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Rosengart TK, Kent KC, Bland KI, et al. Key Tenets of Effective Surgery Leadership: Perspectives From the Society of Surgical Chairs Mentorship Sessions. JAMA Surg. 2016;151(8):768–770. doi:10.1001/jamasurg.2016.0405
This Special Communication summarizes the key points raised at the Society of Surgical Chairs mentorship panel sessions held at the 2014 and 2015 annual meetings of the society. Highlights of these expert panel discussions include senior chairs’ insights into successfully dealing with increasingly complex academic medical organizations and horizontal department management expectations in the context of the arrival of the Millennial Generation into the work force. Three key tenets of effective surgery leadership that arose from these sessions deal with the importance of (1) collaboration and cooperativity, (2) humanized relationships and mentorship, and (3) operational efficiency. Overall, the panel consensus for the future of surgery leadership was optimistic while recognizing that the demands of chairmanship are considerable.
Leadership and management in academic medicine has changed considerably—likely irrevocably—from that of a generation or two ago, reflective of similar changes seen in many other areas of our society. These changes include the reorientation of a largely autocratic, vertically organized hierarchy into a far more democratic, consensus-driven, and horizontally organized management structure. Once largely autonomous academic department silos are also now far more matrixed, with department clinical domains overlapping clinical centers of excellence and academic missions interwoven with hospital priorities and funding models.
This fundamental restructuring of department organization and function coincides with the potentially disruptive arrival of the Millennial Generation: students, residents, and junior faculty bred in a world of enhanced access to information, elevated expectations, and a purported sense of guaranteed entitlement.1 Millennials’ reported demand for a plausible work-life balance, early and frequent promotion and reward, and rationales for meaningful work commitments is juxtaposed with older managerial generations’ fabled respect for authority, unfaltering total commitment to the job, and expectant patience for recognition and advancement.
These tensions represent a potentially significant challenge to department chairs who may model their leadership styles on their own chairs and mentors—typically the classic, all-knowing, Halstedian icon who leads unquestioned and unchallenged. In this context, chairs face the even more daunting and potentially risky endeavor of navigating the new norm of organizational complexity, hyperregulation, hyperaccessibility, and electronic hypercommunication. Perhaps not coincidentally, it is striking that 16% of the chairs in the Society of Surgical Chairs are new members.
To attempt to address these challenges, the Society of Surgical Chairs began an annual mentorship retreat in 2014 that sought to provide guidance on leadership in surgery to its newer members and its membership at large. These events, held at the time of the 2014 and 2015 American College of Surgeons annual meetings, were well attended, highlighting the interest and perceived importance of this issue. The management challenges and solutions described in these sessions reflect a very different nature of leadership in surgery today compared with that of a generation or two ago, highlighted by books on this subject by Gewertz and Logan2 and Kibbe and Chen.3 The following summary of these mentorship sessions could serve as a manual for leadership success in the modern academic environment.
The consensus guidance generated by our mentorship panels of senior chairs (T.J.E., B.L.G., J.G.H., L.D.B., C.A.P., S.C.S., K.I.B., R.J.W., K.D.L., and R.D.S.) and our audience of other Society of Surgical Chairs members highlights a leadership style highly attuned to human management skills and nuanced executive management approaches. More specifically, 3 themes that emerged from these sessions underscore the importance of (1) cooperativity and collaboration between chairs and their colleagues as well as their own department leadership, including chairs’ participation in administrative activities outside the operating room, in addition to their persistent role as an operating surgeon; (2) understanding the human element of faculty and staff (emotional IQ) so that chairs can leverage that knowledge into effective leadership actions4; and (3) chairs’ effective engagement in increasingly complex administrative operations to protect and advance the mission of the department, including the recruitment and retention of faculty supportive of those goals (Table).
Highly collaborative interactions between the department chairs and institutional leadership, other chairs and peers, and departmental direct report leadership are a critical component of successful department leadership. Being in the room for key decision-making meetings and forging strong alliances with other department chairs and institutional leaders in these power-brokering exercises is essential in assuring support for department interests.
