- Email: [email protected]
Physician leadership is a new mandate in surgical training
The American Journal of Surgery 187 (2004) 328 –331
Surgical education
Physician leadership is a new mandate in surgical training Kamal M.F. Itani, M.D.a,b,*, Kathleen Liscum, M.D.b, F. Charles Brunicardi, M.D.b a
Department of Surgery, Houston Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030, USA b Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA Manuscript received November 18, 2002; revised manuscript May 26, 2003
Abstract Background: Traditionally, development of physician leadership has occurred at random in surgical training. One possible reason is that surgical educators have focused on detailed instruction on critical patient situations, resuscitation, and technical skills, but they have provided little formal training in the essential leadership skills. Methods: To determine resident perceptions about the importance of these skills and individual strengths and weaknesses in these areas, a questionnaire was administered to 43 residents in our general surgery program. In part one of the questionnaire, the residents ranked 18 leadership skills on a scale of 1 to 4 in importance (“not important,” “minimally important,” “somewhat important,” and “very important”) for career development. The second portion of the questionnaire asked the residents to rate themselves on a similar scale with regard to their personal confidence and competence in these same areas. Results: Twenty-three residents (53%) completed the entire questionnaire. The majority of the residents (92%) rated all 18 leadership skills “somewhat” or “very important” for career development. More than 50% of the residents rated themselves as not competent or minimally competent in 10 of the 18 areas. Ethics was the only area in which ⬎75% of the residents believed themselves to be more than minimally competent. There were no significant differences between postgraduate training levels in any of the parameters calculated. Conclusions: We conclude that although residents see these nontraditional topics as an important part of their professional education, they do not necessarily feel confident or competent in these areas. Establishing a conscious effort to teach these topics and to emphasize their importance during training will enhance residents’ self-image, performance, and potential as future leaders. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Education; Leadership; Surgery; Training
Surgical residency has traditionally focused on the development of clinical judgment and technical skills [1,2]. Although residents are evaluated on their interpersonal, teaching, and communication skills, formal training in these areas is usually not provided. Furthermore, surgery residents are faced with a variety of stressors such as demanding patients, family issues, multitasking, program requirements, and health care regulatory processes (Fig. 1). Skills to effectively manage these stressors are rarely introduced during the five years of general surgery training. After residency, “on-the-job” training often provides a trial-by-fire introduction to some of these issues after multiple opportunities to develop skills to enhance adaptability have passed. The purpose of this study was to investigate residents’ percep-
* Corresponding author. Tel.: ⫹1-713-794-8026; fax: ⫹1-713-7947352. E-mail address: [email protected]
tions of the importance of these issues and their personal confidence levels with regard to select leadership skills. Methods After we conducted a review of the leadership literature, we developed a 3-part questionnaire. The questionnaire was administered in February 2000 to 43 residents in our general surgery program. In part one, the residents scored 18 skills (Table 1) considered by many [3– 6] to be key components of leadership and personal development. The perceived importance of the skills for career development was scored on a scale of 1 to 4 ( 1 ⫽ not important, 2 ⫽ minimally important, 3 ⫽ somewhat important, 4 ⫽ important). A mean importance score was calculated for each individual skill. The mean importance score for all skills was calculated for each postgraduate level (PGY) of training to look for differences among these groups. The percent of residents
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.12.004
K.M.F. Itani et al. / The American Journal of Surgery 187 (2004) 328 –331
329
In part three of the questionnaire the residents were asked to evaluate themselves with regard to five leadership traits. The residents checked off whether the trait was a personal strength, whether the trait was present but not a strength, or whether the trait was completely absent.
Results
Fig. 1. Surgery resident dealing with various clinical, educational, personal, and administrative requirements and responsibilities.
that provided a score of “3” or “4” for each of the skills was also determined. In part two of the questionnaire the residents were asked to rate themselves with regard to their personal confidence and competence in the same 18 areas. A similar 4-point scoring system was used (1 ⫽ not competent, 2 ⫽ minimally competent, 3 ⫽ somewhat competent, 4 ⫽ very competent). Mean competency scores were calculated for each skill. The mean importance score for all skills was also calculated by PGY level. The percent of residents that provided a score of “1” or “2” for each of the skills was calculated. The Student t test was used to compare the mean importance score and mean competency score for each skill. Significance for both tests was determined at P ⬍0.05. Paired importance and competence responses for individual respondents were reviewed for each skill, and Pearson correlation coefficients were calculated.
