surgical trainees to learn and use a formal time-management program. There are ever-increasing demands placed on surgeons and surgical trainees to deliver the highest quality care in highly regu-lated environments. Furthermore, strict regulations on limita-tion of work hours demand surgical trainees learn patient


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Surgery_Schwartz. and surgical trainees to deliver the highest quality care in highly regu-lated environments. Furthermore, strict regulations on limita-tion of work hours demand surgical trainees learn patient care in a limited amount of time.48-50 All told, these demands are enormously stressful and can lead to burnout, drug and/or alcohol abuse, and poor performance.48-50 A time-motion study of general surgery trainees analyzed residents’ self-reported time logs to determine resident time expenditure on educa-tional/service-related activities (Fig. 1-10).50 Surprisingly, senior residents were noted to spend 13.5% of their time on low-service, low-educational value activities. This time, prop-erly managed, could be used to either reduce work hours or improve educational efficiency in the context of new work hour restrictions. It is therefore critical that time be used wisely on effectively achieving one’s goals.Parkinson’s law, proposed in 1955 by the U.K. politi-cal analyst and historian Cyril


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Surgery_Schwartz. new work hour restrictions. It is therefore critical that time be used wisely on effectively achieving one’s goals.Parkinson’s law, proposed in 1955 by the U.K. politi-cal analyst and historian Cyril Northcote Parkinson, states that work expands to fill the time available for its completion, thus leading individuals to spend the majority of their time on insignificant tasks.51 Pareto’s 80/20 principle states that 80% of goals are achieved by 20% of effort and that achieving the final 20% requires 80% of their effort. Therefore, proper planning for undertaking any goal needs to include an analysis of how much effort will be needed to complete the task.49 Formal time management programs help surgeons and surgical trainees bet-ter understand how their time is spent, enabling them to increase productivity and achieve a better-balanced lifestyle.Various time allocation techniques have been described.49 A frequently used basic technique is the “prioritized list,” also known as the ABC


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Surgery_Schwartz. productivity and achieve a better-balanced lifestyle.Various time allocation techniques have been described.49 A frequently used basic technique is the “prioritized list,” also known as the ABC technique. Individuals list and assign relative 6Low educationLow serviceHigh serviceHigh educationTime Motion StudyLow education, lowservice value (Ex: Waiting duringmandatory in-house call)High education, lowservice value (Ex: Teaching conferences)High education, highservice value (Ex: Operating with a mentor)Low education,high service value (Ex: Repeatedly performing History & Physicals)values to their tasks. The use of the lists and categories serves solely as a reminder, thus falling short of aiding the user in allo-cating time wisely. Another technique is the “time management matrix technique.”49 This technique plots activities on two axes: importance and urgency, yielding four quadrants (Fig. 1-11). Congruous with the Pareto’s 80/20 principle and Parkinson’s law, the time management


Surgery_Schwartz

Surgery_Schwartz. This technique plots activities on two axes: importance and urgency, yielding four quadrants (Fig. 1-11). Congruous with the Pareto’s 80/20 principle and Parkinson’s law, the time management matrix technique channels efforts into quadrant II (important but nonurgent) activities. The activi-ties in this quadrant are high yield and include planning, creative activity, building relationships, and maintaining productivity. Too often, surgeons spend a majority of their time attending to quadrant I (important and urgent) tasks. Quadrant I tasks include emergencies and unplanned or disorganized situations that require intensive and often inefficient effort. While most surgeons and surgical trainees have to deal with emergencies, they often develop the habit of inappropriately assigning activi-ties into quadrant I; excess time spent on quadrant I tasks leads to stress or burnout for the surgeon and distracts from long-term goals. Efficient time management allows surgeons and surgical trainees


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Surgery_Schwartz. into quadrant I; excess time spent on quadrant I tasks leads to stress or burnout for the surgeon and distracts from long-term goals. Efficient time management allows surgeons and surgical trainees to be proactive about shifting energy from quadrant I tasks to quadrant II, emphasizing preplanning and creativity over always attending to the most salient issue at hand, depend-ing on the importance and not the urgency.Finally, “the six areas of interest” is an alternative effec-tive time management model that can help surgeons and surgi-cal trainees achieve their goals, live a better-balanced lifestyle, and improve the quality of their lives.49 The process begins by performing a time-motion study in which the activities of 6-hour increments of time over a routine week are chronicled. At the end of the week, the list of activities is analyzed to determine how the 168 hours in 1 week have been spent. The surgical trainee then selects six broad categories of areas of interest


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Surgery_Schwartz. At the end of the week, the list of activities is analyzed to determine how the 168 hours in 1 week have been spent. The surgical trainee then selects six broad categories of areas of interest ImportantUrgentQuadrant IQuadrant IIIQuadrant IIQuadrant IVNonurgentTime Management MatrixNonimportantFigure 1-11. Time management. (Data from Covey S. The Seven Habits of Highly Effective People. New York, NY: Simon & Schuster; 1989.)Figure 1-10. Surgery resident time-motion study.Brunicardi_Ch01_p0001-p0026.indd 1029/01/19 10:58 AM 11LEADERSHIP IN SURGERYCHAPTER 1(i.e., family, clinical care, education, health, community service, hobbies) and sets a single activity goal in each category every day and monitors whether those goals are achieved. This tech-nique is straightforward and improves one’s quality of life by setting and achieving a balanced set of goals of personal inter-est, while eliminating time-wasting activities.A formal time management program is essential for modern