Generally speaking, what is good for the institution is good for departments of surgery and vice versa, and the surgical voice is extremely important in determining institutional investments in buildings, people, and programs. In this context, the successful chair finds a way to represent departmental and institutional interests simultaneously. An informal poll of the mentorship panel pegs this commitment as occupying up to 50% of a chair’s time.
This premise echoes Beauchamp’s 2005 commentary5 that “it is vital that the chair attends most [of these] meetings to provide critical, practical, strategic, operational, and clinical input into the administrative decision process.” Consistent with this view, a recent survey reported by Slakey et al6 noted that surgery chairs spent nearly as much time in meetings (10%-25%) as in clinical activity (25%).
Some consideration should also be given to the legacy of surgery chairs’ need to hold themselves above other chairs because of their unique responsibilities in the operating room and the high-value/high-profile nature of the surgery portfolio. In this scenario, chairs can safely absent themselves from meetings that do not fit operative schedules. This viewpoint reflects the 2005 lament of Beauchamp5 that the academic chief was at risk of being replaced by the clinical “rainmaker” best able to contribute to the bottom line and by the commentary of Rikkers,7 who chaffed at the task of keeping track of “endless meetings.” The importance of the clinical engagement of chairs in the operating room also allows them to garner respectability through this participation in the lifeblood of the department.
Perhaps the new importance of collaboration, though, is best reflected in the intermediate position that chairmen’s presence in the operating room remains important but that great value is also attained from their nurture of collaborative liaisons with important colleagues (eg, the chair of medicine) who can trustfully and reliably represent surgery department interests, especially when the surgery chair is not present at key meetings.
Faculty growth and development (mentorship) is a second major priority for the modern-day chair of surgery. As a corollary, successful faculty recruitment is one of the most important jobs of chairs, and thoughtful understanding of faculty members as people is critical to this function.
This humanistic strategy, powered by emotional IQ skills,4 is exemplified by what can prove to be productively insightful approaches to problem faculty (ie, the 20% who potentially occupy 80% of a leader’s time) and by emerging perspectives on faculty Millennials. The best path to job satisfaction and optimized productivity for problem and Millennial faculty may be through chairs who take the time to understand both of these groups’ interests and passions to create goals and objectives appropriate for their department.
In considering the best approaches to faculty development, it is interesting to consider that Millennials may not be intrinsically significantly different from other faculty members; their heightened expectations simply make it more important for chairs and other leaders to carefully embrace leadership principles that are useful and appropriate for all staff, including fairness, transparency, and clear definitions of goals and objectives. For example, while Millennials may have different opinions than older staff about the value and even acceptability of being called into the hospital when on call (the so-called work-life balance), it needs to be considered that Millennials too have a drive for academic success that can be harnessed successfully if diligently deciphered and embraced by chairs. Millennials’ involvement in the academic workplace is evidence of such a commitment. Likewise, nonfinancial goals, potentially recognized through mechanisms such as academic relative value units, are likely as important to Millennials as to older academic department members. Fair, thoughtful, and transparent identification and rewarding of efforts toward such goals can often be as effective at engaging and providing job satisfaction to Millennials as it would be to earlier-generation faculty.
Out-of-the-box faculty might also represent potentially highly productive thinkers who first need to be understood and then properly channeled. Such individuals rarely have malevolent motivations, although they may seem to when their actions are not properly understood and effectively redirected. A constructive course of action (meeting, understanding, channeling, and redirecting) is advocated to deal with such faculty.
Diversity among department residents, faculty, and leadership can likewise be enhanced through a thoughtfully developed understanding of the goals and objectives of all department members, including potential barriers to the full participation of some members in department activities under a 1-size-fits-all approach. For example, domestic responsibilities may hinder the participation of some faculty members in early morning or late evening activities, and diverse cultural or socioeconomic backgrounds may interfere with some members’ ability to readily integrate all department policies and practices (eg, expectations for professional attire or interpersonal relationships). Successful identification and mitigation of such diversity challenges can promote the success of a greater proportion of department members and can more broadly advance the careers of a diversified department. Diversity is, in fact, an asset to any department. Multiple perspectives and multiple points of view unleash the creative power of a group.