Twenty-three residents completed parts one and two of the questionnaire (response rate of 53%). Eight residents were in the first year of training (PGY 1), 5 were in PGY 2, 4 were in PGY 3, 3 were in PGY 4, and 3 were in PGY 5. Ninety-two percent of the residents rated all 18 leadership skills as at least somewhat important for career development. All skills were judged to be somewhat to very important by ⬎75% of the residents. Time management received a mean importance score of “4.” The other 3 skills judged by 100% of the residents to be somewhat to very important were effective communication in teaching, conflict resolution, and public speaking. More than 50% of the residents rated themselves as not competent or minimally competent in 10 leadership skills. The 2 skills in which 83% and 74% of the residents rated themselves as somewhat to very confident were ethics and time management, respectively. The skills in which ⬎75% of the residents believed themselves to be minimally to not competent were conflict resolution (96%), billing, coding and compliance (91%), practice management (83%), and leadership theory (78%). For analysis, the PGY 2 and 3 residents were grouped together, and the PGY 4 and 5 residents were grouped together. The mean importance and competence scores for
Table 1 Perceived importance and competence by 23 residents in 18 leadership skills Skills
Importance mean score
Competence mean score
Correlation
Significance
Academic program development Leadership training Leadership theory Effective communication Conflict resolution Management principles Negotiation Time management Private or academic practice, managed care Investment principles Ethics Billing, coding, and compliance Program improvement Writing proposals Writing reports Public speaking Effective presentations Risk management Total
3.2 3.8 3.2 3.7 3.8 3.7 3.7 4 3.6 3.5 3.6 3.5 3 3.3 3.4 3.7 3.7 3.5 3.6
2.4* 2.3* 2.1* 2.7* 3* 2.7* 2.8* 2.8* 2* 2.2* 3.2 1.7* 2* 2.2* 2.4* 2.7* 2.7* 2.1* 2.5*
0.38 ⫺0.06 0.51 ⫺0.09 ⫺0.03 0.27 0.15 ⫺0.04 0 0.36 ⫺0.09 0.15 0.5 0.39 0.49 0.43 ⫺0.25 0.18 0.2
0.08 0.78 0.02 0.68 0.9 0.22 0.5 0.85 1 0.09 0.69 0.49 0.02 0.07 0.02 0.04 0.26 0.43 0.36
* P ⬍0.001 by Student t test between mean importance and mean competence scores.
330
K.M.F. Itani et al. / The American Journal of Surgery 187 (2004) 328 –331
Table 2 Perceived importance and competence in 18 leadership skills by postgraduate level of training PGY
No. of residents
A
B
1 2 and 3 4 and 5
8 9 6
3.5 3.6 3.7
2.3 2.5 2.7
A ⫽ mean importance score; B ⫽ mean competence score; PGY ⫽ postgraduate level.
the two groups of residents were 3.6 and 2.5, respectively. Although there was a slight tendency for the upper-level residents to rate the 18 skills as more important for leadership development and to perceive themselves as more competent in those skill areas, this difference was minimal and did not achieve statistical significance (Table 2). For each of the 18 skills listed, there was a statistically significant difference by Student t test (P ⬍0.001) between perceived importance and perceived competence with the exception of ethics, for which the significance level was P ⫽ 0.09 (Table 2). However, there was no significant correlation between perceived importance and perceived competence for each of the 18 skills (Table 2). Twenty-five residents (58%) responded to part three of the questionnaire. Half or more of the residents rated themselves as average on any of the five leadership traits (Table 3). “Being positive” was the one leadership trait that more residents (13 of 25) believed themselves to possess more than any other trait. On the other hand, “challenging the status quo” was the one trait that more residents (7 of 25) believed themselves not to possess more than any other of the five leadership traits.
