Leadership in surgery [Second edition] 9783319111063, 9783319111070, 9783030198534, 3030198537

Table of contents :
What is leadership? --
Leadership in surgery --
Leadership theories and syles --
Are people born to lead? --
Understanding emotional intelligence and its role in leadership --
Practical tips for developing leadership skills early in a career --
Common mistakes in leadership --
Managing teams effectively: leading, motivating, and prioritizing work --
How to manage difficult team members --
How to effective manage up --
Conflict resolution: how to successfully manage conflict --
Change management: how to effectively lead a cultural or organizational change --
Understanding different health care system and funds flow models in surgery --
Understanding different compensation models in surgery --
Negotiating: how, when and why --
How cultures influence leadership styles --
Women as leaders in surgery --
What does it mean to be an underrepresented minority leader in surgery.

Citation preview

Success in Academic Surgery Series Editors: Lillian Kao · Herbert Chen

Melina R. Kibbe Herbert Chen Editors

Leadership in Surgery

Success in Academic Surgery Series editors Lillian Kao, The University of Texas Health Sciences Center at Houston, Houston, TX, USA Herbert Chen, University of Wisconsin, Madison, Wisconsin, USA

More information about this series at http://www.springer.com/series/11216

Melina R. Kibbe • Herbert Chen Editors

Leadership in Surgery

123

Editors Melina R. Kibbe Department of Surgery Feinberg School of Medicine Northwestern University Chicago, IL, USA

ISSN 2194-7481 Success in Academic Surgery ISBN 978-3-319-11106-3 DOI 10.1007/978-3-319-11107-0

Herbert Chen Department of Surgery University of Wisconsin Madison, WI, USA

ISSN 2194-749X (electronic) ISBN 978-3-319-11107-0 (eBook)

Library of Congress Control Number: 2015936522 Springer Cham Heidelberg New York Dordrecht London © Springer International Publishing Switzerland 2015 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper Springer International Publishing AG Switzerland is part of Springer Science+Business Media (www. springer.com)

Contents

1

What Is Leadership? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Meera Kotagal and Carlos A. Pellegrini

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Leadership in Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Michael W. Mulholland

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Are You Ready to Be a Leader? The Ontology of Leadership . . . . . . . . . Juan Carlos Puyana and Timothy Billiar

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Leadership Theories and Styles . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Melina R. Kibbe

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Leadership Traits: Are People Born to Lead? .. . . . . .. . . . . . . . . . . . . . . . . . . . Jeffrey B. Matthews

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Understanding Emotional Intelligence and Its Role in Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . Harry C. Sax and Bruce L. Gewertz

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Common Mistakes in Leadership . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . David W. McFadden

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Practical Tips for Developing Leadership Skills Early in a Career .. . Gregory Kennedy and Herbert Chen

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Leading Teams Effectively: Motivating and Prioritizing Work . . . . . . . Justin B. Dimick

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10 How to Manage Difficult Team Members . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 107 Nathaniel J. Soper 11 How to Effectively Manage Up . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 115 Gerard M. Doherty

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12 How to Manage Difficult Situations and Decisions: Conflict Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 123 Larry R. Kaiser 13 Change Management: How to Effectively Lead a Cultural or Organizational Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 145 K. Craig Kent 14 How Culture Influences Leadership Styles . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 155 Marco G. Patti and Daniel Albo 15 Women as Leaders in Surgery . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 169 Diana Farmer, Connor Long, and Julie Ann Freischlag 16 What Does It Mean to Be an Underrepresented Minority Leader in Surgery? .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 183 Henri R. Ford, Jeffrey S. Upperman, and Joanna C. Lim Index . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . 195

Contributors

Daniel Albo, MD, PhD, FACS Department of Surgery, Baylor College of Medicine, Houston, TX, USA Timothy Billiar, MD Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA Herbert Chen, MD, FACS Division of General Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA Justin B. Dimick, MD, MPH Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA Center for Healthcare Outcomes & Policy, Ann Arbor, MI, USA Gerard M. Doherty, MD Boston Medical Center, Boston University, Boston, MA, USA Diana Farmer, MD, FACS, FRCS Department of Surgery, UC Davis School of Medicine, UC Davis Children’s Hospital, UC Davis Health System, Sacramento, CA, USA Henri R. Ford Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA Julie Ann Freischlag, MD Human Health Services, UC Davis School of Medicine, UC Davis Health System, Sacramento, CA, USA Bruce L. Gewertz, MD, FACS Department of Surgery, Interventional Services, Academic Affairs, Cedars-Sinai Medical Center, Los Angeles, CA, USA Larry R. Kaiser, MD, FACS Temple University School of Medicine, Philadelphia, USA

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Office of the Dean, Temple University School of Medicine, Temple University Health System, Philadelphia, PA, USA Gregory Kennedy, MD, PhD Section of Colon and Rectal Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA K. Craig Kent, MD Department of Surgery, University of Wisconsin, Madison, WI, USA Melina R. Kibbe, MD, FACS, FAHA Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA Meera Kotagal, MD Department of Surgery, University of Washington, Seattle, WA, USA Joanna C. Lim Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA Connor Long, BS Department of Surgery, UC Davis School of Medicine, Sacramento, CA, USA Jeffrey B. Matthews, MD, FACS Department of Surgery, The University of Chicago, Chicago, IL, USA David W. McFadden, MD, MBA, FACS Department of Surgery, University of Connecticut, UConn Health, Farmington, CT, USA Michael W. Mulholland, MD, PhD Department of Surgery, University of Michigan, Ann Arbor, MI, USA Marco G. Patti, MD, FACS Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA Carlos A. Pellegrini, MD, FACS Department of Surgery, University of Washington, Seattle, WA, USA Juan Carlos Puyana, MD Department of Surgery, Critical Care Medicine and Translational Medicine, University of Pittsburgh, Pittsburgh, PA, USA Harry C. Sax, MD, FACS, FACHE Department of Surgery, Clinical Transformation Initiative, Cedars-Sinai Medical Center, Los Angeles, CA, USA Nathaniel J. Soper, MD Department of Surgery, Northwestern Medicine, Chicago, IL, USA Jeffrey S. Upperman Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA

Chapter 1

What Is Leadership? Meera Kotagal and Carlos A. Pellegrini

1.1 Introduction This book is dedicated to the study of leadership and its role in the success of an academic surgeon’s career. This first chapter is divided into two portions. First, we discuss leadership in general, including the definition, general aspects, and its relationship to other attributes and to the individual, including what leaders do and how they do it. Second, we review the importance of leadership and the role that it plays today in medicine and surgery.

1.2 Leadership “101” 1.2.1 Defining Leadership Leadership is an attribute that involves a combination of a meaningful vision with the ability to influence others by non-coercive means to act in a certain way. These two components of leadership are profoundly influenced by the context of the environment, the time at which the event under discussion occurs, and the circumstances that are present. Furthermore, the leadership we will be discussing is anchored by moral values. This moral imperative differentiates human leadership

M. Kotagal, MD Department of Surgery, University of Washington, 1959 NE Pacific Ave Box 356410, Seattle, WA 98195, USA C.A. Pellegrini, MD, FACS () Department of Surgery, University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195-6410, USA e-mail: [email protected] © Springer International Publishing Switzerland 2015 M.R. Kibbe, H. Chen (eds.), Leadership in Surgery, Success in Academic Surgery, DOI 10.1007/978-3-319-11107-0_1

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from that of other species and plays an important role in the development of the vision. The ability to convince or influence followers by non-coercive means frequently requires the use of emotional intelligence and the establishment of a bond with the followers that is based on trust. In other species, the development of trust is profound and total and follows genetic and phenotypic expressions that make most of the participants of the group natural followers of the one that expresses the ‘alpha’ character. For example, a flock of birds or a pack of wolves self-defines with a leader at the front. Followers are convinced that the leader is aware of the location of the food, the safe environment, and the warm weather. This trust is so profound that in instances when the leader is wrong the entire group perishes. As we move up from the animal kingdom, leadership takes on new characteristics. Indeed, leadership can be identified in almost all human endeavors. Whether in education, healthcare, industry, commerce, or finance, a person or persons emerge that are able to articulate a vision in such a way that others have a tendency to follow. However, quite differently from the animal kingdom, each of these endeavors is complex and the complexity leads to the need for different levels of leadership. This is an important concept because as we explore the values associated with the practice of leadership, we will be assuming that there are infinite levels of leadership. Another important difference between human leadership and that of the animal kingdom is that, as we shall see, a good part of a leader’s work is to influence, manage, and therefore “lead” those above him/her. Leadership is thus an attribute applicable as much to a president of a large corporation, a director of a unit, or a manager of a section, as it is to lower-level employees. All that is required to exercise leadership is the presence of at least two individuals and the ability of one to influence the other.

1.2.2 The Origin of Leaders A theory espoused by T. Carlyle in 1841 “Trait Leadership” suggests that “great men born with certain personal talents, health, or physical characteristics have the capacity to affect change” and become leaders [1]. For some time it was believed therefore that leadership was God given – a part of the genetic make-up. In 1884 Herbert Spencer challenged that concept and described the “situational” theory of leadership which suggested that leaders rise to the circumstances [2]. Spencer proposed that the dominant feature in leadership is the environment, represented by challenges, and that it is those challenges that allow leaders to emerge. These two theories are not necessarily contradictory as it is possible that when the appropriate environmental challenges occur, the individuals likely to emerge are those with a genetic predisposition to do so. However, we know of individuals who throughout their lives did not manifest the traits associated with leadership, and who were more predisposed to be followers, and yet when faced with extraordinary circumstances became strong leaders. There is another theory which suggests that personal will and inspiration can give rise to the appropriate vision, which when expressed in

1 What Is Leadership? Table 1.1 Leadership and values

3 Integrity Humility Kindness Support Fairness Authenticity Flexibility Discipline Honesty Energy

Trust Confidence Model Ethical Skill Moral courage Responsibility Inspire Purpose

Table 1.2 How leaders inspire people Qualitative study of several thousand business and government executives [18] “What values do you look for and admire in your superiors?” Honest Forward looking Inspiring Competent Fair Supportive

