- Email: [email protected]
Attending Surgeons’ Leadership Style in the Operating Room: Comparing Junior Residents’ Experiences and Preferences
ORIGINAL REPORTS
Attending Surgeons’ Leadership Style in the Operating Room: Comparing Junior Residents’ Experiences and Preferences Nicole A. Kissane-Lee, MD, EdM, FACS,*,† Steven Yule, PhD,*,‡ Charles N. Pozner, MD,*,§ and Douglas S. Smink, MD, MPH, FACS*,‡ Neil and Elise Wallace STRATUS Center for Medical Simulation, Boston, Massachusetts; †Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; ‡Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts; and §Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts *
PURPOSE: Recent studies have focused on surgeons’
nontechnical skills in the operating room (OR), especially leadership. In an attempt to identify trainee preferences, we explored junior residents’ opinions about the OR leadership style of teaching faculty. METHODS: Overall, 20 interns and 20 mid-level residents
completed a previously validated survey on the style of leadership they encountered, the style they preferred to receive, and the style they personally employed in the OR. In all, 4 styles were explored; authoritative: leader makes decisions and communicates them firmly; explanatory: leader makes decisions promptly, but explains them fully; consultative: leader consults with trainees when important decisions are made, and delegative: leader puts the problem before the group and makes decisions by majority opinion. Comparisons were completed using chi-square analysis. RESULTS: Junior resident preference for leadership style of attending surgeons in the OR differed from what they encountered. Overall, 62% of residents encountered an authoritative leadership style; however, only 9% preferred this (p o 0.001). Instead, residents preferred explanatory (53%) or consultative styles (41%). Preferences differed by postgraduate year. Although 40% of interns preferred a consultative style, 50% of mid-level residents preferred explanatory leadership. CONCLUSIONS: Junior resident preference of leadership
style in the OR differs from what they actually encounter. This has the potential to create unwanted tension and may erode team performance. Awareness of this difference provides an opportunity for an educational intervention directed at both attendings and trainees. ( J Surg Ed Correspondence: Inquiries to Nicole A. Kissane-Lee, MD, EdM, FACS, 1924 Alcoa Hwy., Box U-11, Knoxville, TN 37920; fax: (865) 525-3460; e-mail: nkissane@ utmck.edu
C ]:]]]-]]]. J 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
KEY WORDS: surgical simulation, leadership in the
operating room, surgical resident education COMPETENCIES: Practice-Based Learning and Improvement,
Interpersonal and Communication Skills, Professionalism
INTRODUCTION Leadership in the operating room (OR) has provoked increasing discussion in the recent surgical literature.1-4 Intraoperative leadership has been widely described as an important component to success, safety, and performance.3,4 In 2011, a systematic review of the literature demonstrated that although there is understanding and recognition that leadership skills are essential for effective workplace performance, the necessary leadership behaviors are not well defined.1 Likewise, when attending surgeon intraoperative leadership behaviors were examined, video analysis revealed that most surgeons’ leadership focus was on other surgeons or trainees, rather than the entire operative team.2 This same video-based study also noted that surgeons adopted a consistent approach to leadership, meaning that regardless of the operative situation, their repertoire and communication tendencies were reliable.2 A recent panel highlighted pitfalls of leadership in the OR, specifically describing leadership styles, management, communication, and performance during crises.3,4 This panel addressed challenges in maintaining manners and behavior when the stresses of the OR can overcome professional disposition.3 Proposed solutions to these challenges included honing fundamental leadership behaviors of listening and sharing information, as well as establishing an environment of motivation and responsibility. The panel
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.08.009
1
specifically noted that a good leader promotes teamwork during critical moments by establishing a sense of trust and respect for all team members. Ultimately, the panel stated that one of the most important leadership responsibilities was acknowledgment of the team with statements of appreciation.3 In the nonsurgical literature, several types of leadership behaviors have been described.5-11 Most can be classified into the following types: authoritative, explanatory, consultative, and delegative. An authoritative leader makes decisions, communicates them firmly, and expects them to be carried out. Authoritarian leaders are also commonly referred to as autocratic leaders. An explanatory leader makes decisions promptly but explains them fully. For example, this style is similar to authoritative leadership; however, the leader provides clear explanations for why it needs to be done. A consultative leader consults with colleagues and team members when important decisions are made. This style focuses on using the skills, experiences, and ideas of others, especially when major decisions involve or affect others. A delegative leader puts the problem before the group and makes decisions by majority opinion. This style has also been referred to as participative. Flin et al.12 surveyed surgery residents in Scotland regarding their experiences in intraoperative leadership styles. These residents reported that they most frequently receive and use the explanatory leadership style. The authors hypothesized that this alignment was owing to surgeon’s positive attitudes toward actions and behaviors, which led to enhanced intraoperative teamwork and safety.12 In addition, the attending surgeons in that study also felt that they predominately exhibited consultative leadership (54%), as opposed to authoritative (8%) and delegative (1%). This study is the only prior survey in the literature describing surgical residents’ preferences and experience with leadership behaviors in the OR. Nontechnical skills are increasingly viewed as vital skills for a safe, proficient surgeon. Leadership in the OR has been previously been incorporated into studies of surgeons’ intraoperative nontechnical skills.13-18 In this study, we examined junior residents perspective on leadership style in the OR,
specifically with respect to the leadership behaviors of attending surgeons. The purpose of our study was to identify trainees’ preference for OR leadership style among teaching faculty. We hypothesized that the leadership style trainees’ preference would differ from what they encountered.