Surgery_Schwartz

Surgery_Schwartz. one’s quality of life by setting and achieving a balanced set of goals of personal inter-est, while eliminating time-wasting activities.A formal time management program is essential for modern leadership. The practice and use of time management strategies can help surgeons and surgical trainees achieve and maintain their goals of excellent clinical care for their patients, while maintaining a more balanced lifestyle.Self-Care and WellnessThe challenges of practicing medicine place unique stresses on surgeons. A departmental program for improving wellness and teaching self-care can help alleviate these stresses. Acknowl-edging these stresses is an important step for any leader to help peers at risk. Quality of life surveys have identified individual protective factors that can be implemented prophylactically. These factors for improving self-care and wellness include regu-lar exercise programs, maintenance of routine medical care, and health screening. The following may not apply to


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Surgery_Schwartz. prophylactically. These factors for improving self-care and wellness include regu-lar exercise programs, maintenance of routine medical care, and health screening. The following may not apply to all physicians; however, religious practices, reflective writing, and maximizing work-life balance have also been demonstrated to be protective.52Surgeons and physicians overall experience increased rates of suicide, depression, substance abuse, marital and family prob-lems, and other stress-related health effects as compared to the general population. Suicide rates in physicians are higher among those who are divorced, widowed, or never married. Depression is a common challenge, with rates as high as 30% among trainees, and higher when lifetime risk is considered. Drug and alcohol abuse among physicians mirrors the general population; however, physicians have higher rates of prescription drug abuse. The abil-ity to self-medicate likely contributes to prescription drug abuse by physicians.


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Surgery_Schwartz. physicians mirrors the general population; however, physicians have higher rates of prescription drug abuse. The abil-ity to self-medicate likely contributes to prescription drug abuse by physicians. Divorce and marriage unhappiness among physi-cians has been attributed to the “psychology of postponement,” compulsive personality traits that are reinforced and selected for during medical training, and lack of work-life balance. Residents, due to their inexperience, may be at higher risk than practicing physicians. For physicians who do not seek professional help, fear of losing their medical license is the most commonly provided reason. Departmental wellness programs may provide an alterna-tive source of support for these surgeons.52-54The past 10 years have seen a significant increase in atten-tion to the issue of physician wellness. Physician wellness has become an issue transcending specialties and resulting in signif-icant research. The creation of wellness and self-care programs


Surgery_Schwartz

Surgery_Schwartz. atten-tion to the issue of physician wellness. Physician wellness has become an issue transcending specialties and resulting in signif-icant research. The creation of wellness and self-care programs within departments represents an opportunity for surgeons to demonstrate leadership qualities.52-54RecruitmentThe challenges of modern medicine and ever-larger medical centers have created a reality where no single surgeon-leader can exercise complete control—it takes a team of leaders with shared vision, mission, and goals. To this end, the previously discussed “level 5 leader” who embodies personal humility and professional will is essential.8 Previous generations whose lead-ers and departments were composed of self-proclaimed giants dominated and suppressed alternative points of view, com-munication, and innovation. In recent years, there has been a change to building teams with authentic leaders who have high ethical standards and well-developed nontechnical skills, who lead by


Surgery_Schwartz

Surgery_Schwartz. com-munication, and innovation. In recent years, there has been a change to building teams with authentic leaders who have high ethical standards and well-developed nontechnical skills, who lead by example, and who never compromise excellence. The surgeon-leader must build a team where talented individuals are placed in the right job for their skills. The essence of a leader is one who enables others to succeed. Team work is imperative to change, and trust is the make-or-break component. Simply put, teams that trust each other work well, and teams that do not trust each other do not work well.9Creating a Culture of Empathy, Patient-Family-Centered Care, and Personalized SurgeryCreating the right culture is the most challenging of all the sur-geon-leader’s tasks. Modern surgical departments should focus on creating a culture of empathy, patient–family-centered care, and personalized surgery. Instilling a positive culture requires both discipline and consistency because it may take


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Surgery_Schwartz. should focus on creating a culture of empathy, patient–family-centered care, and personalized surgery. Instilling a positive culture requires both discipline and consistency because it may take consider-able time to change how people think, feel, and behave.9,55,56 Organizational culture is built around the leader’s vision and values. Coming up with strong values requires genuine com-mitment. A leader should realize that staying true to his or her values can be challenging when conflicts arise.57WHY WE LEADChoosing to Become a LeaderThere are many benefits to becoming a leader. Humankind has pondered the question of whether leaders are born or made for millennia. The best evidence to date indicates that leaders are both born and made. Leadership potential is a skill that all per-sons are born with, to some degree, and that can be formally trained, learned through observation, and honed with practice.13 The positive effects of a leader on others are innumerable, including a leader’s