Comments According to Colin Powell, “Leadership is the art of accomplishing more than the science of management says is possible” [7]. Until recently, there have been few formal opportunities in college, medical school, or clinical practice Table 3 Self-evaluation by residents in 5 leadership traits Leadership traits
Challenging the status quo Inspiring others Helping others to optimize their performance Personal encouragement Being positive
One of my personal strengths
I am average at this
I do not have this characteristic
6
12
7
7 4
17 18
1 3
9
15
1
13
12
0
to introduce management skills and nurture the art of leadership. What skills individual trainees have learned in these areas has occurred through trial and error, observation, and emulation. It is no surprise that a majority of surgical leaders came from a defined set of medical schools and surgical residency programs whose faculties were known to hold most of the leadership positions in American surgery [8]. Graduates of these schools and programs nurtured their leadership skills by observing and emulating the leaders in these places. Today’s physicians are faced with myriad stressors with which our predecessors never had to deal: advances in biomedical knowledge and technology, changes in environmental factors, increasing need for physicians to coordinate a variety of community health services and handle costcontainment measures, and ethical dilemmas. Members of our society have expressed a desire for physicians to be more responsive to their needs. As long ago as 1985, the GPEP report called for medical schools and residency programs to address these needs. The Association of American Medical Colleges has reported the need to emphasize leadership skills in undergraduate and postgraduate medical education [9]. Some programs have recently responded by integrating formal courses within their postgraduate curricula [10 –13]. Surgical educators have started to analyze the job of leadership as it relates to health care in general [14 –16] and have advocated starting the formal training of faculty in that field [2]. This study is the first of its kind to assess the perception of surgical residents in leadership skills. Although small in nature and scope, the results are far reaching and allow for important conclusions. For the novice surgical resident who has not been formally exposed to leadership principles in the past, the importance of the selected leadership skills in our survey achieved an overall score of 3.6 and no less than 3.0 in any of the 18 skills (Table 1). It is no surprise that the surgery resident pulled in various directions by multiple stressors (Fig. 1) gave time management a mean importance of 4.0. Time management is 1 of 2 skill areas in which ⬎75% of the residents believed themselves to be competent, perhaps because time management is a skill most residents acquire by default. The other skill area in which ⬎75% of the residents rated themselves to be somewhat to very competent was ethics, perhaps because of the introduction of ethics courses in most medical school curricula, the presence of ethics committees in hospitals, and/or the exposure to ethical dilemmas faced every day surgeons face. It came as no surprise that billing, coding, compliance, practice, and risk management were among the skills and topics where most residents felt uncomfortable. The continuous change in technology with increasing liabilities, our working environment, and health care policy changes make residents uncomfortable with these skills and topics. The nature of our work requires constant interaction with people from all walks of life as well as ever-shifting environments,
K.M.F. Itani et al. / The American Journal of Surgery 187 (2004) 328 –331
and thus many residents feel uncomfortable about their possible lack of competence in these skill areas. Although the difference in mean scores between importance and competence was significant for each skill except ethics, there was no correlation between the scores (Table 1). This indicates that the level of competence of the residents at a certain skill did not necessarily predict its perceived level of importance. If experience were the best teacher, one would expect the competency scores to increase with increasing postgraduate training. There was a trend for the scores to increase as residents progressed; however, the difference in competency scores did not reach statistical significance (Table 2). This lack of statistical difference may be related to the small number of respondents or by the fact that the more