METHODS We conducted an institutional review board–approved study at the Neil and Elise Wallace STRATUS Center for Medical Simulation at Brigham and Women’s Hospital, Boston, MA. Eligible participants were surgical interns (postgraduate year [PGY] 1), and mid-level residents (PGY 2 and PGY 3). Interns (PGY 1; N ¼ 20) and mid-level residents (PGY 2 and PGY 3; N ¼ 20) were invited to complete a survey on their experiences of attending surgeons’ leadership style in the OR, using a previously validated instrument.12 The survey included definitions of the 4 styles of leadership: authoritative, explanatory, consultative, and delegative, and participants were asked to indicate which (1) type of leadership style they most frequently encountered, (2) type of leadership style they preferred to receive, and (3) type of leadership style they most commonly used themselves. We also asked participants to list any nonsurgical leadership positions they had held in social and work life from a predefined list of 12 options (Appendix 1). Demographics (age, sex, PGY, and number of cases participated in) were also collected. Results were analyzed using chi-square test.
RESULTS Overall, 40 surgical residents (20 interns and 20 mid-level residents) participated in this study. Further demographic data note inclusion of 20 men and 20 women; and 20 PGY1 residents, 10 PGY-2 residents, and 10 PGY-3 residents (Table). Residents’ operative experience is also outlined in Table 1. PGY-3 residents, on average, were first assistants in the most cases (181 open cases and 63.5 laparoscopic cases).
TABLE. Demographics and Questionnaire PGY 1 (Intern), N ¼ 20
PGY 2 (Mid-Level), N ¼ 10
PGY 3 (Mid-Level), N ¼ 10
Age (mean, y) 28.8 29.1 32.1 Sex Male 60% 40% 40% Female 40% 60% 60% Mean of open cases as first assistant (s.d.) 28.90 (19.49) 171.40 (72.45) 181.00 (163.53) Mean of laparoscopic cases as first assistant 5.55 (7.23) 40.90 (15.89) 63.50 (89.75) (s.d.) Mean of observed open cases (s.d.) 61.30 (90.89) 102.00 (153.25) 81.0 (149.78) Mean of observed laparoscopic cases (s.d.) 19.15 (48.15) 32.11 (41.30) 49.40 (94.16) Leadership (LS) (“x” of 12 leadership examples) 3.70 (2.11) (p ¼ NS) 4.80 (1.32) (p ¼ NS) 5.00 (1.70) (p ¼ NS) (s.d.) s.d., standard deviation. 2
Journal of Surgical Education Volume ]/Number ] ] 2015
62%
60 50 30%
40 30 20
8% 0%
10
Percentage of Residents
Percentage of Residents
70
0 Authoritave
Explanatory
Consultave
100 90 80 70 60 50 40 30 20 10 0
Delegave
43%
11% 3%
Authoritave
Leadership Style
PGY-1 residents were first assistants, on average, for only 28.9 open cases and 5.6 laparoscopic cases. Survey respondents reported authoritative leadership (62%) to be the leadership style most frequently encountered in the OR, followed by explanatory (30%), consultative (8%), and delegative (0%) (Fig. 1). By contrast, only 9% preferred an authoritative leadership style (p o 0.001). Instead, respondents preferred explanatory (48%) and consultative (42%) styles (Fig. 2). These preferences did vary by PGY, with 40% of interns preferring a consultative style and 50% of mid-levels preferring explanatory leadership. When asked what leadership style they most often personally employed, the majority used either explanatory (43%) or consultative (43%) styles, with only 9% using authoritative style (Fig. 3). Figure 4 demonstrates that the intraoperative leadership style residents’ encounter from attending surgeons differs from the style they prefer. Overall, 62% of residents report encountering authoritative leadership; however, only 9% prefer that style (p o 0.001). These results did not seem to be affected by main demographic factors gathered. Although sex of the residents was evenly distributed, with 50% women and 50% men in the sample as a whole, 60% of interns were men (n ¼ 12, p ¼ not significant [NS]) and 60% of mid-level residents were women (n ¼ 12, p ¼ NS). Resident reported leadership roles are also reported in Table 1. PGY-1 residents noted an average of 3.7 leadership
Consultave
Delegave
FIGURE 3. Leadership style residents use.