88 % 75 % 68 % 63 % 49 % 41 %

certain ways, inspires others to follow. Deepak Chopra in his book “The Soul of Leadership” describes how one can “look into one’s self and lead from the soul’s unlimited wisdom” [3]. This is the so-called “look and listen” theory in which the individual looks into his/her soul and reflects in order to create the appropriate vision. This theory suggests that most human beings with the ability to read their own feelings, to “look” into their soul, can derive a vision that expresses the moral values of the individual to a greater extent than those generated by other means or coming from circumstances outside the person. These theories, as well as others that have tried to explain leadership, strongly support our belief that leadership skills can be learned and can therefore be practiced in all environments at all levels. It also supports the theory that in the exercise of leadership a person brings her or his own set of values and style and therefore to some extent leadership is “personal.” Table 1.1 shows some of the values associated with leadership. Several studies have looked at how followers grade each one of these personal values in terms of their respect and trust towards their leaders. Table 1.2 shows a representative value scale on the views of followers towards values expressed by leaders. Kail identified six leadership characteristics that define modern leaders: courage, integrity, humility, selflessness, empathy and collaboration [4]. He believes these elements provide the platform for character and that it is character – not accomplishment – which defines a modern leader. Interestingly – especially given the military background of the author – he impresses upon us that courage is related to attachment to moral principles rather than to the capacity to absorb risk in dangerous

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situations. He defines integrity as the most critical attribute that builds trust and connects leader to follower. He believes humility promotes traits which emphasize respect, loyalty and trust, vital elements in a modern team environment. Selflessness is based on serving others and developing the followers to their full capacity, and it allows the leader to focus on the mission and those who can accomplish it. Selflessness allows the leader to exercise authority on behalf of the needs and goals of the team, rather than his/her own needs. Finally, empathy is the ability to relate to another’s needs, to understand his/her ways of thinking and feeling, and to serve by imagining ourselves in their shoes. It is an important “connector” between leaders and followers.

1.2.3 Emotional Intelligence and Leadership Emotional intelligence has been defined as a “personal attribute that facilitates social and professional relationships” by Goleman [5]. As was the case with leadership, some have thought that emotional intelligence is something that one is born with. It is now clear that this is something that, to some extent, can be learned and practiced by everyone willing to do so, although it may come more easily to one individual than another. According to Goleman and Mayer there are five stages in the development of emotional intelligence, each representing a step higher in the process: Stage 1 – Self-Awareness: Knowledge of self implies the development of an ability to determine how we each react emotionally to the circumstances of life, work, pleasure, etc. It is the identification of “the things that make us tick.” Stage 2 – Self-Regulation: Self-regulation refers to the development of the capacity to regulate the expression of emotion. In other words, once we have learned what generates an emotional response in ourselves, this second stage focuses on the ability to regulate that expression so that it is at least not evident (and can cause distress) to others. Stage 3 – Motivation: Motivation is the capacity to regulate the generation of the emotion itself and, once we have identified what causes these emotions to occur, to be able to develop internal methods that allow us to modulate that emotion. The ideal is to reach a level when we do not have to modulate the expression but we simply feel less emotional stress. Stage 4 – Empathy: Empathy relates to the ability to detect what others think and feel; once the individual is able to know him or herself and regulate both the generation and the expression of most emotions, the individual needs to be able to detect what others think or feel in order to exercise leadership. This is a key component of the bridge between the leader and the follower. Stage 5 – Social Skill: This stage focuses on the ability to influence the feelings of others. Now that we know what others are thinking or feeling at a given time under a certain set of circumstances, our ability to influence those feelings

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determines to some extent the success of the leader. Thus one can think of leadership as an activity motivating people to do something because they want to or believe in it. This is the ultimate exercise of leadership: influencing others to the extent they are convinced that a certain thing must be done or a specific action should be taken (and can exercise their own influence on peers and other followers as well).

1.2.4 What Do Leaders Do? Leaders exercise leadership by creating a vision, articulating a purpose, generating and sustaining trust, and motivating individuals to take action. 1. Creating the vision – The creation of a successful vision must be associated with meaning and significance; it must be anchored in the leader’s values and guided by his or her moral compass. When developing the vision, leaders must use their imagination; they must question all aspects of an issue. For example, the fact that something is working well does not mean it will work well forever, and in fact even if it works well now, one may be able to improve it. In other words, leaders need to “free” their imagination to be able to create a new environment, system, device – they must be bold. For example, Colin Powell said, “You don’t know what you can get away with until you try” [6]. He encourages us to follow the principle of “it is easier to get forgiveness than permission” and tells us that “good leaders don’t wait for official blessing to try things out. Indeed, if one asks enough people for permission one will inevitably come up against someone who believes his or her job is to say ‘no’” [6]. It is also important during the development of the vision to be able to gauge and understand the needs of the followers. While vision may sometimes, by its very nature, ignore some of the immediate gratification of the followers, it is important to always look for ways to relate the benefits of the mission to the followers. The mission is then much more likely to succeed. 2. Articulating the purpose – Once the vision has been created, the leader must be able to articulate and to “sell” the purpose to the followers. The key to that effort is the way in which the purpose is expressed coupled with the determination to achieve the goals. It is important that one offers strong points of view that focus everyone on the shared vision, delivers clear expectations to the followers, and demonstrates the need to act with determination to achieve. In the words of Colin Powell, “Perpetual optimism is a force multiplier” [7]. The ripple effect of a leader’s positive words inspires an optimistic response; in the same way, cynicism and pessimism engender a parallel negative response. Leaders who whine and blame engender those same behaviors among their colleagues. In expressing the purpose a leader should do it in a fashion that conveys, “we can change things here, we can achieve awesome goals, we can be the best.”

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3. Generating and sustaining trust – The best way to generate trust is to be a role-model; in other words to ‘walk the walk’ and to have consistency between words and actions. It is important that the followers believe the leader is as engaged as they are and that the leader follows his or her own advice and does the same as what he/she asks of the followers. Trust is generated by listening closely to the followers, communicating candidly with them, and acting with reliability and consistency. While building trust, leaders must encourage openness, disagreement, and even controversial points of view while expressing confidence in the followers in keeping with the concept of the “wisdom of crowd” [8]. The more the leader listens, the more the leader will learn about the needs and expectations of the followers and increase the chance of generating valuable ideas. The process by which trust is generated is slow, progressive and fragile. Good leaders pay intense attention to it. Sustaining trust requires constancy, transparency and role modeling, all the time and every time. By contrast, it only takes a few minutes, a single expression or one act that is perceived as not worthy of trust to destroy the trust that has been generated. 4. Action – Leaders must translate the purpose of the vision into action. They must induce sufficient trust among the followers to inspire them to take action. There will be times when, despite having put substantial effort into the development of the vision (even when that vision was properly articulated to a group of followers that trust the leader), the resulting action falls short of expected. Good leaders recognize that “failure” is part of life and eventually become more comfortable with it. Good leaders will analyze the cause of the failure, study the hurdles that impaired the achievement of the mission in detail, and move forward. These leaders recognize that there is often more to learn from “failure” than from “success” and that openness to those lessons is crucial. Sometimes it is the complexity of the task; sometimes it is the circumstances or the environment. The only way not to fail is not to try. As : : : : : : .St Marie said “the harbor is the safest place for a boat but boats were not made to stay in harbors.” Leaders must remember that “you miss 100 % of the shots you do not take” as Wayne Gretzky said. As much as optimism and positivity are important in creating vision and building trust, these traits are even more important in sustaining trust and moving forward in the face of “failure.” Leaders are “pragmatic dreamers” or “practical idealists”. Leadership is about developing a vision, articulating it with passion, generating trust, and moving the followers to action.

1.2.5 How Do Leaders Do It A leader is best when people barely know he or she exists. When his or her work is done or the aim fulfilled, people will say: We did it ourselves. – Lao Tzu

As was pointed out at the beginning of our chapter, leadership is an attribute. As such, it is exercised by an individual during the course of their activities. It is therefore important to review the time distribution of leadership activities and

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the elements that facilitate and impair its exercise. Dee Hock, founder and former CEO of VISA, suggested that leaders should invest 50 % of their time leading themselves [9]. That time is used for reflection; it is used to search inwardly and to develop a personal vision with regard to ethics, motivation and direction. It is a time to look “into the soul” for guidance, to examine reality and to develop an environment conducive to achieving the shared goals expressed by this vision. Hock suggests that approximately 20 % of the time should be invested in leading those with authority over the leader. This is a very interesting concept because it expresses “upward” leadership, in which a considerable amount of time is invested in the process of leading and checking with those who are above the leader. It is as important for a good leader to “sell” his or her vision to those above as it is to sell it to those below. In fact, it is probably more important, and it is certainly often more difficult to communicate to those above. In those situations while the “vision” will be the same, the “articulation of that vision” has to be done in such a way as to make the boss believe that it is her/his idea, rather than the person who created it. There are very few things that require more use of emotional intelligence than creating ideas in superior’s minds that eventually become so well anchored as to make believe they originated there. Hock suggests that 15 % of the time should be spent leading peers. This is the recognition that an organization’s fulfillment of the goals would be improved if all the units are able to advance at the same time and that the leader him or herself will be better positioned if his/her ideas have been “bought” by peers. Hock leaves only 15 % of the leader’s time to lead the subordinates. He also emphasizes the concept of service leadership saying, “If you do not understand that you work for your subordinates, then you know nothing about leadership. You only know tyranny.” This breakdown of time that Hock describes is central to a model known as metaleadership, representing three of the five components of meta-leadership: leading down, leading up, and leading across [10]. These components are built on the foundation of self-awareness and situational awareness that we have previously described as key to leadership. Two common errors in managing the time spent on leadership are what we call “reverse delegation” and “making other people’s problems your own”. Reverse delegation is always tempting for a leader and it can be described as the process by which something that needs to be done is done by the leader, rather than being delegated to a subordinate. While this may save the leader some time in the short term, by avoiding spending the time to teach, coach, and wait for a turn around by a less experienced follower, it is not a good strategy for at least two reasons. First, it condemns the leader to doing the task again next time it presents – so ultimately the time invested becomes greater, and second, the process demeans the followers. Instead, this can be turned to the leader’s advantage by using the opportunity to show confidence in the followers which improves morale, enhances development and nurtures loyalty toward the leader. Furthermore, when the followers are allowed to take risks and encouraged to develop methods that achieve the tasks in a better way than the leader originally envisioned, leadership is at its best. The leader has in fact created another leader.

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Making other people’s problems your own is a tendency that many leaders have. As a leader, one has no business becoming involved in the troubles of subordinates, even with the best intentions. There is a delicate balance between trying to help other people with their problems and making those problems your own.