junior resident very early in their training realized the value of these skills and have good insight into their level of competence. It is also encouraging to see that most residents rated themselves as average at most leadership traits. The possibility for these residents to nurture those traits if given the opportunity, and add to others that are not present, will enhance their leadership potential. It is distressing to see residents with such great leadership potential develop into the traditional “surgical personality” that has been associated with such negative personality traits as arrogant, dominant, cold, impersonal, impatient, less friendly, aggressive, and authoritarian [17,18]. Surgeons frequently seek leadership roles in the lay and medical communities. It appears unlikely that one can expect others to support and develop allegiance to a representative of a group of individuals who are characteristically considered to be aloof, arrogant, and authoritarian. The future of surgical leadership, and the degree to which that leadership will affect the medical community and society at large, may be determined by the methodology used to select our resident surgical colleagues; the milieu of the surgical training program; and the behavior of mature, practicing surgeons [19]. The responses of the residents in this study have clearly shown that leadership skills are an important part of their professional education and that they do not always feel confident or competent in these areas. Establishing a conscious effort to teach these topics and to emphasize training will enhance residents’ self-image, performance, and potential as future leaders. “The happiest and best physicians of the 21st century are likely to be those who leave their residences with the scientific, analytic, and personal skills and attitudes necessary
331
not only to adapt to their own practice and settings but also to lead continuous improvement in their own practice and settings” [20]. It is our job as surgical educators to provide this opportunity to our residents. References [1] Bowen J. Adapting residency training. Training adaptable residents. West J Med 1998;168:371–377. [2] Shwartz RW. Physician leadership: a new imperative for surgical educators. Am J Surg 1998;176:38 – 40. [3] Jacobs MO, Mott PD. Physician characteristics and training emphasis considered desirable by leaders of HMOs. J Med Educ 1987;62:725– 731. [4] Scott HM, Tangolas EG, Blomberg RA, et al. Survey of physician leadership and management education. Mayo Clinic Proc 1997;72: 659 – 662. [5] Bachrach DJ. Developing physician leaders in academic medical centers. Part I. Their changing role. Med Group Manage J 1996;43: 35–50. [6] Talbott JA. Management, administration, leadership: what’s in a name? Psychiatry Q 1987;58:229 –242. [7] Powell C. A leadership primer. Washington, DC: Department of the Army. [8] Organ CH. The interlocking of American surgery. An analysis of surgical leadership in the United States, 1945 through 1985. Am J Surg 1985;150:638 – 699. [9] Muller S. Physicians for the twenty-first century/report of the Project on the General Professional Education of the Physician and College Preparation for Medicine. J Med Educ 1984;59:1–208. [10] Sims KL, Darcy TP. A leadership-management training curriculum for pathology residents. Am J Clin Path 1997;108:90 –95. [11] Doughty RA, Williams P, Seashore CN. Developing leadership skills for future medical leaders. Am J Dis Child 1991;145:639 – 642. [12] Mygdal WK, Monteiro M, Hitchcock M, et al. Outcomes of the first family practice chief resident leadership conference. Fam Med 1991; 23:308 –310. [13] Pearson SD, Silverman TP, Epstein AL. Leadership and management training: a skill oriented program for medical residents. J Gen Int Med 1994;9:227–231. [14] Souba WN. The job of leadership. J Surg Res 1998;80:1– 8. [15] Cohen JJ. Leadership for medicine’s promising future. Available at: http://www.aamc.org/newsroom/speeches/jjcam97.htm. Accessed November 2002. [16] Zimet CN, Held ML. The development of views of specialties during four years of medical school. J Med Educ 1975;50:157–166. [17] Bruhn JG, Parson OA. Medical student attitudes toward four medical specialties. J Med Educ 1964;19:40 – 49. [18] Wright MR. Self-perception of the elective surgeon and same patient perception correlates. Arch Otolaryngol 1980;106:460 – 465. [19] Thomas JH. The surgical personality: fact or fiction. Am J Surg 1997;174:573–577. [20] Blumenthal D, Thier SO. Managed care and medical education: the new fundaments. JAMA 1996;276:725–727.