roles, as compared with PGY-2 residents who described an average of 4.8 leadership roles and PGY-3 residents who acknowledged 5 leadership roles (p ¼ NS).
DISCUSSION In this survey of junior surgical residents regarding OR leadership style, we found that most residents report receiving an authoritative style but prefer and use explanatory and consultative styles. Thus, residents do not commonly encounter the type of leadership style they prefer. This supported our hypothesis that the leadership style trainees prefer differs from what they encounter. These findings have several significant implications for surgical leadership education in the OR. As noted in the surgical literature, developing leadership skills in the OR includes listening and sharing information and establishing an environment for cooperation and learning.3 These fundamental leadership skills are most akin to explanatory and consultative leadership, not authoritative leadership. As previously noted, Flin et al.12 queried surgery residents in Scotland regarding their experiences in intraoperative leadership styles. Interestingly, these resident responses differed from what was noted in this study. The surgery residents in Scotland reported that they most frequently receive and use the explanatory leadership style. Perhaps this difference from the 70% Observed
60%
48%
Residents (%)
Percentage of Residents
Explanatory
Leadership Style
FIGURE 1. Leadership styles most frequently encountered.
100 90 80 70 60 50 40 30 20 10 0
43%
42%
9% 1%
Preferred
50% 40% 30%
p<0.001
20% 10% 0%
Authoritave
Explanatory
Consultave
Delegave
Leadership Style
FIGURE 2. Leadership style residents prefer. Journal of Surgical Education Volume ]/Number ] ] 2015
Authoritave
Explanatory
Consultave
Delegave
Leadership Style
FIGURE 4. Observed vs preferred leadership style. 3
authoritative style received by the residents in this study is owing to the era and culture. In addition, heightened awareness of the importance of nontechnical surgical skills in Scotland may play a significant role as well. Finally, differences may also be attributed to cultural variances in the structure of surgical training and level of autonomy in the OR. There was no significant difference noted between additional resident leadership experience and leadership preference (Table 1). This may be owing to the importance placed on leadership experience in resident selection in the program observed in this study. Rationale for the discrepancy between perception and preference is multifactorial, and may be a result of the residents’ era of surgical training. The current era of surgical trainees, which in the literature have been referred to as “Millennial” residents, differ in educational and performance expectations as compared with more senior surgeons.19-22 Specifically, senior surgeons may primarily teach via more autocratic or authoritative means owing to their own personal residency experience, rather than the present-day residents who prefer an explanatory or consultative style. Residency programs are increasingly focusing on nontechnical skills in surgery and these skills include opportunities for direct feedback, communication, discussion, and collaboration of ideas.19-22 Awareness and understanding of these differences in generations provides an opportunity to improve education for future trainees.19-22 Another explanation for the discrepancy between “perception” and “preference” includes how the junior residents were surveyed about their leadership experiences. Residents surveyed in this study were asked to describe their attendings “as a whole” and not to focus on specific attendings. This may have led to a variety of presumed leadership styles that were unique to each resident’s personal opinion, specialty preference, or operative exposure. Some residents may have chosen to comment on the leadership style of their mentor, program director, most senior surgeon, or department chair. Others may have commented based on a combination of surgeons, with no specific surgeon in mind. Our study is not without limitations. It was completed at a single institution with all participants from the same surgery residency program, thereby limiting variety of leadership exposure and experience. This study was a component of junior resident simulation education and as such, we were limited to responses by PGY-1, PGY-2, and PGY-3 residents. These junior residents might have a bias in perception of leadership skills owing to limited participation in cases or overall operative experience. Likewise, this survey was based on resident experiences in the simulated OR conducting simple laparoscopic and open cases, not advanced or complex scenarios, which may necessitate greater opportunities for leadership demonstration or awareness (such as in a crises or adverse event). Additional limitations include varying individual, or personal, definitions of leadership, which may have biased resident survey responses. As there was no formal education
