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From art to science: a fairy tale? The future of academic surgery
From Art to Science: A Fairy Tale? The Future of Academic Surgery Marc R. de Leval, MD, FRCS Cardiothoracic Unit, Great Ormond Street Hospital for Children National Health Service Trust, London, England
T
here is still a continuing debate as to whether the same individual can excel as a surgeon and as an academic. According to the dictionary, academic means “excessively concerned with intellectual matters and lacking experience of practical affairs.” In that sense, an academic surgeon is an antinomy, and this view would no doubt be shared by many pure scientists and intellectuals, including our physician colleagues. It is only if we acknowledge the humble level of our intellectual pursuits that one can talk about academic surgeons. With that reservation, I should like to address a few of the many challenges that the academic surgeon faces in the new millennium. The portfolio of the academic surgeon is made up of four equities: clinical practice, research, education, and administration [1].
Clinical Practice First and foremost, the successful academic surgeon must excel as a practicing surgeon. I do not dispute the fact that surgeons of average technical ability have made significant academic contributions. There is no doubt, however, that to play a leading role in academic surgery, an academic institution must retain the most talented surgeons. By and large, academic institutions care for the most complex and higher-risk patients. In addition, academic institutions are training the next generation of surgeons. In an ideal world, those trainees should benefit from the talents of the best technical surgeons. Unfortunately, these goals are not always fulfilled, for a number of reasons. Academic health centers no longer enjoy the position of power and prestige they have held in the past. The traditional financial support of education and research through cross-subsidization, using clinical revenues, has resulted in less competitive, more expensive academic institutions. As a consequence, managed care organizations have diverted primary, secondary, and sometimes even tertiary services away from academic institutions to less expensive nonteaching institutions. Funding of nonclinical activities remains one of the most burning issues of academic medicine. Presented at the Symposium “Panta Rhei,” as part of the 14th Annual Meeting of the European Association for Cardio-Thoracic Surgery, Heidelberg, Germany, Oct 8, 2000. Address reprint requests to Dr de Leval, Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust, Great Ormond St, London WC1N 3JH, England; e-mail: marc.deleval@gosh-tr. nthames.nhs.uk.
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
In many academic institutions, and this is perhaps more common in North America, teaching has become such a priority that chief residents have the primary responsibility for patient management. In such a system, surgical excellence is at risk of becoming the excellence of the transient chief resident who is still at the beginning of his or her learning curve. If those chief residents are then appointed to a teaching institution, they themselves rapidly become mentors, and consequently never mature as operative surgeons. The famous adage “see one, do one, teach one” can become an unfortunate reality. Last but not least, human nature is such that talented surgeons are often tempted to engage themselves in more lucrative activities to the detriment of academic pursuits. In the highly competitive academic world, there is a need to recognize the value of clinical scholarship for academic promotion, and to investigate novel mechanisms of financial rewards to keep talented surgeons in academic institutions.
Research Academic surgery does not exist without active and longstanding commitment to research. I will not discuss clinical research that focuses on outcomes, which remains an important task of the academic surgeon. I should like to concentrate primarily on translational research and its challenges. The old-style clinical research, studying physiology in patients and using animal laboratories to design surgical procedures and refine treatments, is now all but extinct and has given way to basic scientific research, which has always been the cornerstone of a solid academic career [2]. Fundamental changes in both the process and outcome of biomedical research have taken place. They reflect a transition from descriptive research, which was focused on documenting the events associated with a disease process, to an activity in which data provide information about disease mechanisms, including their biochemical and cellular substrates. The transfer of research from observational bedside to bench, from clinical science to molecular studies, has given many insights into the mechanistic understanding of numerous diseases [3]. A safe and effective translation of these multidisciplinary efforts into clinical practice requires careful evaluation by highly trained clinical investigators. This translational research is the clinical research of the future, which has enormous potential. New approaches and competencies will be required of the next generation of researchers who, more than ever before, will need to Ann Thorac Surg 2001;72:9 –12 • 0003-4975/01/$20.00 PII S0003-4975(00)02611-4
10
EDITORIAL de LEVAL FUTURE OF ACADEMIC SURGERY
