As academic surgeons, it is our obligation to transform the society in which we live, not just through scientific innovation but through strong leadership. Goliaths like Thomas Starzl revolutionized not only surgical practice but also entire communities. Leadership is crucial to the efficacy of public health initiatives such as the Stop the Bleed campaign, which was initiated and led by surgeons. Despite being fundamental to the surgical profession, competent leadership is more a desired consequence of surgical training than an explicitly taught skillset in surgical residencies. Training future surgeon-leaders requires formally incorporating leadership into surgical education.
Leadership is crucial for clear communication in the operating room, for coordination of patient care, and for mentoring of trainees to guide professional decision-making and avoid burnout. Because the culture of medicine permeates every aspect of society, our responsibility is not restricted to the hospital setting—we must now, more than ever, participate in civic discourse. Failure to address the broad scope of successful leadership has restricted our ability to teach residents how to be leaders, and has curtailed the sense of responsibility and professional identity in our trainees.
Unfortunately, surgical training, which prioritizes clinical competence over all else, often fails to specifically teach residents how to be effective leaders. Leadership is part of a “hidden curriculum” that trainees are supposed to intuit or learn by watching faculty. However, residents rarely get opportunities to integrate leadership into their professional identities–to practice being leaders. Even during the chief years when residents purportedly exercise their skills as leaders, the extent to which they actually lead varies depending on the structure of the healthcare team, the existence of fellows, and differences in autonomy afforded by their attendings.
Models of leadership development, such as relational and authentic leadership, can guide our understanding of these problems and lead to better outcomes. Relational leadership theory requires the resident to develop his/her identity as a leader through interactions with others. In this respect, identifying as a leader is contingent upon the extent to which others perceive the resident to be a leader. As the field of surgery diversifies, we are beginning to see that the experiences of trainees differ. The degree to which residents identify themselves as surgeons is directly influenced by sociodemographic factors. Movements such as #ILookLikeaSurgeon resist gender-related preconceptions that may undermine a resident’s ability to be perceived as a leader. Changes to institutional policy, such as Penn State College of Medicine’s refusal of patient requests for providers based on race, ethnicity, or gender also play a part in mitigating bias. To this end, teaching leadership is a cooperative social process that requires us, as a profession, to contend with issues of gender and racial disparity.
Authentic leadership theory, taught at various institutions including Harvard Business School, has four main tenets: self-awareness, moral perspective, balanced processing (i.e., critical appraisal of one’s situation and values), and transparency in interpersonal interactions.8 While we would like to believe that we all encompass these behaviors, the reality is that, the competitive, high-stakes nature of our jobs can challenge our ability to act in accordance with authentic leadership theory. To further complicate matters, surgical culture is justifiably steeped in a tradition of hierarchy, which can hamper a junior resident’s ability to exhibit authentic leadership. Dissemination of leadership skills must occur in a manner that harmonizes with the established hierarchy.
The environment of surgical training confers specific challenges to leadership development. In order to mitigate these, we must implement a formal curriculum for leadership as we have for teaching operative skill or clinical judgement.
 The American College of Surgeons. 2016-2018. Bleedingcontrol.org. Accessed February 2, 2018.
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 Reddy, S. How doctors deal with racist patients. The Wall Street Journal. Jan. 22, 2018. https://www.wsj.com/articles/how-doctors-deal-with-racist-patients-1516633710. Accessed February 1, 2018.
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8 Walumbwa, F.O., Avolio, B.J., Gardner, W.L.,Wernsing, T.S. & Peterson, S.J. (2008). Authentic leadership: development and validation of a theory-based measure. Journal of Management, 34, 89-126.