for participants in self-assessment of leadership skills, this was another limitation and may have created a discrepancy or bias in survey responses. Although there are studies that show surgeons are good at self-assessment of technical skills, evidence for self-assessment of nontechnical skills such as leadership is more variable.12-18 This is important when studying leadership as an independent variable predicting a performance outcome; however, the main purpose of this study was to understand the insight surgical residents have about the leadership style of attending surgeons they work with, and for that purpose the authors feel their assessments are valid indicators of their preferences. We also feel that it is not essential to have expertise in a topic to be able to hold a valid opinion and to assess the quality or nature of experience. The surgical residents in this study are medical doctors with first-hand experience working with the surgical leaders they are assessing, and as such are capable of answering questions regarding leadership study and preferences of leadership from their perspective with an acceptable degree of validity. Finally, this study was based on residents’ general perception, rather than specific cases. As a result, this could result in the resident “over-generalizing” a leadership tendency based on assumptions rather than concrete data. The authors designed the questions carefully to avoid hindsight bias as we were interested in dominant leadership styles rather than specific high or low points that may have skewed our results; we deliberately asked participants to reflect on “most frequently encounter” and “most frequently use” when responding. Now that we have established the general pattern of leadership style, we can consider evaluating specific attending surgeons in future research. Future studies are necessary to further evaluate ideal methods by which to teach and evaluate leadership styles in the OR. Owing to increased awareness of intraoperative nontechnical skills, there is a heightened focus on leadership and its pivotal role in resident education. Additional studies would benefit from concrete definitions of each leadership style with inclusion of written scenarios or standardized video examples. Moreover, as the 4 defined leadership styles in this study are not mutually exclusive, and many individuals may have components of each, more standardized written and video-based definitions would facilitate consistency and simultaneously acknowledge the limitations of this overlap. This would facilitate a similar understanding of each leadership style across all participants. In this study, the authors chose to build a picture of the dominant leadership styles used and preferred, so we opted to force participants to choose between these defined styles. We did not account for overlap in our current analysis. Future studies could be based on surveys designed for specific cases, as leadership style likely varies with case complexity. In particular, leadership style encountered in emergency vs elective surgery may highlight additional behaviors unique to these various operative environments. Further research in this area would help us better understand the role of leadership style in surgical training.
4
Journal of Surgical Education Volume ]/Number ] ] 2015
CONCLUSION Our findings show that junior resident preference of leadership style differs from what they typically encounter. Junior residents prefer explanatory or consultative leadership most; however, they frequently encounter authoritative leadership. This has the potential to create unwanted tension within the OR and may erode both operative team performance and resident learning environment. It may also lead to poor learning of leadership skills by residents. Awareness of this difference provides opportunity for an educational intervention for both residents and attendings.
REFERENCES 1. Parker SH, Yule S, Flin R, et al. Towards a model of
surgeons’ leadership in the operating room. BMJ Qual Saf. 2011;20:570-579. 2. Parker SH, Flin R, McKinley A, Yule S. Factors
10. Bass BM, Bass R. The Bass Handbook of Leadership:
Theory, Research, and Managerial Applications. New York, NY: Free Press; 2008. 11. Leadership styles: Choosing the Right Style for the
Situation. Available at: 〈http://www.mindtools.com/ pages/article/newLDR_84.htm〉.
12. Flin R, Yule S, McKenzie L, et al. Attitudes to
teamwork and safety in the operating theatre. Surgeon. 2006;4:145-151. 13. Yule S, Flin R, Paterson-Brown S, et al. Non-technical
skills for surgeons in the operating room: a review of the literature. Surgery. 2006;139(2):140-149. 14. Yule S, Flin R, Paterson-Brown S, et al. Development
of a rating system for surgeons’ non-technical skills. Med Educ. 2006;40:1098-1104. 15. Flin R, Yule S, Paterson-Brown S, et al. The Non-Technical
Skills for Surgeons (NOTSS) System Handbook v1.2.
influencing surgeons’ intraoperative leadership: video analysis of unanticipated events in the operating room. World J Surg. 2014;38(1):4-10 Available at: http://dx. doi.org/10.1007/s00268-013-2241-0.