be familiar with diverse scientific disciplines and be able to collaborate with scientists skilled in these disciplines. Clinical investigators are uniquely positioned to translate basic research advances into clinically meaningful progress. There is an increasing need for new clinical scientists who are broadly trained, for a new generation of polymaths capable of capitalizing on all those discoveries. This is what the Nobel Laureate Murray Gell-Mann was alluding to when he stated that we must get away from the idea that serious work is restricted to “beating to death a well-defined problem in a narrow discipline, while broadly integrative thinking is relegated to cocktail parties. In academic life . . . we encounter a lack of respect for the task of integration” [4]. The ethical and medicolegal implications of introducing new technology and new strategic therapies to clinical practice is another challenge of the new millennium. In the past, surgical innovation often emerged from unforeseen intraoperative circumstances. The line between clinical innovation and reckless experimentation was ill-defined. There was an article some years ago entitled: “There Is No FDA for the Surgeon” [5]. Those days are over, and there is an increasing ethical and medicolegal pressure on the innovators, and consequently a risk of overregulation threatening the development of new therapies. The pure scientists will maintain that a prospective randomized clinical trial is the only scientific way to compare therapeutic strategies. This is not possible, as new technology is developing faster than the profession’s ability to provide evidence-based data before widespread acceptance and application [6]. The half-life of new technology is currently 3 to 5 years, and it is becoming shorter and shorter [7]. New treatments are obsolete before their long-term results are known. This is a dilemma that must be addressed urgently by society at large. Relation with industry is another challenge. Private industry is investing large sums of money in basic research, and new relationships with academic institutions have evolved. One of the fundamental issues of those relationships is that the primary objective of the academic surgeon is, or at least should be, to advance knowledge and improve patient care, whereas profit is the company’s primary objective [8]. The relationship with industry may constitute a threat to the integrity and the intellectual honesty of the academic surgeon and, more than ever, a full disclosure of financial agreements and conflicts of interest are of paramount importance.
Education Teaching surgery is a fundamental mission of the academic surgeon. I will confine my comments to two challenging points. The first is the learning curve of the surgical trainee. Operative mortality and morbidity, even following the most complex procedures, has reached such a low level that people’s expectations are everincreasing, and the concept of learning curve casualties has become totally unacceptable. This puts the trainees
Ann Thorac Surg 2001;72:9 –12
and the trainers under tremendous pressures. Learning curves are unavoidable, yet their negative effects have to be neutralized. Simulators have started to become part of the armamentarium of the surgical educators. Videoscopic and robotic surgery create new ergonomics that are well suited for virtual reality and simulator technology. Surgical training will, however, continue to take the form of an apprenticeship, at least to make the transition between simulators and reality. I expect that in the future, junior staff surgeons will carry out their more complex and higher-risk procedures with the help of more experienced surgeons for extensive periods of time. The exponential growth of knowledge is the other point. I suspect that if I knew all that was known in biomedical sciences when I graduated from medical school, and still remembered it, this would be less than 1% of what is known today. This has been the logical reason for continuously increasing the length of training programs which is, in my opinion, a retrograde step. We are living in an era where the new generation reaches physical, intellectual, and emotional maturity at a younger and younger age. Many top performers in sports are in their late teens. Many top businessmen and women are in their 20s, many of the most powerful heads of state are in their early 40s, and yet we find some justifications for extending the period of training of future cardiac surgeons. If human performance were a security quoted on the stock market, the economists would be quick at developing an ability/responsibility share index. They would invest in individuals whose responsibility curve follows closely the ability curve so as to have an optimum performance throughout their professional life. The risk for the future surgeon is that with a more precocious maturity and a longer period of training, the two curves are more and more dissociated so that their professional life will be divided into two phases, the first one of wasted talents and the second one of declining performance. No investment banker would buy shares in surgeons. The mistake is that we have maintained an archaic attitude towards knowledge acquisition. We still have the outmoded belief that schoolchildren, medical students, and residents have to go through years of painful work to acquire and memorize an increasing amount of theoretical knowledge. Information and computation technology have given us unlimited access to knowledge which, in my view, has to become as important as its own acquisition. It is not uncommon nowadays for some of our patients to have a greater knowledge of their illness than we have ourselves. We must be aware of this revolution. As a challenge, I would like to suggest that if in our generation one could graduate from medical school at the age of 24, the next generation should graduate at the age of 22, and if we could qualify as cardiothoracic surgeons at 34, the next generation should do so at 32.