1.2.6 Relating to Followers: Styles of Leadership When studying relationships between leaders and followers it is important to remember that the leader has to find ways of motivating the followers. Two different approaches have been identified in this motivational exercise: one is the transactional and one is the transformational. The transactional approach is directly related to strict performance and outcomes criteria. The focus is on successfully completing a task and on rewarding that behavior (promotion, pay raise, etc.). When the task is not completed there is a lack of reward or a punishment (no pay, demotion, or dismissal). The transformational style is “principle driven”. This approach embodies dedication to the larger organizational mission. It is “mission centric” and not “task oriented”. It creates meaning for the followers rather than specific rewards. It converts leaders into moral agents and is usually a more enduring style of leadership. In today’s world the transformational style is probably more appropriate. Within these two general approaches, there are several styles of leadership. Goleman, in his book “Primal Leadership,” describes six styles: authoritative, affiliative, coaching, democratic, pace-setting, and commanding [11, 12]. 1. The Authoritative Style: As suggested by the name, this style implies the use of authority. The authoritative leader defines standards that revolve around the vision. Of all the styles of leadership, the authoritative style is the most effective at driving every aspect of climate as the leader has identified clear objectives and demands performance. The authoritative style works well in almost any business situation but is particularly effective when a business is adrift. An authoritative leader charts a new course and sends the followers with a fresh long-term vision. This style is a lot less effective when the leader is working with a team of experts or peers who are, or believe they are, more experienced than the leader. It is, therefore, less likely to work in the medical arena. 2. The Affiliative (or Facilitating) Style: This style revolves around people. Its proponents value individuals, allowing for innovation and creativity. This style allows for risk taking and provides freedom of action to followers. It is a style that proves particularly useful when trying to build team harmony, increase morale, improve communications, or repair broken trust. 3. The Democratic Style: This style is based on a significant amount of listening by the leader who spends time soliciting other people’s ideas. By its nature this style builds the trust of the followers, and provides an excellent way to drive responsibility. One of the main drawbacks is the substantial amount of time

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needed for decisions and in some instances, inaction from endless meetings. This approach works best when a leader is uncertain about the best direction to take and needs ideas and guidance from followers. 4. The Pacesetting Style: In the pacesetting style, the leaders set extremely high performance standards by performing at that high standard themselves. This style is about improving and having everyone do things better and faster, including the leader. Poor performers are required to do better or be left out. This style can lead to poor morale and destruction given that most followers will feel overwhelmed by the pacesetter’s demands. Work becomes not a matter of doing the best along a clear course as much second guessing what the leader wants. 5. The Coaching Style: Coaching leaders help followers identify their unique strengths and weaknesses and tie them to their personal and career goals. They encourage followers to establish long term development goals and help them create the plan for obtaining them. Coaching leaders excel at delegation and challenging employees to grow and develop new skills. 6. The Coercive Style: This style is characterized by strict and immediate enforcement of compliance. Of all the styles of leadership the coercive style is one of the least effective in most situations. In this case the leader makes top down decisions and this tends to inhibit new ideas. The followers’ sense of responsibility evaporates because they are unable to act on their own initiative, lose ownership and feel little accountability toward their performance. Occasionally coercive leadership is important to exercise but should be used with caution. The most important thing to remember is that an individual does not function with only one style of leadership. All styles are necessary from time to time. The circumstances determine the predominant style of leadership that should be exercised at any given time as each style is best suited for a given set of circumstances. Moreover, a single style is usually less likely to lead to success than the combination of two or more styles. The most effective executives use a collection of distinct leadership styles, each in the right measure at just the right time. Such flexibility can be difficult to put into action but it pays off in performance and better yet, it can be learned. For example, during an emergency with a turn of events that was unexpected and requires immediate correction, the combination of an authoritative or a coercive style may be most appropriate. In this situation the use of a democratic or coaching style may be less appropriate. However the pure use of an authoritative style during an emergency can lead to fragmentation and distrust from the rest of the team and may leave the leader all by him or herself. Therefore adding affiliative or pacesetting aspects at that time may modulate the authoritative style and lead to the best outcome. Strong leadership styles have historically highlighted traits associated with masculinity. In fact, most literature on leadership refers to the “he” leader. It is no surprise that in a current survey of 7,000 leadership positions in America men outnumber women in senior leadership positions nearly 4 to 1 [13]. On the surface this raises a moral dilemma, given that about 50 % of the world’s population is composed of women and that today in America women outnumber men as graduates of higher education.

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In his presidential address to the Society of Thoracic Surgeons, Douglas Wood emphasized the need, particularly in academic surgery, to embrace leadership traits historically thought of as “feminine” [14]. He believes that “selfless leadership” – a more modern, accepted, and effective form of leadership – is more likely to be present among women. In fact, a study by Gerzema and D’Antonio that identified 125 different human behavioral traits showed that across age, gender, and cultures, people around the world felt that traits often identified as “feminine” correlated strongly with making the world a better place [15]. The authors found that the traditional “feminine” attributes and values are now more strongly related to leadership than the “macho paradigm” characterized by more “black and white” thinking and the need for control. Traits such as “displaying high integrity and honesty,” “developing others,” “building relationships,” and “collaboration and teamwork” are also traditionally thought to be “feminine” traits. However, it is important to note that traits that are “feminine” or “masculine” can be present across genders. Indeed, one study showed that women scored higher than men in 12 out of 16 traits of leadership including such traditionally masculine traits as “taking initiative”, “driving for results,” or “establishing stretch goals” [15]. In his lecture, Wood noted that “the characteristics of selfless leadership emphasize trust, empathy and the capacity to listen and to relate to others [14]. More than ever before, leadership is about the expression of tolerance combined with integrity and confidence. It requires courage to be both vulnerable and connected to others and it requires humility to accept codependency and acknowledgement of one’s own weaknesses and vulnerability. It is not about competition. It is not about raising oneself up above others; it is certainly not about pulling down those around you. Modern leadership is about elevating the people around you and perhaps people not even noticing that you are the reason.”

1.3 Leadership in Medicine In the latter part of 1800s and throughout the 1900s, the educational system prevailing in medicine emphasized individuality and did not take into consideration the concept of teams, and by extension the concept of leadership. For example, physicians had traditionally been taught to arrive early, review everything personally, and check on their patients with their own eyes. Traditional teaching emphasized “dependence on no one but yourself.” Indeed, the quality of a physician was measured by the personal standards that were practiced without reference to the surrounding environment. In the latter part of the twentieth century it became clear that with the emergence of new drugs, tests, devices, and techniques – a cycle of innovation that was constantly increasing the complexity of the environment in which medicine was practiced – physicians and other health care providers needed to focus their expertise quite narrowly. This narrow focus combined with individuality that had been encouraged in medicine led our system to become fragmented; the care provided to patients became disorganized by its very nature.

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This chaotic care fueled an increasing interest in the development of teams. This meant that the physicians and other health care providers had to learn how to relate to one another, express respect for others’ opinions, transfer care of the patients or at least portions of their care to others, and delegate the performance of tests and procedures. It was the need to coordinate the work of ever enlarging teams of providers that brought about the emergence of leadership as an important concept in the practice of medicine. Initially, leadership emerged as an expression of high level management of a complex set of circumstances by a difficult (mostly individualist) group. Today we recognize that to maximize performance we need “high performing” teams: that is, teams capable of impeccable communication, mutual support and situational awareness led by individuals knowledgeable in the art and practice of leadership. With that, we can say medicine has undergone a 180ı turn when it comes to the relationship between its members. For example, within a team of healthcare providers authority (“this is how I want it to be done!” “this is how my teachers taught me”) was replaced by evidence. The autonomy exercised traditionally by physicians who practiced in an individualistic environment had to change to a spirit of collaboration with other members of the team. Assertion of facts was changed to measurement, publicly expressed with transparency, and self-interest which, although never sanctioned prevailed among many providers, was replaced by focusing our actions to serve public (and patient’s) interest. As these monumental changes occurred at the turn of the century, leadership, in terms of knowledge and application, became more important in the life of physicians. It became important in relationships with patients, in relationships with other colleagues, in relationship to the creation of divisions, departments, and teams of healthcare, centers of excellence, etc. and therefore every physician had to learn to exercise the expression of leadership at one level or another. In fact, the only choice left was to lead or to follow. Beyond the emergence of systems of care, another important factor that fueled the interest in the practice of leadership has been an increasing blurring of traditional boundaries between specialties. Indeed, in the past, the boundaries between most medical specialties and most surgical specialists were well defined. The emergence of newer diagnostic and therapeutic means and innovations in the delivery of care have, in the last two decades, made those boundaries more difficult to define. For example, cardiologists perform revascularization procedures that were once only in the hands of surgeons, and many cardiac surgeons today perform interventional studies in the heart that were once only part of a cardiology practice. The same can be said of gastroenterologists, interventional radiologists, and gastrointestinal surgeons. Managing these relationships is difficult, but where leadership really emerges is when we as a profession can create new working relationships and out-of-the-box modalities that improve patient care, decrease inefficiencies, avoid waste and decrease cost. Creating “new” systems is and will be difficult, but that is only the expression of the vision, the first part of leadership. Making them work, develop and grow (i.e., influencing others to act in a certain way under noncoercive means) is the true expression of leadership. The emergence of Accountable Care Organizations (ACOs) and patient-centered medical homes as even more

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complex systems of care, and the creation of large multi-hospital groups through mergers will add to the complexity of care delivery and finances associated with the work of the physician, including understanding and clarifying the distribution of payments for services among different providers of care. The redesign of current systems is aimed at global improvements in quality and cost. To be successful it will require effective care teams and good management of local operations – what Bohmer calls “Clinical MicroSystems” [16]. Heads of medical and nursing departments have obvious leadership goals but these goals will only be possible with simultaneous parallel leadership by clinicians deeper in the organization, usually without any formal title, leadership job description, or authority. This is an example of leadership at all levels which we previously discussed. Indeed, these “clinical microsystems” as described by Bohmer are composed and often controlled by second and third line clinicians whose primary work is patient care and who, for the most part, have little interest in leadership. Nevertheless, these physicians are key in establishing purpose for their microsystem. They are also key in measuring and assigning importance to transactional performance measures, such as clinic volume and other measures of individual productivity that heretofore have reinforced the individualistic perspective against that of the team. The complexity of their work is compounded by the need to ensure that their clinical microsystem can achieve the goals of the team. Bohmer identifies the big challenge as the need to provide care that balances “between evidence based medicine and patient centric care which requires the flexibility to deliver standard care where the evidence is strong and customized care where it is not.” In these microsystems, the final task of the second and third line physicians is improving performance using the measurements acquired during their work.