16. Mishra A, Catchpole K, McCulloch P. The Oxford
3. Haverson AL, Walsh DS, Rikkers L. Leadership Skills in
17. Hull L, Arora S, Kassab E, et al. Observational
the OR, Part I: Communication Helps Surgeons Avoid Pitfalls. Available at: 〈http://bulletin.facs.org/2012/05〉. 4. Haverson AL, Neumayer L, Dagi TF. Leadership Skills
in the OR, Part II: Recognizing Disruptive Behavior. Available at: 〈http://bulletin.facs.org/2012/06〉. 5. Goleman D, Boyatzis RE, McKee A. Primal Leader-
ship: Realizing the Power of Emotional Intelligence. Boston, MA: Harvard Business School Press; 2002. 6. Helmreich RL, Merritt AC, Wilhelm JA. The evolu-
tion of crew resource management training in commercial aviation. Int J Avait Psychol. 1999;9(1):19-32. 7. Murray A. Leadership Styles. Adapted from “The Wall Street
Journal Guide to Management,” Published by Harper Business. Copyright 2013 Dow Jones & Company; 2013: 1-5.
NOTECHS system: reliability and validity of a tool for measuring teamwork behavior in the operating theatre. Qual Saf Health Care. 2009;18(2):104-108. teamwork assessment for surgery: content validation and tool refinement. J Am Coll Surg. 2011;212(2): 234-243. 18. Sharma B, Mishra A, Aggarwal R, et al. Non-technical
skills assessment in surgery. Surg Oncol. 2011;20(3): 169-177. 19. Wilson ME. Teaching, learning, and millennial stu-
dents. New Dir Stud Serv. 2004;106:59-71. Available at: http://dx.doi.org/10.1002/ss.125. 20. Eckleberry-Hunt J, Tucciarone J. The challenges and
opportunities of teaching “Generation Y”. J Grad Med Educ. 2011;3(4):458-461. Available at: http://dx.doi. org/10.4300/JGME-03-04-15.
21. Borges NJ, Manuel RS, Elam CL, et al. Comparing
ence. Qual Saf Health Care. 2004;13(suppl II):ii45-ii51.
millennial and generation X medical students at one medical school. Acad Med. 2006;81:571-576.
9. Bass B, Avolio B, et al. Improving Organizational
22. Pardue KT, Morgan P. Millennials considered: a new
Effectiveness Through Transformational Leadership. New York, NY: Sage; 1994.
generation, new approaches, and implications for nursing education. Nurs Educ Perspect. 2008;29:74-79.
8. Flin R, Yule S. Leadership for safety: industrial experi-
SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jsurg. 2015.08.009.
Journal of Surgical Education Volume ]/Number ] ] 2015
5
Attending Surgeons’ Leadership Style in the Operating Room: Comparing Junior Residents’ Experiences and Preferences Nicole A. Kissane-Lee, MD, EdM, FACS,*,† Steven Yule, PhD,*,‡ Charles N. Pozner, MD,*,§ and Douglas S. Smink, MD, MPH, FACS*,‡ Neil and Elise Wallace STRATUS Center for Medical Simulation, Boston, Massachusetts; †Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; ‡Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts; and §Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts *
PURPOSE: Recent studies have focused on surgeons’
nontechnical skills in the operating room (OR), especially leadership. In an attempt to identify trainee preferences, we explored junior residents’ opinions about the OR leadership style of teaching faculty. METHODS: Overall, 20 interns and 20 mid-level residents
completed a previously validated survey on the style of leadership they encountered, the style they preferred to receive, and the style they personally employed in the OR. In all, 4 styles were explored; authoritative: leader makes decisions and communicates them firmly; explanatory: leader makes decisions promptly, but explains them fully; consultative: leader consults with trainees when important decisions are made, and delegative: leader puts the problem before the group and makes decisions by majority opinion. Comparisons were completed using chi-square analysis. RESULTS: Junior resident preference for leadership style of attending surgeons in the OR differed from what they encountered. Overall, 62% of residents encountered an authoritative leadership style; however, only 9% preferred this (p o 0.001). Instead, residents preferred explanatory (53%) or consultative styles (41%). Preferences differed by postgraduate year. Although 40% of interns preferred a consultative style, 50% of mid-level residents preferred explanatory leadership. CONCLUSIONS: Junior resident preference of leadership
style in the OR differs from what they actually encounter. This has the potential to create unwanted tension and may erode team performance. Awareness of this difference provides an opportunity for an educational intervention directed at both attendings and trainees. ( J Surg Ed Correspondence: Inquiries to Nicole A. Kissane-Lee, MD, EdM, FACS, 1924 Alcoa Hwy., Box U-11, Knoxville, TN 37920; fax: (865) 525-3460; e-mail: nkissane@ utmck.edu
C ]:]]]-]]]. J 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
KEY WORDS: surgical simulation, leadership in the
operating room, surgical resident education COMPETENCIES: Practice-Based Learning and Improvement,
Interpersonal and Communication Skills, Professionalism