Administration Few surgeons are born administrators; there must be, however, to borrow the words of Fred Crawford [9],
EDITORIAL de LEVAL FUTURE OF ACADEMIC SURGERY
Ann Thorac Surg 2001;72:9 –12
11
Table 1. The Three Character Types Described in The Drama of Leadership Artist
Craftsman
Technocrat Analytical Cerebral Organized Detail-orientated Meticulous Insightful Rational Brilliant Short-term vision Fastidious Distant Stiff Intense Humorless No-nonsense Cold Emotionless
Thought process
Visionary Imaginative Creative Intuitive Open-minded
Wise Knowledgeable Thoughtful Realistic Sensible Non-creative Medium-term vision
Behavior
People-orientated Easygoing Generous Funny Emotional Sometimes has difficulty in distinguishing reality from fantasy
Performance
Entrepreneurial Exciting Unpredictable Noncomformist Defies the conventional wisdom
Trustworthy Realistic Steady Dedicated Predictable Helpful Punctual Humble Listens Pragmatic Skillful Hardworking Produces quality Proud of his product
“ . . . somewhere in the human genome a sequence of amino acids that codes for administrative skills and that these skills can be developed.” Administrative activities have always been an essential part of the portfolio of the academic surgeon who wishes to play a role at institutional, national, and international level, and many have been extremely successful at it. The administrative duties of the academic surgeon have been deeply affected by the healthcare reforms that have taken place in most countries over the past 15 years. Healthcare has become a commodity, and professional sovereignty has been substituted by corporate organizations. The healthcare industry has consequently gone through the same worrisome evolution as most corporate organizations where leadership skills have been progressively replaced by managerial skills. The loss of professional leadership is, in my opinion, the greatest challenge of the new millennium. This phenomenon has been beautifully depicted by Patricia Pitcher in a fascinating book, entitled The Drama of Leadership [10], where she displays the transformation of the leading team of a large financial institution over the past 20 years.
The Drama of Leadership Three character types are described: the Artist, the Craftsman, and the Technocrat (Table 1). The play describes the interactions between the three character types and the changes in the team composition over a twentyyear period which eventually leads to the collapse of the organisation. The Artist and the Craftsman get along well, and to some extent control and complete each other. The Technocrat despises the Artist, whereas the Artist often tolerates or even appreciates a brilliant Technocrat.
Methodological Energetic Predictable Uncompromising Determined Hard-working
In 1980, the Chairman of the Board was an Artist in his late 50s. He had been at the helm for fifteen years. He was imaginative, intuitive, visionary, energetic, and entrepreneurial. In short, an inspiring, gifted, and successful leader. All the chief executives of the various branches were Craftsmen, except for one Technocrat. The chairman began to be criticised and found to be too emotional, letting his feelings interfere with his judgement, and incapable of making logical decisions. He recognised his deficiencies and appointed a Technocrat as a Number 2, as managing director, who soon trumpeted his managerial sophistication. Technocrats are brilliant. They come into board meetings with their five-part plans, their strategies, their projections, their slogans, their vocabulary, their grandiloquence, and their recipes. They are very impressive. They are intimidating to ordinary mortals. Apart from the fact that they are grand parleurs (big talkers), they are strategic about human relationships, they undermine others gradually. Within two years, the Chairman stepped down and was replaced by another Technocrat. These changes were taking place in the late 1980s, when all industries were going through a revolution, and healthcare was no exception. Market forces, cost-cutting exercises, diversification, integration of services, centralisation, processing, five-year strategic plans, mission statements, total quality management, empowerment, re-engineering, strategic alliances, all became part of a new vocabulary, now all too familiar to all of us in healthcare. Both the craftsman and the artist found themselves increasingly ill at ease, and were seeing in these reforms a restriction on their capacity to innovate. One after the other, the Artist and the Craftsman were replaced by Technocrats at all top positions, who continued their extensive programme of reforms and rational-
12
EDITORIAL de LEVAL FUTURE OF ACADEMIC SURGERY
isation. They only focused on short-term profits. Profit became a strategy rather than an outcome. The organisation tipped fatally towards disequilibrium, like a boat that takes in water when everyone leans on one side. Millions were spent in strategic planning instead of strategic thinking, and the group collapsed in 1995. The moral of the story is that Technocrats are great at managing things, but they should not have any authority over people’s dreams. Teamwork is essential, and the biggest barriers to teamwork are Technocrats in positions of authority. We either need Artists at the top to find new visions or Craftsmen who give artists room to breathe and time to create. Technocrats should be kept in their legitimate place and act as managers. These managers have become indispensable and do indeed play a vital role in our profession and organisations. They should not, however, be in a position of authority [10]. This rejoins the message of Floyd Loop, in his address to the American Association for Thoracic Surgery: “The single greatest lesson I have learned in management is that medical centres should be led by physicians. It is easier for a physician to learn business management than for a businessman to learn medicine” [11]. If we look back at our heroes, those who were instrumental in our decision to become surgeons, what they all had in common was that they were exceptional human beings who inspired respect and either had the charisma of the artist, or the candor and the technical brilliance of the craftsman. They were true professional leaders. Leaders are individuals who markedly influence the behaviors, thoughts, and feelings of their fellow human
Ann Thorac Surg 2001;72:9 –12
beings. Great leaders encourage collective creativity, thus making great groups and great institutions. In these creative alliances, the leader and the team achieve something together that neither could achieve alone [12]. Today’s leadership is in crisis. The race of professional leaders is at risk of becoming extinct. If we fail to preserve them for future generations, our profession will cease to attract “la creˆme de la creˆme” it deserves.
