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The importance of good surgical leadership becomes evident when its absence leads a department into difficulty. Leadership may also be abused, as evidenced recently in a German liver transplant programme in which patient data were manipulated to push certain individuals to the top of the waiting list; other patients received liver transplants for questionable reasons. Both of these actions were done to increase the number of transplant procedures.

During the 19th and 20th centuries, gifted men (no women) opened new fields; cardiac and transplant surgery are examples. These advances were based on excellent surgical technique and vision. Often these men wrote memoirs, and sometimes they were honoured by biographies authored by others. These texts provide insight into their thoughts on leadership, as well as their approach to research and teaching. Although many of these great men had some real qualities of leadership, it is unlikely that they had all of the skills required of a leader in the 21st century.

In the past, surgical leaders did not instruct their juniors by assisting them to conduct operations or by teaching them formally during lectures. A trainee would have observed the master at work in the operating room and listened to his wise words during rounds. The leader acted mainly as a role model in the contexts of patient care, surgical science and teaching. Rudolf Nissen wrote about this in his autobiography, quoting William Halsted: ‘There are men who teach best by not teaching at all’[1].

Although the virtues of knowledge, technical excellence, research ability and teaching skill are far from obsolete, the ideal surgical leader of today requires much more. Non-technical matters, such as emotional competence, resilience and communication skills, are essential additional competencies. Psychologists, as well as business and industry professionals tell us, perhaps fortunately, that most of these non-technical or soft leadership skills are not innate natural abilities–they can be learned and developed through education, observation and experience[2]. Halvorsen and colleagues[3] have described the basic principles of those essential non-technical skills. They note that the first step is to recognize one's own strengths and weaknesses, and to learn about the two components of leadership, namely self-management and team management, the prerequisite for both being emotional intelligence. Goleman, a psychologist, has described the four domains of emotional intelligence as self-awareness, self-management, social awareness and social skills[4]. He has also classified different leadership styles: authoritative, coaching, affiliative, democratic, pace-setting and commanding. Multiple leadership styles are necessary for success, to be used according to the specific circumstances of a situation[3], [5].

Almost all we know about team management comes from the airline industry. Team building, situational awareness, briefing strategies, stress management, and the need to flatten hierarchy (so that anyone and everyone may speak out when a problem arises) are considered to be the cornerstones of team management. Surgeons have not been good at this. They tend to have difficulty in recognizing when they lack communication skills[3]. In one study 95 per cent of pilots, but only 55 per cent of surgeons, believed that hierarchies interfered with optimal team performance[6]. Some 13 years have passed since this work was published, and perhaps the recent introduction of standard theatre procedures and checklists run by junior surgeons or circulating nurses have improved things[7]. It remains the case, however, that any evaluation of soft skills as part of the recruiting process for a surgical leader is rare. Most institutions continue to seek the technically well trained surgeon from a prominent institution, who comes with an impressive list of funding and publications[8] (Fig. 1).

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Figure 1. Traditional and contemporary leadership characteristics[2], [8]

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The CanMEDS framework defines seven roles of competence for physicians and surgeons[9]. Most of the non-technical skills mentioned above are included in these roles. When it comes to surgical leaders, these abilities and qualities are essential. In addition, leaders are expected to communicate appropriately, not only with patients and health professionals, but also with the hospital administration, politicians and surgical specialty organizations. Conflict-solving strategies are part of these skills. Listening to all parties and taking their views seriously is crucial, as is observing confidentiality, when required. In Germany, when surgical chairpersons fail and have to step down from their position, this usually relates to inadequate communication with the administration and/or the chairpersons of other departments within the institution.

As managers, surgical leaders should be trained in organizational tasking and in resource allocation; they should understand the basics of hospital and healthcare economy. In recent years in Germany, almost all surgeons who wish to be eligible for the position of departmental chairperson have studied business administration. A Master of Business Administration degree makes them more attractive to appointment committees than yet more efforts in research and teaching, assuming an adequate standard of these last two items and a reasonable proficiency in technical surgery.

The role of a healthcare advocate is an important one for surgical leaders. It is the leader's responsibility to set standards within the department, for instance in deciding whether the volume of a difficult procedure is sufficiently high to guarantee adequate results, or whether to refer patients needing complex major surgery to a more specialist hospital. Training and/or recruiting the best surgeon available is another way of solving such a problem.

Besides maintaining the requirements of a good scholar, surgical professionalism is an essential element of leadership in surgery. Professionalism means ongoing training, defined specialization, knowledge management and team communication[10]. Also of importance are good social skills, appropriate ethical standards and honesty[11]. Disastrous failures, such as the one described at the beginning of this article, should not happen if these virtues are present in a leader.

In daily professional life, social skills allow difficult problems to be solved on the basis of common sense and respect for individuals and groups of healthcare professionals. Ethical standards and honesty are prerequisites for any commitment to clinical competence, for an atmosphere of openness, for adequate patient safety measures, for discussing one's own errors and those of others, and for resisting the (sometimes less than ethical) challenges of hospital administrators. The economic pressure in countries using a reimbursement system, with fixed compensation on one side and the increasing expense for hospital staff, energy, material and devices on the other, can lead to problematic decisions. When leaders are asked–even coerced–improperly to increase the number of patients and their case mix, and to perform more and higher reimbursed procedures, they must be prepared to resist. Unnecessary procedures are unethical. Sadly, such resistance is not always achieved.

A surgical leader, trained for the traditional triathlon of ‘operative skill, research and teaching’, is today inadequately prepared to run a department successfully. The additional requirements described above are prerequisites if all the challenges of a complex healthcare and hospital system are to be met with confidence. Indeed, modern surgical leaders might better be compared to decathletes. Although styles of leadership may vary throughout the world–British, Arabic and Chinese leaders will behave in accord with their native cultures–the principles of modern leadership hold true everywhere.

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

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The author declares no conflict of interest.

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