INTRODUCTION Leadership in the operating room (OR) has provoked increasing discussion in the recent surgical literature.1-4 Intraoperative leadership has been widely described as an important component to success, safety, and performance.3,4 In 2011, a systematic review of the literature demonstrated that although there is understanding and recognition that leadership skills are essential for effective workplace performance, the necessary leadership behaviors are not well defined.1 Likewise, when attending surgeon intraoperative leadership behaviors were examined, video analysis revealed that most surgeons’ leadership focus was on other surgeons or trainees, rather than the entire operative team.2 This same video-based study also noted that surgeons adopted a consistent approach to leadership, meaning that regardless of the operative situation, their repertoire and communication tendencies were reliable.2 A recent panel highlighted pitfalls of leadership in the OR, specifically describing leadership styles, management, communication, and performance during crises.3,4 This panel addressed challenges in maintaining manners and behavior when the stresses of the OR can overcome professional disposition.3 Proposed solutions to these challenges included honing fundamental leadership behaviors of listening and sharing information, as well as establishing an environment of motivation and responsibility. The panel
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.08.009
1
specifically noted that a good leader promotes teamwork during critical moments by establishing a sense of trust and respect for all team members. Ultimately, the panel stated that one of the most important leadership responsibilities was acknowledgment of the team with statements of appreciation.3 In the nonsurgical literature, several types of leadership behaviors have been described.5-11 Most can be classified into the following types: authoritative, explanatory, consultative, and delegative. An authoritative leader makes decisions, communicates them firmly, and expects them to be carried out. Authoritarian leaders are also commonly referred to as autocratic leaders. An explanatory leader makes decisions promptly but explains them fully. For example, this style is similar to authoritative leadership; however, the leader provides clear explanations for why it needs to be done. A consultative leader consults with colleagues and team members when important decisions are made. This style focuses on using the skills, experiences, and ideas of others, especially when major decisions involve or affect others. A delegative leader puts the problem before the group and makes decisions by majority opinion. This style has also been referred to as participative. Flin et al.12 surveyed surgery residents in Scotland regarding their experiences in intraoperative leadership styles. These residents reported that they most frequently receive and use the explanatory leadership style. The authors hypothesized that this alignment was owing to surgeon’s positive attitudes toward actions and behaviors, which led to enhanced intraoperative teamwork and safety.12 In addition, the attending surgeons in that study also felt that they predominately exhibited consultative leadership (54%), as opposed to authoritative (8%) and delegative (1%). This study is the only prior survey in the literature describing surgical residents’ preferences and experience with leadership behaviors in the OR. Nontechnical skills are increasingly viewed as vital skills for a safe, proficient surgeon. Leadership in the OR has been previously been incorporated into studies of surgeons’ intraoperative nontechnical skills.13-18 In this study, we examined junior residents perspective on leadership style in the OR,
specifically with respect to the leadership behaviors of attending surgeons. The purpose of our study was to identify trainees’ preference for OR leadership style among teaching faculty. We hypothesized that the leadership style trainees’ preference would differ from what they encountered.
METHODS We conducted an institutional review board–approved study at the Neil and Elise Wallace STRATUS Center for Medical Simulation at Brigham and Women’s Hospital, Boston, MA. Eligible participants were surgical interns (postgraduate year [PGY] 1), and mid-level residents (PGY 2 and PGY 3). Interns (PGY 1; N ¼ 20) and mid-level residents (PGY 2 and PGY 3; N ¼ 20) were invited to complete a survey on their experiences of attending surgeons’ leadership style in the OR, using a previously validated instrument.12 The survey included definitions of the 4 styles of leadership: authoritative, explanatory, consultative, and delegative, and participants were asked to indicate which (1) type of leadership style they most frequently encountered, (2) type of leadership style they preferred to receive, and (3) type of leadership style they most commonly used themselves. We also asked participants to list any nonsurgical leadership positions they had held in social and work life from a predefined list of 12 options (Appendix 1). Demographics (age, sex, PGY, and number of cases participated in) were also collected. Results were analyzed using chi-square test.
RESULTS Overall, 40 surgical residents (20 interns and 20 mid-level residents) participated in this study. Further demographic data note inclusion of 20 men and 20 women; and 20 PGY1 residents, 10 PGY-2 residents, and 10 PGY-3 residents (Table). Residents’ operative experience is also outlined in Table 1. PGY-3 residents, on average, were first assistants in the most cases (181 open cases and 63.5 laparoscopic cases).