References 1. Verrier ED. Getting started in academic cardiothoracic surgery. J Thorac Cardiovasc Surg 2000;119:S1–10. 2. Bell JI. Clinical research is dead: long live clinical research. Nature Med 1999;5:477– 8. 3. Lenfant C. Training the next generations of biomedical researchers. Challenges and opportunities. Circulation 2000; 102:368–70. 4. Gell-Mann M. The quark and the jaguar. Boston and London: Little Brown, 1994. 5. Spodick DH. Numerators without denominators. There is no FDA for the surgeon. JAMA 1975;232:35– 6. 6. Jones JW. Ethics of rapid surgical technological advancement. Ann Thorac Surg 2000;69:676–7. 7. Loop FD. Mentoring. J Thorac Cardiovasc Surg 2000;119: S45– 8. 8. Kaiser LR. The academic surgeon and industry. J Thorac Cardiovasc Surg 2000;119:S29 –32. 9. Crawford FA. Developing administrative skills. J Thorac Cardiovasc Surg 2000;119:S33–7. 10. Pitcher P. The drama of leadership. New York: John Wiley and Sons, 1997. 11. Loop FD. The first living and the last dying. J Thorac Cardiovasc Surg 1998;116:683– 8. 12. Gardner H. Leading minds. London: HarperCollins, 1995.
T
here is still a continuing debate as to whether the same individual can excel as a surgeon and as an academic. According to the dictionary, academic means “excessively concerned with intellectual matters and lacking experience of practical affairs.” In that sense, an academic surgeon is an antinomy, and this view would no doubt be shared by many pure scientists and intellectuals, including our physician colleagues. It is only if we acknowledge the humble level of our intellectual pursuits that one can talk about academic surgeons. With that reservation, I should like to address a few of the many challenges that the academic surgeon faces in the new millennium. The portfolio of the academic surgeon is made up of four equities: clinical practice, research, education, and administration [1].
Clinical Practice First and foremost, the successful academic surgeon must excel as a practicing surgeon. I do not dispute the fact that surgeons of average technical ability have made significant academic contributions. There is no doubt, however, that to play a leading role in academic surgery, an academic institution must retain the most talented surgeons. By and large, academic institutions care for the most complex and higher-risk patients. In addition, academic institutions are training the next generation of surgeons. In an ideal world, those trainees should benefit from the talents of the best technical surgeons. Unfortunately, these goals are not always fulfilled, for a number of reasons. Academic health centers no longer enjoy the position of power and prestige they have held in the past. The traditional financial support of education and research through cross-subsidization, using clinical revenues, has resulted in less competitive, more expensive academic institutions. As a consequence, managed care organizations have diverted primary, secondary, and sometimes even tertiary services away from academic institutions to less expensive nonteaching institutions. Funding of nonclinical activities remains one of the most burning issues of academic medicine. Presented at the Symposium “Panta Rhei,” as part of the 14th Annual Meeting of the European Association for Cardio-Thoracic Surgery, Heidelberg, Germany, Oct 8, 2000. Address reprint requests to Dr de Leval, Cardiothoracic Unit, Great Ormond Street Hospital for Children NHS Trust, Great Ormond St, London WC1N 3JH, England; e-mail: marc.deleval@gosh-tr. nthames.nhs.uk.