Surgery_Schwartz

Surgery_Schwartz. born with, to some degree, and that can be formally trained, learned through observation, and honed with practice.13 The positive effects of a leader on others are innumerable, including a leader’s positive influence on innovation, diversity, culture, and quality. For modern surgeons, leadership skills are essential for the delivery of quality patient care; therefore, it is the duty of the surgeon to study leadership.For the surgeon studying to be a better leader, effective leadership also has many individual benefits, including rec-ognition from one’s peers, promotion, and autonomy. Mod-ern leaders are increasingly required to be humble about their accomplishments in order to be successful and effective.8 Beyond recognition, promotion, and autonomy there are more selfless reasons for surgeons to desire leadership. Leadership is a tool to help make a difference. Leadership is a good path towards a career as an educator, which offers the leader a sense of accomplishment and


Surgery_Schwartz

Surgery_Schwartz. for surgeons to desire leadership. Leadership is a tool to help make a difference. Leadership is a good path towards a career as an educator, which offers the leader a sense of accomplishment and satisfaction in seeing others succeed. Some choose to become leaders out of a sense of selfless ser-vice, taking on leadership for the benefit of others, or out of a desire to solve problems. Leadership may come with material rewards, including wealth and power, which motivate some.Whatever the motivation, surgeons, in their role as lead-ers of patient care teams, have a duty to develop some skill in leadership. It would be best for individuals, departments, and patients if all surgeons sought to develop leadership skills and experience in some area of administration, patient care, educa-tion, or research. The benefits to the individual are numerous.Leadership’s Effect on Healthcare Cost and Clinical OutcomesMuch attention has rightly been paid to historical leaders’ impact on humanity.


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Surgery_Schwartz. or research. The benefits to the individual are numerous.Leadership’s Effect on Healthcare Cost and Clinical OutcomesMuch attention has rightly been paid to historical leaders’ impact on humanity. Surgical leaders of the past have made great contributions on which we may build. All surgeons have a responsibility to be leaders, whether at the team level or in Brunicardi_Ch01_p0001-p0026.indd 1129/01/19 10:58 AM 12BASIC CONSIDERATIONSPART Ian administrative or organizational capacity. To that end, it is worth noting the benefits of formal leadership education.Large observational studies using trained observers assessed the effects of different surgical leadership styles on operative cases. Team cohesion and collective efficiency were reduced when leaders utilized abusive supervision or over-controlling methods. Abusive supervision alone was associated with decreased “psychological safety.”58 Surgeons perceived as having positive leadership characteristics by their staff have lower


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Surgery_Schwartz. over-controlling methods. Abusive supervision alone was associated with decreased “psychological safety.”58 Surgeons perceived as having positive leadership characteristics by their staff have lower 30-day all-cause mortality.59 This is likely due to creating a culture of safety where the staff can speak up if they notice an error and feel they have the latitude to do what is best for the patient quickly and autonomously.59,60With increased recognition and attention on human error, nontechnical skills, including leadership, play a role in patient safety. The landmark study, “To Err Is Human,” estimated that almost 100,000 people die each year due to medical errors.20 In the surgical setting, 40% to 50% of errors may be attributed to communication breakdown. The Multifactor Leadership Ques-tionnaire scores subjects on their demonstration of transforma-tional leadership behaviors. Transformational leaders exhibit the qualities of charisma, inspired motivation, intellectual stimulation,


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Surgery_Schwartz. scores subjects on their demonstration of transforma-tional leadership behaviors. Transformational leaders exhibit the qualities of charisma, inspired motivation, intellectual stimulation, and individualized consideration. In video analysis of complex surgical operations, surgeons scoring even a single point higher on the transformational leadership score exhibited 3 times more information sharing behaviors, 5 times more posi-tive voice behaviors, and 10 times more supportive behaviors, all while displaying poor behaviors 12.5 times less frequently than their peers.60 Exhibiting the characteristics of transforma-tional leadership clearly has much to offer the surgeon-leader in preventing serious errors.58-60The field of trauma contains the largest body of formal study demonstrating the positive effects of leadership on clini-cal results. Strong leadership skills improve both the speed of resuscitation and completion of the initial trauma evaluation.61-63 There is no one optimal style


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Surgery_Schwartz. effects of leadership on clini-cal results. Strong leadership skills improve both the speed of resuscitation and completion of the initial trauma evaluation.61-63 There is no one optimal style of leadership covering all situa-tions; some call for a more empowering leadership style while others call for a more directive style. The optimal style of lead-ership varies based on team composition, with less experienced teams better responding to the directive style, while more expe-rienced teams work faster with trust and an empowering style. The formally educated surgical leader should be able to switch easily between styles based on the situation at hand.56,58,60-64Leadership styles affect responses to patient safety con-cerns and protect the organization as a whole. The surgical leader adopts a supervisory capacity while creating a culture of safety. In detail, frontline staff must be encouraged to partici-pate in safety improvement. Staff ownership of safety must be established and