TABLE. Demographics and Questionnaire PGY 1 (Intern), N ¼ 20
PGY 2 (Mid-Level), N ¼ 10
PGY 3 (Mid-Level), N ¼ 10
Age (mean, y) 28.8 29.1 32.1 Sex Male 60% 40% 40% Female 40% 60% 60% Mean of open cases as first assistant (s.d.) 28.90 (19.49) 171.40 (72.45) 181.00 (163.53) Mean of laparoscopic cases as first assistant 5.55 (7.23) 40.90 (15.89) 63.50 (89.75) (s.d.) Mean of observed open cases (s.d.) 61.30 (90.89) 102.00 (153.25) 81.0 (149.78) Mean of observed laparoscopic cases (s.d.) 19.15 (48.15) 32.11 (41.30) 49.40 (94.16) Leadership (LS) (“x” of 12 leadership examples) 3.70 (2.11) (p ¼ NS) 4.80 (1.32) (p ¼ NS) 5.00 (1.70) (p ¼ NS) (s.d.) s.d., standard deviation. 2
Journal of Surgical Education Volume ]/Number ] ] 2015
62%
60 50 30%
40 30 20
8% 0%
10
Percentage of Residents
Percentage of Residents
70
0 Authoritave
Explanatory
Consultave
100 90 80 70 60 50 40 30 20 10 0
Delegave
43%
11% 3%
Authoritave
Leadership Style
PGY-1 residents were first assistants, on average, for only 28.9 open cases and 5.6 laparoscopic cases. Survey respondents reported authoritative leadership (62%) to be the leadership style most frequently encountered in the OR, followed by explanatory (30%), consultative (8%), and delegative (0%) (Fig. 1). By contrast, only 9% preferred an authoritative leadership style (p o 0.001). Instead, respondents preferred explanatory (48%) and consultative (42%) styles (Fig. 2). These preferences did vary by PGY, with 40% of interns preferring a consultative style and 50% of mid-levels preferring explanatory leadership. When asked what leadership style they most often personally employed, the majority used either explanatory (43%) or consultative (43%) styles, with only 9% using authoritative style (Fig. 3). Figure 4 demonstrates that the intraoperative leadership style residents’ encounter from attending surgeons differs from the style they prefer. Overall, 62% of residents report encountering authoritative leadership; however, only 9% prefer that style (p o 0.001). These results did not seem to be affected by main demographic factors gathered. Although sex of the residents was evenly distributed, with 50% women and 50% men in the sample as a whole, 60% of interns were men (n ¼ 12, p ¼ not significant [NS]) and 60% of mid-level residents were women (n ¼ 12, p ¼ NS). Resident reported leadership roles are also reported in Table 1. PGY-1 residents noted an average of 3.7 leadership
Consultave
Delegave
FIGURE 3. Leadership style residents use.
roles, as compared with PGY-2 residents who described an average of 4.8 leadership roles and PGY-3 residents who acknowledged 5 leadership roles (p ¼ NS).
DISCUSSION In this survey of junior surgical residents regarding OR leadership style, we found that most residents report receiving an authoritative style but prefer and use explanatory and consultative styles. Thus, residents do not commonly encounter the type of leadership style they prefer. This supported our hypothesis that the leadership style trainees prefer differs from what they encounter. These findings have several significant implications for surgical leadership education in the OR. As noted in the surgical literature, developing leadership skills in the OR includes listening and sharing information and establishing an environment for cooperation and learning.3 These fundamental leadership skills are most akin to explanatory and consultative leadership, not authoritative leadership. As previously noted, Flin et al.12 queried surgery residents in Scotland regarding their experiences in intraoperative leadership styles. Interestingly, these resident responses differed from what was noted in this study. The surgery residents in Scotland reported that they most frequently receive and use the explanatory leadership style. Perhaps this difference from the 70% Observed
60%
48%
Residents (%)
Percentage of Residents
Explanatory
Leadership Style
FIGURE 1. Leadership styles most frequently encountered.