1.4 Conclusion In conclusion, leadership implies an ability to influence (processes, people, actions) by non-coercive means. Leadership is an attribute and as such can be applied by every person through most of their actions. Some people are born with the traits of leadership, and on occasion environmental factors create the need for leadership that emerges. Both those who were born with traits of leadership and those who learned it have a chance to develop leadership through self-awareness (looking into themselves) and situational awareness (looking at the surrounding circumstances). Leadership is rooted in the core values of an individual; those values provide character and are expressed during the exercise of leadership. Leadership is useless if it does not take into consideration the social contract, and it must be anchored in profound and clear moral values. Leaders do not exist in a vacuum. The best leaders are capable of contextual diagnosis (determining what the circumstances are and matching the vision with reality checks). True leaders use the theory of adaptation; they constantly transform their conduct and perspective to match the needs of the circumstances. They change their style and their actions to reach socially desirable

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goals. They have developed profound knowledge of emotional intelligence and practice its principles at every turn. They understand that the circumstances, the times and the places in which leadership will be expressed require different styles. Leadership is doing what is right, not what you have the right to do. Lastly, as Martin Luther King, Jr. stated, a good leader is “obedient to the unenforceable” because good leadership goes beyond obedience to the law, beyond what is expected [17]. It creates an environment where all develop and grow while serving the greater need of humanity. Leadership is essential to modern medicine, and physicians who become knowledgeable in its art, its science and its practice are likely to be personally and socially successful and to leave a meaningful legacy.

References 1. 2. 3. 4.

Carlyle T. On heroes, hero-worship, and the heroic in history. Boston: Houghton Mifflin; 1841. Spencer H. The study of sociology. New York: D. Appleton and Company; 1896. Chopra D. The soul of leadership: unlocking your potential. New York: Harmony Books; 2010. Kail E. Leadership character: introduction. Washington Post, 10 June 2011. On Leadership Blog edition. 5. Goleman D. What makes a leader? Harvard Business Review, 1 Jan 2004. p. 1–12. 6. Powell C. A leadership primer. Washington, DC: Department of the Army; 2001. 7. Powell C. My American journey. New York: Random House Publishing Group; 1996. 8. Surowiecki J. The wisdom of crowds. New York: Anchor Books; 2004. 9. Hock D. Birth of the chaordic age. San Francisco: Berrett-Koehler Publishers, Inc; 1999. 10. National Leadership Preparedness Initiative. Crisis preparedness and crisis response: the metaleadership model and method. In: Homeland security handbook. New York: McGraw-Hill; 2012. 11. Goleman D, Boyatzis R, McKee A. Primal leadership: realizing the power of emotional intelligence. Boston: Harvard Business Press; 2002. 12. Goleman D. Leadership that gets results. Harvard Business Review, 1 Apr 2000. p. 78–90. 13. Zenger J, Folkman J. Are women better leaders than men. Harvard Business Review, 15 Mar 2012. p. 80–85. 14. Wood DE. Take it to the limit. Ann Thorac Surg. 2014;98(6):1893–901. 15. D’Antonio M, Gerzema J. the Athena doctrine: how women (and the men who think like them) will rule the future. San Francisco: Jossey-Bass; 2013. 16. Bohmer RMJ. Leading clinicians and clinicians leading. N Engl J Med. 2013;368(16):1468– 70. 17. Martin Luther King Jr, Luker R, Russell PA. The Papers of Martin Luther King, Jr.: Volume VI, Advocate of the Social Gospel, September 1948-March 1963. Berkeley: University of California Press; 2007. 18. Kouzes JM, Posner BZ. Credibility: how leaders gain and lose it, why people demand it. San Francisco: Jossey-Bass; 2003.

Chapter 2

Leadership in Surgery Michael W. Mulholland

2.1 Surgical Leadership in a Time of Change Surgery currently holds a central place in the complex American health care system, but change is everywhere. Approximately 100 million procedures are performed annually by 275,000 surgical specialists. Surgical services are expensive, costing $500 billion each year, and operative procedures are uniquely remunerative to hospitals, typically accounting for 40 % of hospital revenue. The technical aspects of surgical practice have evolved very rapidly in the two decades since the widespread adoption of laparoscopic cholecystectomy. Laparoscopic approaches have supplanted most open operations, now joined by thoracoscopy, endovascular therapy, and image-guided surgery. Scientific advances have also changed the intellectual underpinnings of surgical practice. Insights into the structure and function of the human genome are reflected in personalized medicine, to be joined shortly by personalized surgical therapy. Restrictions on postgraduate training hours, beginning in 2002, have fundamentally altered surgical training, positively and negatively. Strong surgical leadership is required for Surgery to remain relevant to the future practice of medicine. Failing that, Surgery may be reduced to a technical specialty like interventional radiology, and vulnerable to loss of identity and to displacement from decision making regarding delivery of care. Surgical leadership must be futureoriented, applying lessons from the past to circumstances yet to come. At its best,

M.W. Mulholland, MD, PhD () Department of Surgery, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA e-mail: [email protected] © Springer International Publishing Switzerland 2015 M.R. Kibbe, H. Chen (eds.), Leadership in Surgery, Success in Academic Surgery, DOI 10.1007/978-3-319-11107-0_2

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leadership involves creation of a positive future by communicating the idea that cooperative behavior always achieves more than self-motivated behavior. Leaders create the future by: 1. 2. 3. 4.

Developing a compelling vision; Communicating that view of the future; Enlisting others to participate in the pursuit of future accomplishments; Demonstrating commitment over time to achievement of that vision.

2.2 The Leadership Imperative As a first step in considering surgical leadership, it is important to consider the activities with which surgeons are engaged, and then to ask how these tasks promote leadership.

2.2.1 The Clinical Mission Surgeons express the clinical mission in care of individual patients and health systems are organized to facilitate the provision of operative care. Operating room suites are central physical features of every hospital in this country. Operating room construction is highly regulated and uniquely expensive, making disproportionate claims on hospital capital and operating funds. Personnel requirements exceed those of other areas of hospital operations, magnified by the 24/7 nature of surgical activity at most large hospitals. In addition, operating room functions make large demands upon other services, including radiology, blood banking, and pathology. In many systems, ambulatory clinics and emergency rooms are explicitly designed to efficiently funnel patients to surgical providers. Within this system, surgeons have possessed unique degrees of personal autonomy and flexibility. Anesthesiologists, operating room nurses and surgical support personnel are assigned to a daily surgical schedule and are committed to finishing the cases presented. With many fewer constraints, surgeons may schedule elective operations at their discretion and in ways that maximize professional gain while minimizing personal conflicts. Surgeons are allowed greater degrees of freedom in equipment and supply requests than other physicians. For example, most operating rooms maintain an extensive list of “doctor preference cards” that outline the needs of each surgeon for commonly performed operations, the cards often substantially different for operations that are largely similar. Even though operating room personnel are highly skilled and expensive, surgery does not begin until the surgeon is ready. As these few examples illustrate, the operating room is a highly artificial environment designed to maximize productivity of surgeons. Unfortunately, these hierarchical aspects of surgical care, long part of surgical culture, are not conducive

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to leadership development. Moreover, this surgeon-centric model of practice is vanishing, as are autocratic forms of surgical leadership so common in the past. Within the operating room, the importance of communication and interpersonal relationship has been recognized in recent years through team-building efforts. Surgical checklists, pre-incision time outs and postoperative debriefing are all expressions of the same incredibly simple, but powerful idea: every member of a surgical team has unique insights and value is gained by sharing information. The results have been impressive. As reported by de Vries and colleagues, the institution of a multidisciplinary surgical safety checklist, including medications, marking of the operative site and postoperative instructions significantly improved operative results [1]. The number of complications per 100 patients decreased from 27 to 17 and the rate of complications decreased by one-third. Astoundingly, this simple intervention cut in-hospital mortality from 1.5 to 0.8 %, almost by half. Similar results were reported by the Safe Surgery Saves Lives Study Group [2]. Surgical care is now multidisciplinary care. Long the domain of surgical oncologists and transplant surgeons, multidisciplinary clinics and case conferences increasingly dominate cardiovascular surgery, bariatric surgery, pediatric surgery, and many other disciplines. Success in multidisciplinary settings requires the practitioner to be knowledgeable of the others’ disciplines, to appreciate and respect alternative perspectives, to resolve ambiguity and to engage in multilateral negotiation. These attributes are precisely the characteristics required for modern surgical leadership. Surgical leaders must interpret the demands of surgery to others. Provision of surgical care is resource and capital intensive and may conflict with other health system demands. For example, in hospitals with high occupancy, admissions from the emergency department may compete for beds devoted to elective surgical cases. The recently-enacted Affordable Care Act shifts financial risk progressively to health systems and may convert surgical services from revenue generating units to cost centers. Future bundled payments will require substantial internal readjustments. The interpersonal skills exemplified by multidisciplinary care are directly relevant to navigating these coming changes. Most importantly, surgical leaders must imagine and empower a future in which treatment of the next generation of patients is better than contemporary care.

2.2.2 The Research Mission In academic medical centers, innovation is the chief source of differentiation and competitive advantage, and surgeons must actively engage in scientific discovery to remain relevant. In contemporary basic investigation, however, there is no surgical research, just research. Basic investigation is reductionist and mechanistically oriented. Western blotting and polymerase chain reaction and transgenic animal models apply equally to investigators from Surgery, Immunology or Biochemistry. In addition, methodological advances in genetics, metabolomics and biocomputation,

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among many others, make it impossible for any single investigator to master all techniques. Basic science is now and forever a team sport. As such, success in basic science requires equal measures of analytic talent and personality. As clinical medicine has become multidisciplinary, so too has biology. The performance of an operation constitutes a clear transition in care, and a cause and effect relationship between intervention and outcomes like complication or death is less equivocal than for non-surgical treatment. The link between operation and outcome has been the intellectual lynchpin of surgical health services research. To date, the clarity of this relationship has allowed health services research to remain “surgical”. This situation will not persist. The creation of “big data” and the influence of ideas from economics and social research will change and enrich this field as well. Soon there will be no surgical health services research, just health services research. Surgical leaders are talent scouts. Most physicians are ultimately drawn to the intellectual foundations of the disciplines they choose, but many are initially attracted to the field by the example of a more senior mentor. Talented young people are stimulated by environments that are open, accepting of differences, rewarding. A small research project becomes a presentation at a symposium, which begets a larger project, which blossoms into an investigative career. An inevitable tension exists between the clear demands and tangible rewards of clinical surgery and the uncertainty of research. A long line of past patients and a seemingly unlimited number of future patients confront the surgeon. The emergency department demands attention every day. The emotional rewards of a well-executed operation are immediate. Financial results are obvious. In contrast, novel ideas are fleeting and rare. Surgical leaders can shape the research mission through personal research accomplishments and scholarship. They also support investigation by displaying intellectual engagement, perseverance and curiosity. As with clinical care, surgical leaders must imagine and fund future investigation.