Surgery_Schwartz

Surgery_Schwartz. a supervisory capacity while creating a culture of safety. In detail, frontline staff must be encouraged to partici-pate in safety improvement. Staff ownership of safety must be established and upheld. In order to assure this outcome, whistle-blowers must be protected. A culture of psychological safety, organizational fairness, and continuous learning is required. Subordinates require appropriate authority, autonomy, and lati-tude to do their jobs and care for patients.60Formal leadership training has been well studied within the Veteran’s Health Administration system using the Surgical Care Improvement Program. The Medical Team Training Pro-gram, for instance, has been shown to result in a 18% decrease in 30-day mortality65 and a 17% decrease in 30-day morbidity.66Also at the organizational level, leaders using an empowering style may improve process of care protocols and increase efficiency. Operating room turnover times specifically have been shown to be reducible.67 Value-based


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Surgery_Schwartz. level, leaders using an empowering style may improve process of care protocols and increase efficiency. Operating room turnover times specifically have been shown to be reducible.67 Value-based purchasing benchmarks, such as hospital-acquired infections, which affect reimbursement, can be reduced or eliminated depending on the measure.68,69 Medical errors may be reduced, and significant medical errors may have their effects mitigated. Patient satis-faction may be improved. The overall financial performance of the institution can be affected in a positive manner.69,70There are positive correlations between mutual respect, clinical leadership, and surgical safety. Traditional command and control style leadership negatively impacts psychological safety resulting in the development of more modern leadership styles. The best clinical processes have the potential to break down when there is a toxic work environment and lack of psy-chological safety within the team.The Importance of


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Surgery_Schwartz. more modern leadership styles. The best clinical processes have the potential to break down when there is a toxic work environment and lack of psy-chological safety within the team.The Importance of Diversity and LeadershipThe past quarter century has seen a steady increase in diversity within the field of surgery. Women, as of 2015, represent 38% of surgical trainees and 10% of academic professors currently, but have doubled their representation in the past 20 years.71 Some fields, such as head and neck surgery and plastic surgery72 have studied their own subspecialty groups with similar find-ings. African Americans comprise both 6% of medical school graduates, 6% surgical trainees, and 2% to 4% of professors of surgery nationwide.73 Hispanics represent 5% of graduat-ing medical students, 9% of general surgery trainees, and 4% to 5% of persons at all levels of academic surgery.73 Physician diversity is crucial and may help to address disparities in social determinants of


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Surgery_Schwartz. students, 9% of general surgery trainees, and 4% to 5% of persons at all levels of academic surgery.73 Physician diversity is crucial and may help to address disparities in social determinants of health.74Studies indicate that the bottleneck in diversity occurs at the level of the medical school application pool, which in turn is caused by educational deficiencies at the primary, secondary, and collegiate level.73,75-78 As an attempted solution, the University of Michigan developed a “pipeline” program that pairs grade-school and high-school students with physicians for experiential learn-ing and the development of mentoring, presentation skills, and networking.75 It is important for departments of surgery to develop a diversity program for recruitment of residents and faculty. Multi-institutional blinded studies indicate that the implementa-tion of formal leadership and diversity training improves diversity leadership and strategic human resource management.74,78LEADERSHIP STYLESThe


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Surgery_Schwartz. blinded studies indicate that the implementa-tion of formal leadership and diversity training improves diversity leadership and strategic human resource management.74,78LEADERSHIP STYLESThe principles of leadership can be practiced in a variety of styles. Just as there are many definitions of leadership, many classifications of styles exist as well. A landmark study by Daniel Goleman in Harvard Business Review identified six distinct leadership styles, based on different components of emotional intelligence.79 Emotional intelligence is the ability to recognize, understand, and control the emotions in others and ourselves. By learning different styles, surgeons and trainees can recognize their own leadership style and the effect on the team dynamic. Furthermore, it teaches when the situation may demand change in style for the best outcome. The six leadership styles identified are coercive, authoritative, affiliative, demo-cratic, pacesetting, and coaching.The coercive leader demands


Surgery_Schwartz

Surgery_Schwartz. may demand change in style for the best outcome. The six leadership styles identified are coercive, authoritative, affiliative, demo-cratic, pacesetting, and coaching.The coercive leader demands immediate compliance. This style reflects the command and control style that has histori-cally dominated surgery. Excessive coercive leadership erodes team members’ sense of responsibility, motivation, sense of participation in a shared vision, and ultimately, performance. The phrase, “Do what I tell you!” brings to mind the coercive leader. However, it is effective in times of crisis to deliver clear, Brunicardi_Ch01_p0001-p0026.indd 1229/01/19 10:58 AM 13LEADERSHIP IN SURGERYCHAPTER 1concise instruction. This style should be used sparingly and is best suited for emergencies.The authoritative leader embodies the phrase “Come with me,” focusing on mobilizing the team toward a common, grand vision. This type of leader allows the team freedom to innovate, experiment, and devise its own