100 90 80 70 60 50 40 30 20 10 0
43%
42%
9% 1%
Preferred
50% 40% 30%
p<0.001
20% 10% 0%
Authoritave
Explanatory
Consultave
Delegave
Leadership Style
FIGURE 2. Leadership style residents prefer. Journal of Surgical Education Volume ]/Number ] ] 2015
Authoritave
Explanatory
Consultave
Delegave
Leadership Style
FIGURE 4. Observed vs preferred leadership style. 3
authoritative style received by the residents in this study is owing to the era and culture. In addition, heightened awareness of the importance of nontechnical surgical skills in Scotland may play a significant role as well. Finally, differences may also be attributed to cultural variances in the structure of surgical training and level of autonomy in the OR. There was no significant difference noted between additional resident leadership experience and leadership preference (Table 1). This may be owing to the importance placed on leadership experience in resident selection in the program observed in this study. Rationale for the discrepancy between perception and preference is multifactorial, and may be a result of the residents’ era of surgical training. The current era of surgical trainees, which in the literature have been referred to as “Millennial” residents, differ in educational and performance expectations as compared with more senior surgeons.19-22 Specifically, senior surgeons may primarily teach via more autocratic or authoritative means owing to their own personal residency experience, rather than the present-day residents who prefer an explanatory or consultative style. Residency programs are increasingly focusing on nontechnical skills in surgery and these skills include opportunities for direct feedback, communication, discussion, and collaboration of ideas.19-22 Awareness and understanding of these differences in generations provides an opportunity to improve education for future trainees.19-22 Another explanation for the discrepancy between “perception” and “preference” includes how the junior residents were surveyed about their leadership experiences. Residents surveyed in this study were asked to describe their attendings “as a whole” and not to focus on specific attendings. This may have led to a variety of presumed leadership styles that were unique to each resident’s personal opinion, specialty preference, or operative exposure. Some residents may have chosen to comment on the leadership style of their mentor, program director, most senior surgeon, or department chair. Others may have commented based on a combination of surgeons, with no specific surgeon in mind. Our study is not without limitations. It was completed at a single institution with all participants from the same surgery residency program, thereby limiting variety of leadership exposure and experience. This study was a component of junior resident simulation education and as such, we were limited to responses by PGY-1, PGY-2, and PGY-3 residents. These junior residents might have a bias in perception of leadership skills owing to limited participation in cases or overall operative experience. Likewise, this survey was based on resident experiences in the simulated OR conducting simple laparoscopic and open cases, not advanced or complex scenarios, which may necessitate greater opportunities for leadership demonstration or awareness (such as in a crises or adverse event). Additional limitations include varying individual, or personal, definitions of leadership, which may have biased resident survey responses. As there was no formal education
for participants in self-assessment of leadership skills, this was another limitation and may have created a discrepancy or bias in survey responses. Although there are studies that show surgeons are good at self-assessment of technical skills, evidence for self-assessment of nontechnical skills such as leadership is more variable.12-18 This is important when studying leadership as an independent variable predicting a performance outcome; however, the main purpose of this study was to understand the insight surgical residents have about the leadership style of attending surgeons they work with, and for that purpose the authors feel their assessments are valid indicators of their preferences. We also feel that it is not essential to have expertise in a topic to be able to hold a valid opinion and to assess the quality or nature of experience. The surgical residents in this study are medical doctors with first-hand experience working with the surgical leaders they are assessing, and as such are capable of answering questions regarding leadership study and preferences of leadership from their perspective with an acceptable degree of validity. Finally, this study was based on residents’ general perception, rather than specific cases. As a result, this could result in the resident “over-generalizing” a leadership tendency based on assumptions rather than concrete data. The authors designed the questions carefully to avoid hindsight bias as we were interested in dominant leadership styles rather than specific high or low points that may have skewed our results; we deliberately asked participants to reflect on “most frequently encounter” and “most frequently use” when responding. Now that we have established the general pattern of leadership style, we can consider evaluating specific attending surgeons in future research. Future studies are necessary to further evaluate ideal methods by which to teach and evaluate leadership styles in the OR. Owing to increased awareness of intraoperative nontechnical skills, there is a heightened focus on leadership and its pivotal role in resident education. Additional studies would benefit from concrete definitions of each leadership style with inclusion of written scenarios or standardized video examples. Moreover, as the 4 defined leadership styles in this study are not mutually exclusive, and many individuals may have components of each, more standardized written and video-based definitions would facilitate consistency and simultaneously acknowledge the limitations of this overlap. This would facilitate a similar understanding of each leadership style across all participants. In this study, the authors chose to build a picture of the dominant leadership styles used and preferred, so we opted to force participants to choose between these defined styles. We did not account for overlap in our current analysis. Future studies could be based on surveys designed for specific cases, as leadership style likely varies with case complexity. In particular, leadership style encountered in emergency vs elective surgery may highlight additional behaviors unique to these various operative environments. Further research in this area would help us better understand the role of leadership style in surgical training.
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CONCLUSION Our findings show that junior resident preference of leadership style differs from what they typically encounter. Junior residents prefer explanatory or consultative leadership most; however, they frequently encounter authoritative leadership. This has the potential to create unwanted tension within the OR and may erode both operative team performance and resident learning environment. It may also lead to poor learning of leadership skills by residents. Awareness of this difference provides opportunity for an educational intervention for both residents and attendings.
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SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jsurg. 2015.08.009.
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