2.2.3 The Teaching Mission Surgeons involved in undergraduate medical education and in postgraduate training are uniquely privileged. Beyond the patients they treat directly, these individuals influence the lives of thousands of others, cared for in turn by their trainees. Cognitive development in surgical training is not different from that associated with other medical disciplines. The principles of adult learning apply equally to both groups of learners. In contrast, the technical aspects of surgical training have no parallels in non-surgical disciplines. The teaching of surgery requires special traits of the instructor – patience, the ability to instill confidence in another person, communication through both verbal and non-verbal cues, and the self-possession required to help another succeed. Training to be a surgeon can be emotionally trying, and not for the obvious reasons that the hours can be long and physically fatiguing or that surgical

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emergencies are stressful. Surgery is difficult because committing to an operation imparts responsibility to the surgeon for another person’s life. Not all patients can be cured; palliation may be elusive; complications occur. Failure is intrinsic to the practice of surgery. The best teachers of surgery are empathic to their trainees and are able to guide emotional maturation. These traits are surely the substrate of leadership.

2.3 Initial Faculty Experiences During junior faculty years, those immediately following the completion of residency or fellowship training, formal administrative responsibilities should be avoided. Every surgeon upon entering independent practice must develop personal clinical judgment, determine how he will comport himself in an operating room, and must establish ties to referring physicians. Complications occur in every practice and the young surgeon must learn to face them forthrightly and with equanimity. In teaching hospitals, the young faculty member must switch from receiving instruction to providing guidance. The first years are especially important in research; lack of focus and productivity at this juncture can permanently short circuit an investigative career. In the most positive sense, these years should be a self-directed investment in future productivity. While many of these activities are the building blocks of leadership, and while every year provides opportunities for leadership, personal development requires time and focus. Surgical practice is intrinsically risky. Surgical procedures all have known complication rates, and many have an expected mortality. In addition to physical impairment, surgical complications are financially costly. It has been estimated that each surgical complication adds $11,000 to the cost of surgical care. In addition, surgery is the most public form of medical practice. As an obvious example, surgical procedures are performed in an operating room with a scrub nurse and a circulating nurse, anesthesiology care giver and often one or more trainees. At another level, the direct relationship of surgical complications to the performance of an operation makes public examination of imperfect results routine. A weekly morbidity and mortality conference is a staple of every surgical training program in this country. The risk inherent to surgery, its public nature and the resultant scrutiny thrusts surgical leaders into positions of judgment. Credibility in this regard is contingent upon the leader’s clinical abilities. Strong cultural norms in American Surgery make it very difficult for surgeons that are not clinically experienced and active to assume meaningful leadership roles. Research is the key to improving current surgical practice. Investigation is also uncertain and expensive. Surgical research is not relevant to non-academic medical centers, and has become optional and endangered at many others. Where research is important, early investigative success is an essential criterion for surgical leadership.

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Clinical teaching is less embattled than research and is a foundation of most departments of surgery. A commitment to teaching and a record of teaching ability should be considered a prerequisite to leadership development.

2.4 Temperament and Values While experience is influential in leadership development, in many ways temperament is more important. To succeed in these dimensions, surgical leaders must possess integrity, selflessness, the ability to communicate and curiosity. Personal integrity is the single most important quality of leadership. While integrity alone does not guarantee leadership success, the perceived absence of this quality does guarantee failure. At the simplest level, integrity means that the effective leader does what he has said he will do. For example, if the surgical leader has committed to provide resources to a newly recruited faculty member, integrity means that those resources have been accrued and will be available. If a salary has been negotiated, the money will be paid. Operating room time promised will be delivered. Promises that are made for material or financial benefits will be met. However, integrity in this sense is purely transactional. Transactional interactions do not engage group imagination or collective action, and leadership that rests solely on the authority to provide material benefit or financial transfers is fragile [3]. At the next level, integrity means the group perceives that the leader does what she thinks is right. This state implies that the organization understands that the leader has a moral framework that informs decisions, is consistently true to those convictions, and that she resists powerful forces within the organization if she thinks they are wrong or threaten group welfare. Consider the promises alluded to above. In any surgical department, there is never enough lab space, money or operating room time to satisfy the needs and aspirations of all. Necessarily, commitment of resources to one faculty recruit, salary increase to another or operating room time to a third, affects the whole organization. In addition, there are no guarantees at the time of commitment that those resources will be used productively or to the benefit of the whole organization. Decisions of the leader that are seen to arise from a moral center of gravity allow the group to accept the risks that commitment of resources always entails. Integrity also has a time element. Personal integrity displayed over time creates trust. Trust is hard-earned, resilient, and very powerful in that this condition allows the group to engage with the leader’s longer term vision. With trust, a belief develops that the leader will be consistent through success and failure, through thick and thin, that the leader encountered today will express the same values in the future. Let the reader imagine a personal example. Think of a person in your life that you trust. Imagine that you have not seen him or her in a month, a year, perhaps a decade. Trust means you believe that when you meet this person next he or she will display a consistent set of values and will treat you fairly, as you have been treated in the past.

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Effective leaders work to achieve a vision for the future that maximizes the potential of others and benefits the organization, for example a department of surgery. To do so, the leader must be outward-looking and not concerned with personal advantage or benefit. There must be joy and satisfaction for the leader in the success and recognition of others. This quality of selflessness is a core ethical value in medicine in which the welfare and benefit of the patient takes precedence over the self-interest of the treating physician. This viewpoint is diametrically opposed to modern American business practices in which maximizing profit is the standard and in which placing personal interest first is an accepted ethical starting point. Selflessness cannot be taught. For surgical leaders, this quality requires a bedrock sense of personal wholeness and confidence. Communication is absolutely essential to leadership. Effective leadership requires a commitment to continuous expression of core values, institutional objectives and future aspirations. The most powerful communication resides in the manner in which a leader lives his or her life. For better and worse, leaders are observed and their actions (and inactions) are scrutinized. Respectful language, humility, and humane treatment of others’ failings resonate strongly and positively. Positive communication of this sort allows the leader to accumulate credit in a bank of goodwill. This credit can be depleted incredibly rapidly, sometimes instantly, by crude humor, hubris, or cruelty. Perceived hypocrisy in a leader is especially corrosive. A leader cannot profess value in teaching and at the same time ignore medical students, and cannot ask others to be productive in research while not being academically engaged. The surgical leader’s professional life is on brightest display in the operating room. The surgeon leader does not need to be the slickest operator in the department, but he or she absolutely must be the most respectful to the nurses, the calmest when problems arise, the person with whom the anesthesiologists feel most comfortable. True surgical leadership cannot be gained solely in the operating room, but it can surely be lost. In our verbal society, spoken communication is key, and effective leaders develop multiple styles of verbal expression. It seems obvious that talking privately with a junior house officer struggling with a major postoperative complication would differ in approach than annual salary negotiations with senior faculty. Public presentations to scientifically sophisticated professional audiences require different language skills than do talks to lay groups. Effective communication uses a variety of verbal tools, and leaders must work to master all. Consider the power of analogy. This author might describe his work at a research seminar by saying “My laboratory studies hypothalamic control of ingestive behavior and metabolic rate. We have deep expertise in the melanocortin signaling system and have developed a number of transgenic animal models to examine signal transduction in this system.” This description probably would not work with a successful business person considering laboratory endowment. Perhaps it might be better to say “I study eating. The brain has an area that acts like

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a thermostat. Turn the thermostat up and we feel hungry; turn it down and we stop eating. I’m trying to see if we can control that thermostat so we can cure overweight.” While verbal expression is important, listening is crucial. Effective listening is not passive, and active listening is a skill that must be developed. Listening effectively involves asking questions as the other speaks to elicit deeper meaning, to clarify ambiguity and to draw forth new ideas. Active listening involves verbal encouragement and visual cues, and sometimes just sitting silently while the speaker organizes his or her thoughts. The best leaders practice a 2:1 rule; the leader listens 2 min for every minute that he or she talks. Listening is not easy; it requires practice. Because we live in such a verbal/visual society, there is special power for leaders that can express themselves in writing with style and clarity. Writing is hard work. Ann Patchett, the highly successful novelist, has recently written “Logic dictates that writing should be a natural act, a function of a well-operating human body, along the lines of speaking and walking and breathing. We should be able to tap into the constant narrative flow our minds provide, the roaring river of words filling up our heads, and direct it out into a neat stream of organized thought so that other people can read it : : : : : : .But it’s right about there, right about when we sit down to write that story, that things fall apart” [4]. Aspiring leaders should not despair. Like many difficult and important skills, writing becomes easier with daily practice. The technical complexity of surgical practice has accelerated at an unprecedented pace in the past decade, and non-operative therapy must be integrated with surgical care. Every branch of surgery has examples. Abdominal aortic aneurysms may be treated via laparotomy or endovascularly, depending upon anatomic variability and patient characteristics. The proper treatment of breast cancer requires knowledge of the cell biology of nuclear receptors and angiogenesis in additional to sentinel lymph node biopsy. Care for patients with choledocholithiasis combines endoscopic retrograde cholangiography and laparoscopic cholecystectomy, each applied expertly. As a consequence of these advances, clinical surgery has become increasingly specialized and narrowly focused. Similar forces affect surgical research. Basic investigation advances apace, and so does health services research, but they use fundamentally different techniques. Surgical leaders are called to promote and coordinate diverse surgical specialties and to simultaneously advance surgical knowledge. The ability to do so rests upon openness to novelty and change and a habit of mind that restlessly seeks the stimulation of new ideas. Pasteur noted “Chance only favours the prepared mind.” Just so. Leadership belongs to the curious.