Surgery_Schwartz

Surgery_Schwartz. leader embodies the phrase “Come with me,” focusing on mobilizing the team toward a common, grand vision. This type of leader allows the team freedom to innovate, experiment, and devise its own means. Goleman’s research indicates this style is often the most effective. These leaders display self-confidence, empathy, and proficiency in initiating new ideas and leading people in a new direction. This is best used when a shift in paradigm is needed.The affiliative leader creates harmony and builds emo-tional bonds. This requires employment of empathy, building relationships, and emphasis on communication. An affiliative leader frequently gives positive feedback. This style can allow poor performance to go uncorrected if too little constructive/critical advice is given. Affiliative leadership is most useful when motivating people during stressful circumstances or heal-ing rifts in a team.The coaching style of leadership focuses on developing people for the future. Coaching is leadership


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Surgery_Schwartz. is most useful when motivating people during stressful circumstances or heal-ing rifts in a team.The coaching style of leadership focuses on developing people for the future. Coaching is leadership through mentor-ship. The coach gives team members challenging tasks, coun-sels, encourages, and delegates. Unlike the affiliative leader who focuses on positive feedback, the coach helps people iden-tify their weaknesses and improve their performance, and ties their work into their long-term career aspirations. This leader-ship style builds team capabilities by helping motivated learners improve. However, this style does not work well when team members are defiant and unwilling to change or learn, or if the leader lacks proficiency.The democratic leader forges consensus through participa-tion. This leadership style listens to and values each member’s input. It is not the best choice in an emergency situation, when time is limited, or when teammates cannot contribute informed guidance to the


Surgery_Schwartz

Surgery_Schwartz. leadership style listens to and values each member’s input. It is not the best choice in an emergency situation, when time is limited, or when teammates cannot contribute informed guidance to the leader. It can also be exasperating if a clear vision does not arise from the collaborative process. This style is most appropriate when it is important to obtain team consensus, quell conflict, or create harmony.The pacesetter leader sets high standards for performance and exemplifies them. These leaders identify poor performers and demand more from them. However, unlike the coach, the pacesetter does not build the skills of those who are not keep-ing up. Rather, a pacesetter will either take over the task him-self or delegate the task to another team member. This style can be summed up best by the phrase, “Do as I do, now.” This leadership style works well when it is important to obtain high-quality results and there is a motivated, capable team. However, pacesetters can easily become


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Surgery_Schwartz. by the phrase, “Do as I do, now.” This leadership style works well when it is important to obtain high-quality results and there is a motivated, capable team. However, pacesetters can easily become micromanagers who have diffi-culty delegating tasks to team members, which leads to burn out on the part of the leader. Additionally, team members can feel overwhelmed and demoralized by the demands for excellence without an empathic counter balance.Each of the above styles of leadership has strengths and weakness. Importantly, leaders who are the most successful do not rely only on one leadership style alone. They use sev-eral of them seamlessly depending on the situation and the team members at hand. Therefore, the more styles a leader has mastered, the better, with particular emphasis on the authorita-tive, affiliative, democratic, and coaching styles. Each leader-ship style is a tool that is ultimately employed to guide a team to realizing a vision or goal. Thus, leadership training


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Surgery_Schwartz. the authorita-tive, affiliative, democratic, and coaching styles. Each leader-ship style is a tool that is ultimately employed to guide a team to realizing a vision or goal. Thus, leadership training programs should teach the proper use of all leadership styles while adher-ing to the principles of leadership.7FORMAL LEADERSHIP TRAINING PROGRAMS IN SURGERYHistory of Leadership Training and the Multifactor Leadership QuestionnaireSince it has been shown that effective leadership can improve patient outcomes, leadership principles and skills should be taught to surgical trainees using formal leadership training programs. The importance of teaching leadership skills is reflected by the ACGME mandated core competencies (see Table 1-1). However, surgical trainees, most notably chief residents, find themselves in various leadership roles without ever having experienced formal-ized leadership training, which has been shown to result in a self-perceived lack of leadership ability.2 When


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Surgery_Schwartz. find themselves in various leadership roles without ever having experienced formal-ized leadership training, which has been shown to result in a self-perceived lack of leadership ability.2 When surveyed on 18 core leadership skills (Table 1-3), 92% of residents rated all 18 skills as important, but over half rated themselves as “minimally” or “not competent” in 10 out of 18 skills.2 Increasingly, residents and junior faculty are requesting leadership training and wish to close the gap between perceived need for training and the implementa-tion of formal leadership training programs.80-86A number of leadership workshops have been created. Extracurricular leadership programs have been designed mostly Table 1-3Eighteen leadership training modulesSKILLSIMPORTANCE MEAN SCORECOMPETENCE MEAN SCORE*Academic program development3.22.4*Leadership training3.82.3*Leadership theory3.22.1*Effective communication3.72.7*Conflict resolution3.83*Management principles3.72.7*Negotiation3.72.8*Time