Surgical education
Physician leadership is a new mandate in surgical training Kamal M.F. Itani, M.D.a,b,*, Kathleen Liscum, M.D.b, F. Charles Brunicardi, M.D.b a
Department of Surgery, Houston Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030, USA b Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA Manuscript received November 18, 2002; revised manuscript May 26, 2003
Abstract Background: Traditionally, development of physician leadership has occurred at random in surgical training. One possible reason is that surgical educators have focused on detailed instruction on critical patient situations, resuscitation, and technical skills, but they have provided little formal training in the essential leadership skills. Methods: To determine resident perceptions about the importance of these skills and individual strengths and weaknesses in these areas, a questionnaire was administered to 43 residents in our general surgery program. In part one of the questionnaire, the residents ranked 18 leadership skills on a scale of 1 to 4 in importance (“not important,” “minimally important,” “somewhat important,” and “very important”) for career development. The second portion of the questionnaire asked the residents to rate themselves on a similar scale with regard to their personal confidence and competence in these same areas. Results: Twenty-three residents (53%) completed the entire questionnaire. The majority of the residents (92%) rated all 18 leadership skills “somewhat” or “very important” for career development. More than 50% of the residents rated themselves as not competent or minimally competent in 10 of the 18 areas. Ethics was the only area in which ⬎75% of the residents believed themselves to be more than minimally competent. There were no significant differences between postgraduate training levels in any of the parameters calculated. Conclusions: We conclude that although residents see these nontraditional topics as an important part of their professional education, they do not necessarily feel confident or competent in these areas. Establishing a conscious effort to teach these topics and to emphasize their importance during training will enhance residents’ self-image, performance, and potential as future leaders. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Education; Leadership; Surgery; Training
Surgical residency has traditionally focused on the development of clinical judgment and technical skills [1,2]. Although residents are evaluated on their interpersonal, teaching, and communication skills, formal training in these areas is usually not provided. Furthermore, surgery residents are faced with a variety of stressors such as demanding patients, family issues, multitasking, program requirements, and health care regulatory processes (Fig. 1). Skills to effectively manage these stressors are rarely introduced during the five years of general surgery training. After residency, “on-the-job” training often provides a trial-by-fire introduction to some of these issues after multiple opportunities to develop skills to enhance adaptability have passed. The purpose of this study was to investigate residents’ percep-
* Corresponding author. Tel.: ⫹1-713-794-8026; fax: ⫹1-713-7947352. E-mail address: [email protected]
tions of the importance of these issues and their personal confidence levels with regard to select leadership skills. Methods After we conducted a review of the leadership literature, we developed a 3-part questionnaire. The questionnaire was administered in February 2000 to 43 residents in our general surgery program. In part one, the residents scored 18 skills (Table 1) considered by many [3– 6] to be key components of leadership and personal development. The perceived importance of the skills for career development was scored on a scale of 1 to 4 ( 1 ⫽ not important, 2 ⫽ minimally important, 3 ⫽ somewhat important, 4 ⫽ important). A mean importance score was calculated for each individual skill. The mean importance score for all skills was calculated for each postgraduate level (PGY) of training to look for differences among these groups. The percent of residents
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.12.004
K.M.F. Itani et al. / The American Journal of Surgery 187 (2004) 328 –331
329
In part three of the questionnaire the residents were asked to evaluate themselves with regard to five leadership traits. The residents checked off whether the trait was a personal strength, whether the trait was present but not a strength, or whether the trait was completely absent.
Results
Fig. 1. Surgery resident dealing with various clinical, educational, personal, and administrative requirements and responsibilities.
that provided a score of “3” or “4” for each of the skills was also determined. In part two of the questionnaire the residents were asked to rate themselves with regard to their personal confidence and competence in the same 18 areas. A similar 4-point scoring system was used (1 ⫽ not competent, 2 ⫽ minimally competent, 3 ⫽ somewhat competent, 4 ⫽ very competent). Mean competency scores were calculated for each skill. The mean importance score for all skills was also calculated by PGY level. The percent of residents that provided a score of “1” or “2” for each of the skills was calculated. The Student t test was used to compare the mean importance score and mean competency score for each skill. Significance for both tests was determined at P ⬍0.05. Paired importance and competence responses for individual respondents were reviewed for each skill, and Pearson correlation coefficients were calculated.