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
In many academic institutions, and this is perhaps more common in North America, teaching has become such a priority that chief residents have the primary responsibility for patient management. In such a system, surgical excellence is at risk of becoming the excellence of the transient chief resident who is still at the beginning of his or her learning curve. If those chief residents are then appointed to a teaching institution, they themselves rapidly become mentors, and consequently never mature as operative surgeons. The famous adage “see one, do one, teach one” can become an unfortunate reality. Last but not least, human nature is such that talented surgeons are often tempted to engage themselves in more lucrative activities to the detriment of academic pursuits. In the highly competitive academic world, there is a need to recognize the value of clinical scholarship for academic promotion, and to investigate novel mechanisms of financial rewards to keep talented surgeons in academic institutions.
Research Academic surgery does not exist without active and longstanding commitment to research. I will not discuss clinical research that focuses on outcomes, which remains an important task of the academic surgeon. I should like to concentrate primarily on translational research and its challenges. The old-style clinical research, studying physiology in patients and using animal laboratories to design surgical procedures and refine treatments, is now all but extinct and has given way to basic scientific research, which has always been the cornerstone of a solid academic career [2]. Fundamental changes in both the process and outcome of biomedical research have taken place. They reflect a transition from descriptive research, which was focused on documenting the events associated with a disease process, to an activity in which data provide information about disease mechanisms, including their biochemical and cellular substrates. The transfer of research from observational bedside to bench, from clinical science to molecular studies, has given many insights into the mechanistic understanding of numerous diseases [3]. A safe and effective translation of these multidisciplinary efforts into clinical practice requires careful evaluation by highly trained clinical investigators. This translational research is the clinical research of the future, which has enormous potential. New approaches and competencies will be required of the next generation of researchers who, more than ever before, will need to Ann Thorac Surg 2001;72:9 –12 • 0003-4975/01/$20.00 PII S0003-4975(00)02611-4
10
EDITORIAL de LEVAL FUTURE OF ACADEMIC SURGERY
be familiar with diverse scientific disciplines and be able to collaborate with scientists skilled in these disciplines. Clinical investigators are uniquely positioned to translate basic research advances into clinically meaningful progress. There is an increasing need for new clinical scientists who are broadly trained, for a new generation of polymaths capable of capitalizing on all those discoveries. This is what the Nobel Laureate Murray Gell-Mann was alluding to when he stated that we must get away from the idea that serious work is restricted to “beating to death a well-defined problem in a narrow discipline, while broadly integrative thinking is relegated to cocktail parties. In academic life . . . we encounter a lack of respect for the task of integration” [4]. The ethical and medicolegal implications of introducing new technology and new strategic therapies to clinical practice is another challenge of the new millennium. In the past, surgical innovation often emerged from unforeseen intraoperative circumstances. The line between clinical innovation and reckless experimentation was ill-defined. There was an article some years ago entitled: “There Is No FDA for the Surgeon” [5]. Those days are over, and there is an increasing ethical and medicolegal pressure on the innovators, and consequently a risk of overregulation threatening the development of new therapies. The pure scientists will maintain that a prospective randomized clinical trial is the only scientific way to compare therapeutic strategies. This is not possible, as new technology is developing faster than the profession’s ability to provide evidence-based data before widespread acceptance and application [6]. The half-life of new technology is currently 3 to 5 years, and it is becoming shorter and shorter [7]. New treatments are obsolete before their long-term results are known. This is a dilemma that must be addressed urgently by society at large. Relation with industry is another challenge. Private industry is investing large sums of money in basic research, and new relationships with academic institutions have evolved. One of the fundamental issues of those relationships is that the primary objective of the academic surgeon is, or at least should be, to advance knowledge and improve patient care, whereas profit is the company’s primary objective [8]. The relationship with industry may constitute a threat to the integrity and the intellectual honesty of the academic surgeon and, more than ever, a full disclosure of financial agreements and conflicts of interest are of paramount importance.