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Surgery_Schwartz. SCORE*Academic program development3.22.4*Leadership training3.82.3*Leadership theory3.22.1*Effective communication3.72.7*Conflict resolution3.83*Management principles3.72.7*Negotiation3.72.8*Time management42.8*Private or academic practice, managed care3.62*Investment principles3.52.2*Ethics3.63.2Billing, coding, and compliance3.51.7*Program improvement32*Writing proposals3.32.2*Writing reports3.42.4*Public speaking3.72.7*Effective presentations3.72.7*Risk management3.52.1*Total3.62.5**P <0.001 by Student t-test between mean importance and mean competence scores.Reproduced with permission from Itani KMF, Liscum K, Brunicardi FC: Physician leadership is a new mandate in surgical training, Am J Surg. 2004 Mar;187(3):328-331.Brunicardi_Ch01_p0001-p0026.indd 1329/01/19 10:58 AM 14BASIC CONSIDERATIONSPART Ifor physicians with an MBA or management background but have not been incorporated into the core residency training program.80 Also, there are many institutions that have published


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Surgery_Schwartz. physicians with an MBA or management background but have not been incorporated into the core residency training program.80 Also, there are many institutions that have published experiences with leadership retreats or seminars for residents or young physicians.81-84 The ACGME hosts multiple leader-ship skills workshops for chief residents, mostly targeted toward pediatricians, family practitioners, and psychiatrists.85 Similarly, the American College of Surgeons leads an annual 3-day lead-ership conference focusing on leadership attributes, consensus development, team building, conflict resolution, and translation of leadership principles into clinical practice.86-87 These pro-grams were all received well by participants and represent a call for a formal leadership program for all surgical trainees.An innovative leadership curriculum first implemented in 2000, prior to work-hour restrictions, taught general surgery trainees’ collaborative leadership skills at a time when the


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Surgery_Schwartz. surgical trainees.An innovative leadership curriculum first implemented in 2000, prior to work-hour restrictions, taught general surgery trainees’ collaborative leadership skills at a time when the tradi-tional command-and-control leadership style predominated.2,89,90 Surgical residents participated in 18-hour-long modules based on the leadership principles and skills listed in Table 1-2, taught by the surgical faculty. A number of leadership techniques, including time management techniques and applied conflict resolution techniques described earlier, were designed and implemented as part of this leadership training program. Within 6 months of implementation, residents’ self-perceived total commitment to the highest personal and professional standards, communication skills, visualization of clear missions of patient care, and leadership of others toward that mission increased sig-nificantly.2,89,90 Remarkably, the positive impact of this leader-ship curriculum was significant when


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Surgery_Schwartz. of clear missions of patient care, and leadership of others toward that mission increased sig-nificantly.2,89,90 Remarkably, the positive impact of this leader-ship curriculum was significant when measured using tools, such as the Multifactor Leadership Questionnaire (MLQ), social skills inventory, personality inventory, and internal strength scorecard.2,89,90 The MLQ is a well-validated instrument that objectively quantifies leadership beliefs and self-perceived out-comes across medical and nonmedical disciplines. Based on the MLQ, surgical residents more often use a passive-avoidance style of leadership that emphasizes taking corrective action only after a problem is “significant and obvious.” This tool can also be used to track progress toward more effective, collaborative styles of leadership. These studies demonstrated the ability to measure leadership behavior of surgical trainees in a standard-ized, quantifiable format.2,89,90 Taken together, these studies sup-port the concept


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Surgery_Schwartz. These studies demonstrated the ability to measure leadership behavior of surgical trainees in a standard-ized, quantifiable format.2,89,90 Taken together, these studies sup-port the concept that leadership skills can and should be taught to surgical trainees, and there are validated tools to measure outcomes.Designing the ProgramSuccess in designing a formal leadership development program can be achieved through the following method. First, select the right participants at the right time in their career. Junior sur-geons new to practice are ideal; however, they should be given a chance to get their clinical and research interests off the ground before they are asked to lead others. Candidates, should be open to taking on leadership roles and have the right combination of introspection and humility that lends to professional develop-ment. High-quality speakers from the business, legal, creative, and medical worlds should be brought as guest speakers. Topics could include leadership


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Surgery_Schwartz. and humility that lends to professional develop-ment. High-quality speakers from the business, legal, creative, and medical worlds should be brought as guest speakers. Topics could include leadership overall, strategy, finance, management skills, feedback, and coaching. Constructive criticism is essential because prospective leaders will need guidance and mentoring. Surgeons who have been through a formal leadership training program will become proficient at team-building skills and man-agement and will become self-empowered individuals.918Formal leadership training is not restricted to faculty alone. Leadership training should begin early and continue throughout residency. Surgical residents’ leadership styles have been studied in environments where they are given an assistant to supervise, as if they were an attending. Most residents were able to adapt to difficult operative challenges, in this setting, by providing a more directed style of leadership to their assistants. When faced