Twenty-three residents completed parts one and two of the questionnaire (response rate of 53%). Eight residents were in the first year of training (PGY 1), 5 were in PGY 2, 4 were in PGY 3, 3 were in PGY 4, and 3 were in PGY 5. Ninety-two percent of the residents rated all 18 leadership skills as at least somewhat important for career development. All skills were judged to be somewhat to very important by ⬎75% of the residents. Time management received a mean importance score of “4.” The other 3 skills judged by 100% of the residents to be somewhat to very important were effective communication in teaching, conflict resolution, and public speaking. More than 50% of the residents rated themselves as not competent or minimally competent in 10 leadership skills. The 2 skills in which 83% and 74% of the residents rated themselves as somewhat to very confident were ethics and time management, respectively. The skills in which ⬎75% of the residents believed themselves to be minimally to not competent were conflict resolution (96%), billing, coding and compliance (91%), practice management (83%), and leadership theory (78%). For analysis, the PGY 2 and 3 residents were grouped together, and the PGY 4 and 5 residents were grouped together. The mean importance and competence scores for
Table 1 Perceived importance and competence by 23 residents in 18 leadership skills Skills
Importance mean score
Competence mean score
Correlation
Significance
Academic program development Leadership training Leadership theory Effective communication Conflict resolution Management principles Negotiation Time management Private or academic practice, managed care Investment principles Ethics Billing, coding, and compliance Program improvement Writing proposals Writing reports Public speaking Effective presentations Risk management Total
3.2 3.8 3.2 3.7 3.8 3.7 3.7 4 3.6 3.5 3.6 3.5 3 3.3 3.4 3.7 3.7 3.5 3.6
2.4* 2.3* 2.1* 2.7* 3* 2.7* 2.8* 2.8* 2* 2.2* 3.2 1.7* 2* 2.2* 2.4* 2.7* 2.7* 2.1* 2.5*
0.38 ⫺0.06 0.51 ⫺0.09 ⫺0.03 0.27 0.15 ⫺0.04 0 0.36 ⫺0.09 0.15 0.5 0.39 0.49 0.43 ⫺0.25 0.18 0.2
0.08 0.78 0.02 0.68 0.9 0.22 0.5 0.85 1 0.09 0.69 0.49 0.02 0.07 0.02 0.04 0.26 0.43 0.36
* P ⬍0.001 by Student t test between mean importance and mean competence scores.
330
K.M.F. Itani et al. / The American Journal of Surgery 187 (2004) 328 –331
Table 2 Perceived importance and competence in 18 leadership skills by postgraduate level of training PGY
No. of residents
A
B
1 2 and 3 4 and 5
8 9 6
3.5 3.6 3.7
2.3 2.5 2.7
A ⫽ mean importance score; B ⫽ mean competence score; PGY ⫽ postgraduate level.
the two groups of residents were 3.6 and 2.5, respectively. Although there was a slight tendency for the upper-level residents to rate the 18 skills as more important for leadership development and to perceive themselves as more competent in those skill areas, this difference was minimal and did not achieve statistical significance (Table 2). For each of the 18 skills listed, there was a statistically significant difference by Student t test (P ⬍0.001) between perceived importance and perceived competence with the exception of ethics, for which the significance level was P ⫽ 0.09 (Table 2). However, there was no significant correlation between perceived importance and perceived competence for each of the 18 skills (Table 2). Twenty-five residents (58%) responded to part three of the questionnaire. Half or more of the residents rated themselves as average on any of the five leadership traits (Table 3). “Being positive” was the one leadership trait that more residents (13 of 25) believed themselves to possess more than any other trait. On the other hand, “challenging the status quo” was the one trait that more residents (7 of 25) believed themselves not to possess more than any other of the five leadership traits.