These perspectives affirm that the classic “triple threat” faculty member rarely, if ever, still exists and that a chair’s job is to mix and match individual faculty members’ interests into an integrated team able to accomplish a complete spectrum of the academic mission as a mosaic of individual interest-based efforts. This exercise underlines another chair priority: supporting and nurturing department faculty or, as Beauchamp5 phrases it, being “gratified to shine in the reflected glory of the faculty members.”
When such strategies are unsuccessful, early discharge policy may be required because it is unwise to assume all faculty will ultimately be a good fit for a given department. Collaborative interactions with recruiting chairs are helpful in finding good fits for such departing (strong or less strong) faculty. In the new order of the nonmonolithic leader, the chair should involve other leaders, such as division chiefs, in the mentoring of challenging as well as thriving faculty, so that the chair will not alone be encumbered by the significant time commitment to this process.
The third major area of leadership focus is operational effectiveness, embodied in the protection and advancement of the mission of the department through careful recognition and effective integration of institutional goals. In this context, new chairs are admonished to proceed by “evolution, not revolution,” advancing when institutional and departmental cultures, goals, and methods of operation are clearly understood and populating departments with faculty and staff who can and will embrace those goals—either through recruitment or cultural shifts over time.
Specific aspects of effective management include a recognition that the return of capitation and managed care is imminent and unavoidable. In this scenario, surgery will likely become a cost center and not a revenue resource. Therefore, improving surgeons’ quality performance is critical, and case volume will become deprioritized. Intensive provider-specific outcomes reporting, already available through Crimson, United HealthCare Services, the American College of Surgeons’ National Surgical Quality Improvement Program, and other third party databases, should be embraced. Quality improvement feedback to faculty, including (blinded) comparisons to peer groups’ length of stay and cost/resource use data, is also critical to achieving quality improvement.
In the context of the evolving clinical practice landscape, it need be recognized that extradepartmental, interdisciplinary, hospital-based clinical centers are on the rise and will likely be a new challenge for department chairs. A chair’s understanding of these new threats as opportunities is critical to department vitality. It is not clear how the funds that will flow through such centers will be structured, but chairs’ efforts to align these centers’ funds with department cost and quality incentives is strongly endorsed.
Overall, the perspectives on surgery leadership generated by the Society of Surgical Chairs mentorship panelists highlight a general optimism for the future success of surgery chairs, albeit one that looks significantly different from that of their predecessors and one that requires significant attention to a host of new and demanding challenges. This perspective encompasses chairs’ thoughtful and collaborative involvement outside the clinical arena while maintaining their surgical bona fides; engagement with faculty and peers as complex personalities with their own viewpoints, interests, and objectives; and proficient functioning in the administrative arena. Despite these challenges, current surgery chairs’ average tenure of 8 years5 speaks well of the efforts of today’s chairs to adapt to these challenges and remold themselves in the modern era.
Corresponding Author: Todd K. Rosengart, MD, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 1 Baylor Plz, Houston, TX 77030-3411 (email@example.com).
Accepted for Publication: December 30, 2015.
Published Online: April 20, 2016. doi:10.1001/jamasurg.2016.0405.
Author Contributions: Dr Rosengart had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Rosengart, Kent, Britt, Eberlein, Gewertz, Schulick, Stain, Weigel.
Acquisition, analysis, or interpretation of data: Rosengart, Kent, Bland, Hunter, Lillemoe, Pellegrini.
Drafting of the manuscript: Rosengart, Kent, Bland, Lillemoe.
Critical revision of the manuscript for important intellectual content: Rosengart, Kent, Britt, Eberlein, Gewertz, Hunter, Pellegrini, Schulick, Stain, Weigel.
Administrative, technical, or material support: Eberlein, Gewertz, Hunter.
Study supervision: Rosengart, Kent, Eberlein, Hunter, Lillemoe, Pellegrini, Schulick, Weigel.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Ellen Waller, BA (American College of Surgeons, Chicago, Illinois), for her able assistance coordinating the Society of Surgical Chairs mentorship panel sessions and the Society of Surgical Chairs for the opportunity to conduct these meetings. Ms Waller was not compensated for her contribution.
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