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Surgery_Schwartz. as if they were an attending. Most residents were able to adapt to difficult operative challenges, in this setting, by providing a more directed style of leadership to their assistants. When faced with a less challenging task, or when the surgery resident’s confidence was particularly high, their leadership score was also high. For the surgical resident preparing to move on to the attending level, such skills are necessary to develop.92Nontechnical surgical skills, such as leadership, demon-strate a number of desired effects for the operative team. Patient safety, including all cause 30-day mortality, is improved by stronger nontechnical skills.59 Development of clear and effec-tive communication, situational awareness, team skills, and decision-making all are correlated with reduced surgical errors. Interruptions, such as needing to answer a page during an opera-tion, are the only nontechnical factors in surgical error that are not directly attributable to leadership style.93Surgical


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Surgery_Schwartz. errors. Interruptions, such as needing to answer a page during an opera-tion, are the only nontechnical factors in surgical error that are not directly attributable to leadership style.93Surgical leaders have a responsibility to make ethical deci-sions. At this time, there is no standard curriculum to formally train surgical residents in ethics, despite interest from a majority of residency program directors.94-97 Several solutions have been proposed. A case-based approach to ethics training appears to have some merit, where monthly hour long ethical dilemmas are discussed in an informal, nonhierarchical setting.98 In another study, an ICU-based simulation model demonstrated promise for teaching compassion and end-of-life ethics to surgical resi-dents. In this model, surgery residents have their first end-of-life conversations with standardized patients simulating the surgical ICU environment.99,100Practicing Leadership Skills and Assessing Leadership Formally With Objective


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Surgery_Schwartz. have their first end-of-life conversations with standardized patients simulating the surgical ICU environment.99,100Practicing Leadership Skills and Assessing Leadership Formally With Objective Structured Clinical Examination (OSCE) and SimulationThe past decade has seen a demonstrable increase in our knowl-edge of how to develop leadership skills, particularly through simulation, as well as leadership evaluation through OSCE and other tools. Multiple groups have assessed multidisciplinary teams, typically composed of nurses, anesthesia groups, and surgeons for the leadership associated nontechnical skills of communication, teamwork, and situational awareness. Through increasingly validated instruments and assessment tools, these nontechnical skills have been found to be trainable.101 The OSCE has been established as the gold standard102 for the train-ing and assessment of a wide range of clinical and nontechnical skills with high reliability and validity.103-106The OSCE was developed


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Surgery_Schwartz. OSCE has been established as the gold standard102 for the train-ing and assessment of a wide range of clinical and nontechnical skills with high reliability and validity.103-106The OSCE was developed by Harden, at the Ninewells Hospital in Dundee, Scotland, and first published in 1975.107 He subsequently coined the term “OSCE” in his 1979 publica-tion “Assessment of Clinical Competence Using an Objective Structured Clinical Examination (OSCE).”108 The purpose of the OSCE was to address the lack of a reliable method to evalu-ate the clinical abilities of physicians and featured a compre-hensive assessment of history-taking and physical examination skills. Early versions also assessed nontechnical skills, patient interaction, and professionalism. Since its inception, the OSCE has matured, been subjected to rigorous tests of reliability and validity, and has seen widespread adoption.109-111OSCEs remain a critical portion of resident evaluation. They have been well validated for teaching


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Surgery_Schwartz. subjected to rigorous tests of reliability and validity, and has seen widespread adoption.109-111OSCEs remain a critical portion of resident evaluation. They have been well validated for teaching leadership skills in Brunicardi_Ch01_p0001-p0026.indd 1429/01/19 10:58 AM 15LEADERSHIP IN SURGERYCHAPTER 1trauma and interacting with simulated patients in difficult sce-narios. OSCEs can be tailored to a variety of circumstances, including practicing breaking bad news or discussing end of life care, dealing with angry or aggressive patients, and simulating disagreements with other providers or family members.109-112 The potential for OSCEs to train, test, and perfect nontechnical skills, such as leadership, is extraordinary.A pilot project for the Medical Council of Canada was conducted by the University of Toronto and published in 1988 describing the use of an OSCE for evaluating the clinical skills of international medical graduates applying to Canadian resi-dency.113 Effective


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Surgery_Schwartz. by the University of Toronto and published in 1988 describing the use of an OSCE for evaluating the clinical skills of international medical graduates applying to Canadian resi-dency.113 Effective communication and language proficiency have been key components since the beginning. A compre-hensive review of this program 2 years later confirmed the reliability and validity of using an OSCE for this purpose.114 The Medical Council of Canada has subsequently mandated a requirement for an OSCE evaluation of all international gradu-ates applying for positions in Canada. In place for the past two decades, the program has ensured a baseline proficiency of skill, attitude, knowledge, and other nontechnical skills.115OSCEs quickly gained acceptance as an established tool to assess learners in a comprehensive manner and became the inspiration for the creation of the USMLE Step 2 Clinical Skills (CS) examination, required for all U.S. medical students prior to licensure.116 Indeed, medical