Education Teaching surgery is a fundamental mission of the academic surgeon. I will confine my comments to two challenging points. The first is the learning curve of the surgical trainee. Operative mortality and morbidity, even following the most complex procedures, has reached such a low level that people’s expectations are everincreasing, and the concept of learning curve casualties has become totally unacceptable. This puts the trainees
Ann Thorac Surg 2001;72:9 –12
and the trainers under tremendous pressures. Learning curves are unavoidable, yet their negative effects have to be neutralized. Simulators have started to become part of the armamentarium of the surgical educators. Videoscopic and robotic surgery create new ergonomics that are well suited for virtual reality and simulator technology. Surgical training will, however, continue to take the form of an apprenticeship, at least to make the transition between simulators and reality. I expect that in the future, junior staff surgeons will carry out their more complex and higher-risk procedures with the help of more experienced surgeons for extensive periods of time. The exponential growth of knowledge is the other point. I suspect that if I knew all that was known in biomedical sciences when I graduated from medical school, and still remembered it, this would be less than 1% of what is known today. This has been the logical reason for continuously increasing the length of training programs which is, in my opinion, a retrograde step. We are living in an era where the new generation reaches physical, intellectual, and emotional maturity at a younger and younger age. Many top performers in sports are in their late teens. Many top businessmen and women are in their 20s, many of the most powerful heads of state are in their early 40s, and yet we find some justifications for extending the period of training of future cardiac surgeons. If human performance were a security quoted on the stock market, the economists would be quick at developing an ability/responsibility share index. They would invest in individuals whose responsibility curve follows closely the ability curve so as to have an optimum performance throughout their professional life. The risk for the future surgeon is that with a more precocious maturity and a longer period of training, the two curves are more and more dissociated so that their professional life will be divided into two phases, the first one of wasted talents and the second one of declining performance. No investment banker would buy shares in surgeons. The mistake is that we have maintained an archaic attitude towards knowledge acquisition. We still have the outmoded belief that schoolchildren, medical students, and residents have to go through years of painful work to acquire and memorize an increasing amount of theoretical knowledge. Information and computation technology have given us unlimited access to knowledge which, in my view, has to become as important as its own acquisition. It is not uncommon nowadays for some of our patients to have a greater knowledge of their illness than we have ourselves. We must be aware of this revolution. As a challenge, I would like to suggest that if in our generation one could graduate from medical school at the age of 24, the next generation should graduate at the age of 22, and if we could qualify as cardiothoracic surgeons at 34, the next generation should do so at 32.
Administration Few surgeons are born administrators; there must be, however, to borrow the words of Fred Crawford [9],
EDITORIAL de LEVAL FUTURE OF ACADEMIC SURGERY
Ann Thorac Surg 2001;72:9 –12
11
Table 1. The Three Character Types Described in The Drama of Leadership Artist
Craftsman
Technocrat Analytical Cerebral Organized Detail-orientated Meticulous Insightful Rational Brilliant Short-term vision Fastidious Distant Stiff Intense Humorless No-nonsense Cold Emotionless
Thought process
Visionary Imaginative Creative Intuitive Open-minded
Wise Knowledgeable Thoughtful Realistic Sensible Non-creative Medium-term vision
Behavior
People-orientated Easygoing Generous Funny Emotional Sometimes has difficulty in distinguishing reality from fantasy
Performance
Entrepreneurial Exciting Unpredictable Noncomformist Defies the conventional wisdom
Trustworthy Realistic Steady Dedicated Predictable Helpful Punctual Humble Listens Pragmatic Skillful Hardworking Produces quality Proud of his product
“ . . . somewhere in the human genome a sequence of amino acids that codes for administrative skills and that these skills can be developed.” Administrative activities have always been an essential part of the portfolio of the academic surgeon who wishes to play a role at institutional, national, and international level, and many have been extremely successful at it. The administrative duties of the academic surgeon have been deeply affected by the healthcare reforms that have taken place in most countries over the past 15 years. Healthcare has become a commodity, and professional sovereignty has been substituted by corporate organizations. The healthcare industry has consequently gone through the same worrisome evolution as most corporate organizations where leadership skills have been progressively replaced by managerial skills. The loss of professional leadership is, in my opinion, the greatest challenge of the new millennium. This phenomenon has been beautifully depicted by Patricia Pitcher in a fascinating book, entitled The Drama of Leadership [10], where she displays the transformation of the leading team of a large financial institution over the past 20 years.
The Drama of Leadership Three character types are described: the Artist, the Craftsman, and the Technocrat (Table 1). The play describes the interactions between the three character types and the changes in the team composition over a twentyyear period which eventually leads to the collapse of the organisation. The Artist and the Craftsman get along well, and to some extent control and complete each other. The Technocrat despises the Artist, whereas the Artist often tolerates or even appreciates a brilliant Technocrat.