2.5 A Call to Leadership For most, the call to leadership does not arrive with a clarion note, a neon sign that flashes LEAD, LEAD, LEAD or some similar epiphany. Rather, the young faculty member establishes a reputation for clinical excellence, or a robust research

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program, or becomes a valued teacher, and someone asks for help or collaboration or guidance. Someone asks for leadership. And a little voice whispers, “You can do this. You can reach beyond yourself. Maybe you can be a leader.” When this happens, there is only one sensible thing to do. Stop right away. Ask this question: Do you really want to help and develop others at the expense of yourself? Be sure the answer is yes.

2.6 Leadership Phenotype A leadership stereotype has come to dominate American business and political culture. Leaders are characterized as extroverted, assertive, dominating, and often self-aggrandizing. Twentieth century American history provides many examples – General Douglas MacArthur, President Clinton, General Electric chairman Jack Welch to name a few. In her book, Quiet, author Susan Cain contends that these traits may not actually characterize effective leadership. She writes “Contrary to the Harvard Business School model of vocal leadership, the ranks of effective CEOs turns out to be filled with introverts, including Charles Schwab; Bill Gates; Brenda Barnes, CEO of Sara Lee; and James Copeland, former CEO of Deloitte Touche Tohmatsu. ‘Among the most effective leaders I have encountered and worked with in half a century,’ the management guru Peter Drucker has written, ‘some locked themselves in their office and others were ultra-gregarious. Some were quick and impulsive, while others studied the situation and took forever to come to a decision. The one and only personality trait the effective ones I encountered did have in common was something they did not have: They had little or no ‘charisma’ and little use either for the term or what it signifies’” [5]. Leadership is different from authority. The rapid change and uncertainty that characterizes modern surgical practice requires creative risk taking; effective leaders create an environment in which talented people feel safe to take risks. This confidence comes from knowing that the price of failure is not too great, and from being part of a group of like-minded people. Uncertainty requires creativity to resolve unknowns. Leaders must use influence beyond a position of authority because authority alone does not stimulate creativity. Many have heard the bromide that “She is a born leader” and have uncritically accepted this truism. Consider an alternative statement that “She is a born surgeon.” Almost all surgeons would reject such a notion out of hand. Surgical mastery requires a lifetime of focused work. Surgical training consumes 5–10 years after medical school. Refined physical skills require thousands of hours of intentional practice to obtain and hone; mature judgment is hard earned. According to one study, surgical results improve progressively as surgeons age, peaking in the decade between 50 and 60 years [6]. Surgical mastery surely requires intrinsic talent – physical dexterity, ability to think in three dimensions and concentration – but surgical skill is acquired not intrinsic. That is why it is called the practice of surgery. So too, leadership skills. Potential leaders need to possess relevant talents, including confidence, altruism and analytical ability. Leadership skills are built on this foundation.

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2.7 Leadership Preparation Aspiring leaders require additional preparation beyond those experiences described above to function optimally in our complex health care system. For many, enrollment in a formal leadership development program is beneficial. Aspects of leadership preparation programs are covered in detail in other chapters of this volume. The following elements are essential: 1. 2. 3. 4. 5. 6. 7. 8.

Leading change Team building Innovation Strategy Finance Marketing Operations management Health care policy.

In 2012, the Department of Surgery at the University of Michigan inaugurated the Leadership Development Program in Surgery. The program, which extended over a year, was explicitly designed to include each of the content domains listed, and was directed at Michigan’s emerging surgical leaders. The initial class included 24 mid-level faculty members in the Department of Surgery, approximately 20 % of total surgical faculty. The Leadership Development Program was led by Dr. Justin Dimick, Associate Chair for Faculty Affairs in the Department of Surgery and by Dr. Christy Lemak, Director of the Griffith Leadership Center and The National Center for Healthcare Leadership within the Michigan School of Public Health. Professor Lemak’s teaching focuses on management, leadership and strategies of health care organizations. Her research focuses on how payers and providers interact to achieve better cost and quality performance, collaborative models for improving surgical outcomes, and leadership development of clinicians and other health professionals. The Griffith Leadership Center is ranked #1 in the United States among schools of public health. Dr. Dimick serves on the leadership team for the Institute for Healthcare Policy and Innovation at the University of Michigan where he has an active research program focused on quality measurement, policy evaluation, and large-scale quality improvement interventions. The faculty for the Leadership Development Program was drawn from the Medical School, School of Public Health and the Ross School of Business at the University of Michigan. Being able to draw faculty from three top-10 schools on the same central campus was deemed essential for the success of the program. For leadership programs to be successful the participants must be selected carefully. Leadership development programs intended for medical professionals benefit by having a broad representation of specialties; such diversity is helpful by providing a range of experiences and perspectives. For surgically oriented programs, the participants should each have demonstrated personal achievement in clinical care, research and instruction and should have made an overt decision to seek

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broader engagement. Asking potential participants to write an essay outlining their aspirations is a useful way to gauge future goals. Essays were used to select participants in the Michigan Leadership Development Program. Successful leadership development programs boost group morale and create strong teams, but team building takes time. For this to happen, potential participants must fully commit to the time needed and schedules must be rearranged to assure unbroken attendance. The instructional sessions for the Leadership Development Program consisted of a series of all-day Friday blocks. The meetings were held on-campus but remote from the hospital. Prospective participants were required to commit to all sessions and to forego any other activities – clinical work, professional travel, vacation, etc. – for all sessions. Inability to make this commitment precluded participation. Administrative leaders were then contacted to rearrange schedules so that this obligation would be met. Assurances were provided that no financial penalty would apply to any leadership program participant because of absence from other scheduled activities. Leadership programs must begin with well-articulated visions and goals. The goals of the Michigan Leadership Development Program were to provide emerging leaders with the knowledge, perspectives and tools required to succeed in the contemporary medical environment. These goals were to be met through exposure to thought leaders and content experts in relevant topical fields, through team-building exercises and via self-initiated team-based projects. Leadership programs are generally benefitted by having practicing leaders provide instruction. For example, health care finance is a topic of every program. Learning how to calculate a return on investment (ROI) or the meaning of net present value (NPV) are crucial exercises. These topics were covered by professors from the Ross School of Business and the School of Public Health. However, examining a balance sheet detached from real-world context, while crucial, is admitted also a dry exercise for most clinicians. These topics came to life when the University Hospital CEO followed the didactic session by explaining the long-term sources and uses of hospital capital, and especially when the Department of Surgery chair used the department’s balance sheet as a teaching aid. Many leadership programs entail the performance of projects that seek to build coherent teams and to solve currently pressing problems. These efforts are helpful to illustrate the use of the topics covered in the curriculum, for example, financial analysis or operational optimization. In the Leadership Development Program, the participants were divided into a series of teams, most with 4 members. Selfselected projects were proposed and then vetted by the entire group. Deliverable outcomes were required. After group approval, funding and personnel resources were provided. Projects ranged from referring physician outreach to creation of new clinical programs to development of unique electronic media for postgraduate teaching. To have lasting effect, leadership development programs should seek to move beyond discrete initiatives. The best projects do not end. The most successful project leads to another area for improvement and thence another project. In fact, the best projects are not actually about results; the best are simply vehicles that create a

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TAPS-Team Action Projects in Surgery Faculty for content expertise, resources

Faculty

Resident(s)

Medical students

Resident identification of action-based quality improvement projects, Leadership development opportunities.

Undergraduate students

Research experience for student teams

Fig. 2.1 Structure of team action projects in surgery

culture of innovation and inquiry. Engagement always trumps outcomes because, while projects are transient, cultural transformation is persistent. An example of this process which was derived from the Leadership Development Program is called Team Action Projects in Surgery – TAPS. Headed by Dr. Sandra Wong, newly appointed Associate Chair for Clinical Affairs, TAPS is structured as shown in Figs. 2.1 and 2.2. The teams are led from the middle by third-year surgical residents. Faculty members are involved to lend guidance and perspective and to provide material resources. The teams always include students, including undergraduates of the University of Michigan, first and second year medical students and graduate students from non-medical disciplines. For surgical house staff, this structure provides experience in team building and engagement in areas not traditionally part of surgical training. Essential leadership skills in areas of communication and innovation are required. Students provide energy, fresh perspectives and nonmedical skills. In addition, for some students, participation has sparked interest in a medical career. Surgical faculty benefit by the inclusion of talented and motivated young people dedicated to solution of practical problems. For example, the first project examined high variability in performance times of laparoscopic cholecystectomy, one of the most common procedures in General Surgery. Formal preparation should be followed by leadership auditions. Every participant in the Leadership Development Program was provided opportunity for a larger leadership role within the Department of Surgery. In any department of surgery there are many opportunities: clerkship director, associate chair for research, division head, residency program director. The auditions were structured to give graded responsibilities and the possibility of larger leadership roles. These tests of leadership are designed to answer two fundamental questions. From the perspectives of the other members of the department: Is the developing leader good at leading?

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Identified problem: Variability in OR time for laparoscopic cholecystectomy

Students

Faculty

New Associate Chair for Clincal Affairs

Residents

General Surgery house staff

Industrial Engineering/ Operations Management students

Medical students

Fig. 2.2 Example of team composition

From the perspective of the new leader: Do I like being out front? And, is this something I want to be a permanent part of my life? Leadership development is stimulated by feedback. A powerful tool for intermittent feedback is the 360ı evaluation method. In this process, differing perspectives of the leader – from supervisors, peers, direct reports, nurses, and house staff – provide appraisal of strengths, weaknesses and areas for improvement. The responses are rendered anonymous to encourage candor. Usually, both a structured evaluation instrument and written comments are provided. All leaders need periodic feedback on their performances as leaders. The structure of the 360 method with its holistic view and anonymous evaluations helps leaders see themselves as others see them. Leadership improves with practice. What changes is the leader’s capacity to use interpersonal relationships to move and shape people and events. All participants in the Leadership Development Program were required to participate in a 360ı evaluation. A series of professional coaching sessions then followed to first interpret the results and then to suggest methods for leadership improvement.