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Surgery_Schwartz. a comprehensive manner and became the inspiration for the creation of the USMLE Step 2 Clinical Skills (CS) examination, required for all U.S. medical students prior to licensure.116 Indeed, medical students whose schools use OSCE as practice do better on USMLE Step 2.117 The USMLE Step 2 CS examination meets the criteria, discussed in the following section, for a thorough and well-designed OSCE examination, due to its 12-station design which takes 8 hours to complete. It has been found to be a valid and comprehensive evaluation of a student’s clinical abilities, admittedly at massive expense to medical students.118 In the United States, osteopathic medical students take the OSCE-style Level 2 Performance Evaluation.119Although station number and total duration are not com-pletely agreed upon, data indicate that the OSCE examination should be between 3 and 6 hours and 8 to 10 stations in length in order to obtain reliable (r = ≥0.7) communication, history, and physical examination


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Surgery_Schwartz. upon, data indicate that the OSCE examination should be between 3 and 6 hours and 8 to 10 stations in length in order to obtain reliable (r = ≥0.7) communication, history, and physical examination skills. A guideline was that at least seven cases are needed in any domain to achieve reliability. The testing period may be spread over several sessions making up an aggregate score in order to maintain validity. Many medical schools prepare their students for clinical practice with OSCE-style examinations throughout the year, which, taken together, are summative of a high-quality, multistation, valid OSCE. Checklists are typically the standard scoring tools; however, checklists alone may not be as reliable as a more comprehen-sive review by more experienced clinicians—particularly when assessing more advanced students and residents.120 All of the licensure examinations, discussed previously, meet the criteria for a well-designed OSCE based on number of stations and time duration.Beginning


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Surgery_Schwartz. more advanced students and residents.120 All of the licensure examinations, discussed previously, meet the criteria for a well-designed OSCE based on number of stations and time duration.Beginning in 2003, the ACGME mandated the use of OSCEs within residency programs. At the time, residents were wary of its adoption, particularly fearing its use as a tool for determining promotion. Residents’ perceptions of the examina-tion, over time, did change to reflect an acceptance of its use for grading both technical and nontechnical skills.121-123In the United States, the OSCE assesses technical and nontechnical skills in an accurate and valid fashion. The OSCE demonstrates a rapid progression of technical skills highly cor-related to a postgraduate year, whereas clinical skills improve at a more moderate rate121 (Fig. 1-12).10.5123PGY Level45z score0–0.5–1Technical stationsClinical stationsFigure 1-12. Resident assessment by year of training by OSCE. Technical skills assessment demonstrates


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Surgery_Schwartz. moderate rate121 (Fig. 1-12).10.5123PGY Level45z score0–0.5–1Technical stationsClinical stationsFigure 1-12. Resident assessment by year of training by OSCE. Technical skills assessment demonstrates a rapid and continual pro-gression through 5 years of training, whereas clinical evaluations show only modest improvement over the same time period. (Data from Turner JL, Dankoski ME. Objective structured clinical exams: a critical review, Fam Med. 2008 Sep;40(8):574-578.)The past 2 to 3 years has seen an explosion in simula-tion technology and research. In one particularly strong study, multiple teams were assessed for hemorrhage and airway emer-gencies. The Non-Technical Skills for Surgeons (NOTSS) tool was used to assess teams prior to and during simulation. For surgeons, higher NOTSS scores were associated with a quicker resolution of the simulation crisis.125 Advances are being made in using simulation to solve difficult to teach physical examina-tion skills such as breast lump


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Surgery_Schwartz. scores were associated with a quicker resolution of the simulation crisis.125 Advances are being made in using simulation to solve difficult to teach physical examina-tion skills such as breast lump detection and prostate or rectal cancers.126,127 Studies assessing these new simulation tools have also indicated that many attending level surgeons would benefit from continued simulation practice both for keeping operative skills fresh and preventing the decline of physical exam skills, for instance during dedicated research time.126-128The Objective Structured Assessment of Technical Skills (OSATS) was initially developed as a bench station examination. It was later applied to intraoperative skill assessment, and appears to be an additional option for programs seeking a validated and reliable method for mixing technical skills assessment into simu-lations of nontechnical exercises to create a more “real world” simulation.129-133 With recent focus on milestones and proficiency-based


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Surgery_Schwartz. method for mixing technical skills assessment into simu-lations of nontechnical exercises to create a more “real world” simulation.129-133 With recent focus on milestones and proficiency-based promotion, as compared to time-based promotion of resi-dents, there is a need to reliably assess intraoperative skill.134 Digitization and modern computing have created new opportu-nities for simulation and education. One proposed method is a real-time, mobile web system featuring consistent and accurate assessment of the residents’ performance. The platform enabled timely recording of data, was efficient in terms of how much fac-ulty time it took to complete an assessment (average 2 minutes), and from a validity standpoint did trend well overall with resident postgraduate year. The system itself fulfilled the ACGME and American Board of Surgery mandate for program assessment of resident performance in the operating room.134Nontechnical skills often erode during stressful events, particularly in