Methodological Energetic Predictable Uncompromising Determined Hard-working
In 1980, the Chairman of the Board was an Artist in his late 50s. He had been at the helm for fifteen years. He was imaginative, intuitive, visionary, energetic, and entrepreneurial. In short, an inspiring, gifted, and successful leader. All the chief executives of the various branches were Craftsmen, except for one Technocrat. The chairman began to be criticised and found to be too emotional, letting his feelings interfere with his judgement, and incapable of making logical decisions. He recognised his deficiencies and appointed a Technocrat as a Number 2, as managing director, who soon trumpeted his managerial sophistication. Technocrats are brilliant. They come into board meetings with their five-part plans, their strategies, their projections, their slogans, their vocabulary, their grandiloquence, and their recipes. They are very impressive. They are intimidating to ordinary mortals. Apart from the fact that they are grand parleurs (big talkers), they are strategic about human relationships, they undermine others gradually. Within two years, the Chairman stepped down and was replaced by another Technocrat. These changes were taking place in the late 1980s, when all industries were going through a revolution, and healthcare was no exception. Market forces, cost-cutting exercises, diversification, integration of services, centralisation, processing, five-year strategic plans, mission statements, total quality management, empowerment, re-engineering, strategic alliances, all became part of a new vocabulary, now all too familiar to all of us in healthcare. Both the craftsman and the artist found themselves increasingly ill at ease, and were seeing in these reforms a restriction on their capacity to innovate. One after the other, the Artist and the Craftsman were replaced by Technocrats at all top positions, who continued their extensive programme of reforms and rational-
12
EDITORIAL de LEVAL FUTURE OF ACADEMIC SURGERY
isation. They only focused on short-term profits. Profit became a strategy rather than an outcome. The organisation tipped fatally towards disequilibrium, like a boat that takes in water when everyone leans on one side. Millions were spent in strategic planning instead of strategic thinking, and the group collapsed in 1995. The moral of the story is that Technocrats are great at managing things, but they should not have any authority over people’s dreams. Teamwork is essential, and the biggest barriers to teamwork are Technocrats in positions of authority. We either need Artists at the top to find new visions or Craftsmen who give artists room to breathe and time to create. Technocrats should be kept in their legitimate place and act as managers. These managers have become indispensable and do indeed play a vital role in our profession and organisations. They should not, however, be in a position of authority [10]. This rejoins the message of Floyd Loop, in his address to the American Association for Thoracic Surgery: “The single greatest lesson I have learned in management is that medical centres should be led by physicians. It is easier for a physician to learn business management than for a businessman to learn medicine” [11]. If we look back at our heroes, those who were instrumental in our decision to become surgeons, what they all had in common was that they were exceptional human beings who inspired respect and either had the charisma of the artist, or the candor and the technical brilliance of the craftsman. They were true professional leaders. Leaders are individuals who markedly influence the behaviors, thoughts, and feelings of their fellow human
Ann Thorac Surg 2001;72:9 –12
beings. Great leaders encourage collective creativity, thus making great groups and great institutions. In these creative alliances, the leader and the team achieve something together that neither could achieve alone [12]. Today’s leadership is in crisis. The race of professional leaders is at risk of becoming extinct. If we fail to preserve them for future generations, our profession will cease to attract “la creˆme de la creˆme” it deserves.
References 1. Verrier ED. Getting started in academic cardiothoracic surgery. J Thorac Cardiovasc Surg 2000;119:S1–10. 2. Bell JI. Clinical research is dead: long live clinical research. Nature Med 1999;5:477– 8. 3. Lenfant C. Training the next generations of biomedical researchers. Challenges and opportunities. Circulation 2000; 102:368–70. 4. Gell-Mann M. The quark and the jaguar. Boston and London: Little Brown, 1994. 5. Spodick DH. Numerators without denominators. There is no FDA for the surgeon. JAMA 1975;232:35– 6. 6. Jones JW. Ethics of rapid surgical technological advancement. Ann Thorac Surg 2000;69:676–7. 7. Loop FD. Mentoring. J Thorac Cardiovasc Surg 2000;119: S45– 8. 8. Kaiser LR. The academic surgeon and industry. J Thorac Cardiovasc Surg 2000;119:S29 –32. 9. Crawford FA. Developing administrative skills. J Thorac Cardiovasc Surg 2000;119:S33–7. 10. Pitcher P. The drama of leadership. New York: John Wiley and Sons, 1997. 11. Loop FD. The first living and the last dying. J Thorac Cardiovasc Surg 1998;116:683– 8. 12. Gardner H. Leading minds. London: HarperCollins, 1995.