Comments According to Colin Powell, “Leadership is the art of accomplishing more than the science of management says is possible” [7]. Until recently, there have been few formal opportunities in college, medical school, or clinical practice Table 3 Self-evaluation by residents in 5 leadership traits Leadership traits
Challenging the status quo Inspiring others Helping others to optimize their performance Personal encouragement Being positive
One of my personal strengths
I am average at this
I do not have this characteristic
6
12
7
7 4
17 18
1 3
9
15
1
13
12
0
to introduce management skills and nurture the art of leadership. What skills individual trainees have learned in these areas has occurred through trial and error, observation, and emulation. It is no surprise that a majority of surgical leaders came from a defined set of medical schools and surgical residency programs whose faculties were known to hold most of the leadership positions in American surgery [8]. Graduates of these schools and programs nurtured their leadership skills by observing and emulating the leaders in these places. Today’s physicians are faced with myriad stressors with which our predecessors never had to deal: advances in biomedical knowledge and technology, changes in environmental factors, increasing need for physicians to coordinate a variety of community health services and handle costcontainment measures, and ethical dilemmas. Members of our society have expressed a desire for physicians to be more responsive to their needs. As long ago as 1985, the GPEP report called for medical schools and residency programs to address these needs. The Association of American Medical Colleges has reported the need to emphasize leadership skills in undergraduate and postgraduate medical education [9]. Some programs have recently responded by integrating formal courses within their postgraduate curricula [10 –13]. Surgical educators have started to analyze the job of leadership as it relates to health care in general [14 –16] and have advocated starting the formal training of faculty in that field [2]. This study is the first of its kind to assess the perception of surgical residents in leadership skills. Although small in nature and scope, the results are far reaching and allow for important conclusions. For the novice surgical resident who has not been formally exposed to leadership principles in the past, the importance of the selected leadership skills in our survey achieved an overall score of 3.6 and no less than 3.0 in any of the 18 skills (Table 1). It is no surprise that the surgery resident pulled in various directions by multiple stressors (Fig. 1) gave time management a mean importance of 4.0. Time management is 1 of 2 skill areas in which ⬎75% of the residents believed themselves to be competent, perhaps because time management is a skill most residents acquire by default. The other skill area in which ⬎75% of the residents rated themselves to be somewhat to very competent was ethics, perhaps because of the introduction of ethics courses in most medical school curricula, the presence of ethics committees in hospitals, and/or the exposure to ethical dilemmas faced every day surgeons face. It came as no surprise that billing, coding, compliance, practice, and risk management were among the skills and topics where most residents felt uncomfortable. The continuous change in technology with increasing liabilities, our working environment, and health care policy changes make residents uncomfortable with these skills and topics. The nature of our work requires constant interaction with people from all walks of life as well as ever-shifting environments,
K.M.F. Itani et al. / The American Journal of Surgery 187 (2004) 328 –331
and thus many residents feel uncomfortable about their possible lack of competence in these skill areas. Although the difference in mean scores between importance and competence was significant for each skill except ethics, there was no correlation between the scores (Table 1). This indicates that the level of competence of the residents at a certain skill did not necessarily predict its perceived level of importance. If experience were the best teacher, one would expect the competency scores to increase with increasing postgraduate training. There was a trend for the scores to increase as residents progressed; however, the difference in competency scores did not reach statistical significance (Table 2). This lack of statistical difference may be related to the small number of respondents or by the fact that the more junior resident very early in their training realized the value of these skills and have good insight into their level of competence. It is also encouraging to see that most residents rated themselves as average at most leadership traits. The possibility for these residents to nurture those traits if given the opportunity, and add to others that are not present, will enhance their leadership potential. It is distressing to see residents with such great leadership potential develop into the traditional “surgical personality” that has been associated with such negative personality traits as arrogant, dominant, cold, impersonal, impatient, less friendly, aggressive, and authoritarian [17,18]. Surgeons frequently seek leadership roles in the lay and medical communities. It appears unlikely that one can expect others to support and develop allegiance to a representative of a group of individuals who are characteristically considered to be aloof, arrogant, and authoritarian. The future of surgical leadership, and the degree to which that leadership will affect the medical community and society at large, may be determined by the methodology used to select our resident surgical colleagues; the milieu of the surgical training program; and the behavior of mature, practicing surgeons [19]. The responses of the residents in this study have clearly shown that leadership skills are an important part of their professional education and that they do not always feel confident or competent in these areas. Establishing a conscious effort to teach these topics and to emphasize training will enhance residents’ self-image, performance, and potential as future leaders. “The happiest and best physicians of the 21st century are likely to be those who leave their residences with the scientific, analytic, and personal skills and attitudes necessary
331
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