2.8 The Leadership Dilemma As Chatman and Kennedy note, “The obvious traits such as confidence, dominance, assertiveness or intelligence, have not, it turns out, shown the level of predictive

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validity that one would hope for. Rather, we suggest three subtle but likely more powerful qualities that transcend particular individual differences and behaviors. They are a leader’s diagnostic capabilities, the breadth and flexibility of his behavioral repertoire, and his understanding of the leadership paradox” [7]. Here diagnostic acumen is meant as the ability to determine for every situation the unique contribution that the leader could make to crafting a solution to that particular circumstance. The obvious value is that every challenge is considered on its own merits and that proposed solutions are tailored. It also follows that leaders need a broad and flexible array of behaviors to respond to an equally wide array of complex situations. The effective leader is very self-aware, has a clear moral center, is fair and balanced, and is interpersonally skilled, but ultimately, is also dispensable. Effective leaders are dispensable because they create a culture of shared decision making and attract other leaders. The most powerful strategy, the hardest to create but the most durable, is creating a culture in which leaders strive to develop other leaders and provide experience which is useful for that purpose. As Chapman and Kennedy observe, “The ultimate test of leadership is how well the team does when the leader is not present” [4]. This is the leadership paradox.

2.9 New Leaders A new generation of surgical leaders is emerging. Their strong surgical leadership will assure that the discipline of Surgery remains at the forefront of contemporary medical practice. Surgical leadership that is imaginative, engaged with other specialties, and open to new ideas will draw the best lessons from the past to build a positive future. This form of leadership, at its best, will motivate departure from the routine, stimulate new learning and inspire new action. Change is everywhere. Creative change requires creative leadership.

References 1. De Vries EN, Prins HA, Crolla RMPH, et al. Effect of comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363:1928–37. 2. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med. 2009;360:491–9. 3. Porter ME, Nohria N. What is leadership? The CEO’s role in large, complex organizations. Boston, MA: Harvard Business Press; 2010. p. 433–73. 4. Patchett A. This is the story of a happy marriage. New York: HarperCollins; 2013. 5. Cain S. Quiet. New York: Broadway Books; 2012. 6. Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD. Surgeon age and operative mortality in the United States. Ann Surg. 2006;244:353–62. 7. Chatman JA, Kennedy JA. Psychological perspectives on leadership. In: Handbook of leadership theory and practice. Boston, MA: Harvard Business Press; 2010. p. 159–81.

Chapter 3

Are You Ready to Be a Leader? The Ontology of Leadership Juan Carlos Puyana and Timothy Billiar

3.1 Introduction Leadership training programs for physicians continue to expand and are now offered through many mechanisms including surgical societies, professional organizations, and continuing medical education programs within academic centers, as well as in their affiliated health systems organizations. These programs have grown in an exponential fashion across the United States and abroad. Any program with the word “leadership” in the title appears to automatically imply that the organizing authority or promoting entity sponsoring such programs possesses the actual knowledge and the secret of providing what needs to be provided in order to prepare people for leadership. What can be further from the truth? A cursory examination of the current state of affairs throughout this country and the world would indicate that it is the lack of leadership that is at the center of what underlines most crises. At the risk of sounding terribly pessimistic or even “fatalistic”, it would appear that there is a great deficiency of level I evidence-based data regarding the value of these leadership training courses and the overall state of affairs regarding effective leadership. Perhaps there are many successful leaders out there all trained under these programs and each and every one of these leaders may be exercising effective leadership within their own world. Yet in our world “the one that affects us all”, we continue to see chaos and poor leadership. Just open the newspaper today, or better yet turn on your iPad to observe this crisis. J.C. Puyana, MD () Department of Surgery, Critical Care Medicine and Translational Medicine, University of Pittsburgh, Pittsburgh, PA, USA e-mail: [email protected] T. Billiar, MD Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA © Springer International Publishing Switzerland 2015 M.R. Kibbe, H. Chen (eds.), Leadership in Surgery, Success in Academic Surgery, DOI 10.1007/978-3-319-11107-0_3

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Sadly, merely being in a leadership position or holding a position of authority does not necessarily mean that an individual in such position or with such responsibility will exercise leadership effectively. This is a common delusion that tints our daily lives and leaves us with great expectations and an equal number of frustrations emanating from our current “leaders” and their lack of effective leadership.

3.2 Leadership Vacuum As surgeons and surgeon scientists, it should come to us a surprise that there is not a lot written about leadership as a science. Warren Benis in “The Challenges of Leadership in the Modern World” states that it is almost a cliché of leadership literature that a single definition of leadership is lacking [1]. In most scientific disciplines, there are basic units of analysis and terms of reference which are generally understood within that discipline. Yet in the study of leadership, no such agreements upon conceptual foundations yet exist [2]. JC Rost wrote that for many years the emphasis given by those who “teach” leadership has been centered in only two concerns of leadership, the peripheral aspect and the content. There has been little science developed aimed at understanding the essential nature of what leadership is. He goes on to say that it is crucial that scholars and practitioners interested in leadership concentrate on the fundamental principles (i.e., the science of leadership) for there is no possibility of framing a new paradigm of leadership if we cannot articulate what it is we are studying and practicing [3]. Many of the complex challenges our world faces are not new and yet remain unresolved despite generations of effort. This vacuum requires that leaders go beyond their familiar various prescriptions for the world, and for the situations with which they are dealing, as Granger succinctly stated in Fig. 3.1 [4]. More generally, to be a leader you must be able to exercise leadership with bosses, peers, those in other organizations, any others over whom you have no authority, and the people you’re the leader of before you have earned the right with them to lead. Time has come for us to dwell deeper into the very nature of the human being from the ontological view point; specifically, that is to say the nature and function of being for human beings, and to deepen our ability to distinguish the ontology of

Fig. 3.1 Leadership vacuum: The need for leadership in any given circumstance

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leader and leadership. If such a goal could be accomplished, then being a leader, and the effective exercise of leadership, should happen as one’s natural self-expression, rather than as a learned activity in trying to emulate the characteristics or styles of noteworthy leaders, or learning what effective leaders do and trying to emulate them. For those of us who are involved in the art of training young physicians to become surgeons, perhaps it may come easy to distinguish what it is to use a skill or a trait “as your natural self-expression”. We have certainly witnessed when some of our residents begin to perform in the operating room “naturally”; admittedly, this moment may come with experience, but we all have seen junior residents who are moving their hands “naturally” faster and earlier than some of our most vetted chief residents. I believe this paragon may serve us well to advance through this chapter in an effort to share with the reader a number of distinctions that must be part of the basic core of the ontology of leadership. Leadership ontology is what we all would like to master in order to be able to communicate those valuable skills or traits that will leave them not just being surgeons but being leaders as their natural self-expression. Although being a leader and being a surgeon are two completely different things, the previous example continues to be useful. If you are not being a leader and you are simply trying to act like a leader, you are likely to fail. This is a classic example of lack of authenticity that is deadly in an attempt to exercise leadership and most certainly deadly when pretending to be a surgeon. Fortunately, such circumstances occur infrequently in our surgical training programs. However, all of us have encountered individuals who eventually had to abandon their surgical residency program or their clinical practice because being a surgeon never came naturally to them despite that they may have mastered the epistemological aspects of surgery (i.e., the knowing of surgery rather than being a surgeon). This chapter is our first attempt to introduce the ontological basis of being a leader in the setting of training surgeons; the distinctions shared here and the resemblances between teaching how to become a surgeon and allowing young individuals to discover by themselves what it takes within themselves to be leaders may not necessarily apply to all circumstances. But whenever possible, we will continue to move freely between these two parallels not with the intention of confusing the reader, but certainly with the idea of taking advantage of the fact that most of us who stand on the left side of the operating room table while we let someone younger and less experienced operate under our responsibility are in a unique position to distinguish what it means to perform as our “natural selfexpression”. The materials shared with you here are the result of participating in an innovative course on leadership that has been developed over the last 10 years, first under the auspices of the U. of Rochester Simon School of Business and later under the Air Force Academy. The technology and the course are founded on what the creators of the course term an ontological/phenomenological model of human nature. The ontological approach is uniquely effective in providing actionable access to being a leader and exercising leadership effectively. The course has been designed to leave participants being leaders and exercising leadership effectively as their natural

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self-expression, and to contribute to creating a new science of leadership. Some of the material is drawn from work published by Steve Zaffron: “Being A Leader and the Effective Exercise of Leadership: An Ontological Model” [5]. Other material summarized in this chapter is also based on program material of the Vanto Group, and from material presented in the Landmark Forum and other programs offered by Landmark Worldwide LLC [6]. The unique ideas and the methodology created by Werner Erhard underlie much of the original work [7]. An integral part of gaining access to being a leader and the effective exercise of leadership as one’s natural self-expression requires dealing with those factors present in all human beings that constrain each person’s freedom to be. When dealing with the ontology of leadership, our inability to find that freedom ends up constraining ourselves and shaping our own perceptions, emotions, creative imagination, thinking, planning, and actions. When one is not constrained or shaped by these factors, one’s way of being and acting must result naturally in one’s personal best. The “ontological constraints” must be discovered by the individual in his or her quest to become an effective leader. We will share with the reader some of the most common and basic ontological constraints so that they also begin to discover by themselves what stands in their way to effectively exercise leadership. The objective of this chapter is to introduce a new model of leadership and leadership development, and adapt the distinctions made available in this material to the current reality of residency training in surgery as a platform to present this material to those interested in promulgating leadership during the formative years of training as a surgeon. Although the ultimate objective of the full course being summarized in this chapter is to leave participants being leaders and exercising leadership as a their natural self-expression, this chapter will obviously fall short of such promise; it will simply be an introduction of the methodology and its usefulness, with the hope that we gather enough interest so that those in charge of resident education may contemplate the possibility of incorporating the material to teach the ontological aspects of leadership during the residency program. This material is significantly different from others the reader may have known or experienced. In fact, when teaching the ontological bases for leadership, we begin from the proposition that given being and action by the right context everyone has the capacity to be a leader and that in most cases there are personal obstacles (constraints) that everyone needs to discover and deal with in order to actualize that capacity for leadership. It is not about teaching leadership strategies or providing a “how to” guide, but rather it is simply allowing participants to create for themselves a context that will enable and empower them for being a leader as one’s natural self-expression. This is only possible by “being aware of”, which according to Souba is defined as a state that grants us the ability to perceive, to feel, and to be conscious of events, objects, and sensations [8]. Awareness, as he describes it, speaks to the concept of a human being as an observer who is present in the moment especially to be attentive to distinguish one’s own filters and blind spots (ontological constraints). What we would like to share with you in this chapter is highly relevant, and certainly complementary, to those issues related to management be it of an academic nature or business nature. It is also related to organizational behavior, organizational

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change, and development. All of these topics are undoubtedly related to leadership, yet what we are referring to here IS NOT any of these other disciplines. Therefore, we request that during the reading of this chapter you (the reader) avoid any attempt to make what you read “like” any of these other disciplines listed above. We would like to further emphasize this point by sharing with you a quote from Claude Bernard, the father of modern physiology and the founder of experimental medicine as a scientific method: “It is what we already know that often prevent us from learning”. While reading this chapter we request that you do not attempt to make this like anything you already know. We understand this may be a human tendency, but allowing yourself to think that this is like something you already have seen will prevent you from distinguishing what will be discussed next. In the following sections we will share with you a number of distinctions that, given under the methodology on the ontology of leadership, are designed to provide actionable access to leader and leadership. We are concerned specifically with the nature and impact of being when being a leader. As we mentioned earlier, we would like to generate enough curiosity and interest on the distinctions of the ontological bases of leadership that the reader will seek to participate in the full content of this material offered elsewhere. This material is being taken up by the academic realm, and many universities in the United States are incorporating such material in full semester courses that continue to burgeon. The complete material can also be taken in a full 8 days compressed format as well [9]. At the end, however, the ultimate objective of distinguishing the ontological basis of leadership is to get the participants to live a personal transformation; the participants are not expected to have all the experience and knowledge that is necessary to be a truly extraordinary leader. However, they should leave ready to be who they need to be to be a leader and with what it takes for them to exercise leadership effectively. There are three major components that make the ontological bases for leadership. The first one is the foundational elements of leadership and these are: 1. 2. 3. 4.

Integrity, Authenticity, Being committed to something bigger than yourself and Being aware or as other refer to being cause in the matter.

The second component is the Contextual Framework. The third component is the ontological constraints that we mentioned briefly earlier.

3.3 The Four Foundational Elements of Leadership 3.3.1 Integrity “Integrity is a matter of a person’s word-nothing more and nothing else” (Michael Jensen). Integrity refers to the condition of an object, person, or organization as being whole, complete, and perfect [10]. Integrity is an indispensable condition

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for functionality and workability. In fact, when we act with lack of integrity, our performance is diminished and the degree of energy required to maintain our own functionality is directly proportional to the lack of integrity. Integrity is what it takes for a person to be whole and complete. An individual is whole and complete when their word is whole and complete, and their word is whole and complete when they honor their word. There are only two ways of honoring our word: first, by keeping our word, and that means keeping our word on time; and second, by realizing that when you cannot keep your word you immediately inform all parties who were counting on you to keep your word and clean up any mess that you have caused in their lives by not keeping your word. When we do this, we are honoring our word despite having not kept it, and we have maintained our integrity [10]. If you fail to see that who you are as a person is your word, that is, thinking that you are anything other than your word, it leaves you unable to see that when your word is less than complete, you are diminished as a person. Being your word requires transparency about what one is giving one’s word to, to whom it is being given, and by when the promise given by the word will be attained. In the absence of this foundation, exceptional performance is not possible and definitely not sustainable, making any attempts to effective leadership completely futile. In being a leader, you must think very carefully before giving your word to anyone or anything and beware of giving your word to two or more things that may be mutually inconsistent. If you want to be up to anything important in life, you will not always be able to keep your word, and that is alright, but if you are a person of integrity you will always honor your word. At the end, honoring your word is the only actionable route to being trusted by others. The distinction of integrity is easy to follow and most of us would agree with the statements made above, yet a conversation about integrity is not complete unless we all recognize that the most important aspect of integrity involves the relationship one has with oneself. By not being solemn when we give our word to ourselves, we lose the opportunity to maintain our integrity, that is, honoring our word to ourselves. As a direct consequence of our own lack of integrity, we create unworkability in our life: people will see our inconsistencies, and we will appear unreliable and unpredictable. Unfortunately, most of us are quick to rationalize and justify the “background” mess of our own everyday life and fail to see that such mess is a direct consequence of not having integrity. A common mistake is to consider integrity as a virtue instead of an essential condition for performance. When held merely as a virtue rather than as an element of production integrity is easily sacrificed when it appears that a person must do so to succeed. Furthermore, when seen as a virtue it may then generate the admiration of others. Admiration turns out to be something more valuable than money and as such is venerated as the highest currency existing today. Let me explain why. We all want to be admired. Any situation that threatens us with a loss of admiration can easily lead us to out of integrity behavior. Integrity is a mountain with no top. It is our human condition that constantly makes us unaware that we have not kept our word. Most of the time all we see are the reasons, rationalization, or excuses for not keeping our word. In fact,

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people systematically deceive themselves about who they have been and what they have done. “Put simply, people consistently act inconsistently unaware of the contradiction between their espoused theory and their actual theory, i.e., between the way they think they are acting and the way they really act” [11]. In fact, the combination of: (1) often not seeing our own out of integrity behavior, (2) believing that we are people of integrity, and (3) soothing ourselves with the notion that next time we will restore ourselves to being a person of integrity keeps us from realizing that these perpetuating rules place us in a mountain with no top. Our best bet is to recognize this fact and keep climbing; indeed, life should be about learning to enjoy the climb rather than whining about the slope, and not forgetting that the higher you climb the steeper it gets [10]. Therefore, to empower and enable yourself as a leader, you will have to be rigorous in honoring your word – with yourself, with those you lead, and with those who lead you. Living in a constant quest for integrity can be seen as the best practice for being a leader. Lastly, integrity must be looked at as a purely positive proposition. It has nothing to do with good versus bad. It is rather, a law, like the law of gravity. There is no such a thing as good or bad gravity. Like integrity, it just “is”. More importantly, integrity is a necessary condition for maximum performance. As integrity declines, workability declines and as workability declines, value also declines. Attempting to violate the law of integrity generates painful consequences just as surely as attempting to violate the law of gravity [12].

3.3.2 Authenticity The word authentic originates from the Greek word authentes meaning “one acting on one’s own authority”. In other words, one is accountable for one’s actions and behaviors. Being authentic is being and acting consistent with who you hold yourself out to be for others and who you hold yourself to be for yourself [8]. Being authentic has a direct implication on our ability, or lack thereof, to recognize our out of integrity behaviors. Said in another way, it is our desire for approval and admiration that often drives inauthentic actions and behaviors. Souba, in writing about this subject, describes our attraction to the six As – admiration, achievement, attention, authority, appearance and affluence – as powerful lures towards inauthenticity. He goes on to say that “this inevitable ‘thrownness’ to self-concern dislodges us from the full possibility of being with others and is a major source of our inauthenticity” [8]. Being authentic is critical to being a leader. Inauthenticity is one of the barriers to being a leader and to having access to the effective exercise of leadership. The ideal scenario to empower students to be effective leaders is best realized by giving to them the opportunity to recognize their own inauthenticities. While most of us don’t like seeing them, by distinguishing these weaknesses in ourselves, we will open the doors to the pathway towards authenticity. In fact, it is easy to recognize

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that sometimes we find ourselves being limited in our ability to perform, out of fear of the loss of admiration, fear of being accused of being disloyal, or fear of looking bad. When you are appreciative of such insights and welcome them, you will benefit from them. How can we begin to overcome such fears? Is there an ontological response to these challenges? Tillich in his book “The Courage to Be” states: “courage as the universal and essential self-affirmation of one’s being is an ontological concept [13]. The courage to be is the act in which a man or a woman affirms his/her own being in spite of those elements of his/her existence which conflicts with his/her essential self-affirmation.” Yet in our world it is perhaps something even less threatening than fear that prevents us from meaningful leadership. A tendency to accept a simple role of spectator by allowing ourselves to sink into a stalling realm of passivity may be the prevailing attitude of modern society. There is a disengagement associated with submissiveness that according to John Gardner is the greatest danger looming on our world. Our comfortable way of being is thwarting us from seeking the experience of participating in meaningful decisions concerning our own life and work [14]. The emphasis on authenticity while sharing this material on the ontology of leadership refers to the simple fact that being authentic is a requirement for being a leader. The trainer is not concerned on the good or bad or the right or wrong of neither being inauthentic, nor do they offer an examination of anything normative. The ultimate goal is to help our students to discover their own path to authenticity. We all want to be admired, and almost none of us is willing to confront just how much we want to be admired, and how readily we will fudge on being straightforward and completely honest in a situation where we perceive doing so threatens us with a loss of admiration. Indeed, we spend a lot of our time on the run “doing” – achieving, impressing, acquiring, and parleying in order to measure up, be popular, and be accepted. We always appreciate and listen carefully for confirmation that what we are saying is accepted as right. In fact, “admiration is the highest coin in the realm” [4]. We will do anything to be admired and the loss of authenticity seems a small price to pay, especially when we don’t even notice that we are being inauthentic and even if we did, are unaware that being inauthentic costs us being whole and complete as a person. In addition, most of us have a pathetic need for looking good, and almost none of us are willing to confront just how much we care about looking good – even to the extent of the silliness of pretending to have followed and understood something when we haven’t. The threat of looking bad destroys the possibility of being authentic. Here is when courage becomes extremely handy; anyone who wants to be a leader needs courage to be straight when he or she is wrong.

3.3.3 Being Committed to Something Bigger Than Oneself The word commitment is derived from the Latin word committere meaning to unite, connect, and bring together. It also means a pledge or an obligation of oneself. In the act of leading, leaders begin as ordinary people yet by the time when we learn

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about their accomplishments they all appear to be extraordinary people. However, when the story is told every great leader started as an ordinary person who was given being and action by something bigger than themselves. When we assume that only extraordinary people can be leaders, we are actually ignoring or depreciating what must have taken for someone to go beyond what they were before being leaders. If we tell our students that they need to be extraordinary people to be leaders, we are automatically concealing their access to being a leader. Quoted directly from the creators of this material [4], on Being a Leader and the Effective Exercise of Leadership: An Ontological/Phenomenological Model: “If you aspire to be a great leader, your life and your career or schooling and your relationships will have to be about something bigger than you, something bigger than your concerns for yourself – even bigger than the hopes, dreams, and grand ideas of the person you ‘wound up being’. And that surely includes something bigger than your dreams about your personal fame, position, authority, or money. If that is what is giving you being and action, you can forget about being a leader. Are you a stand for something beyond yourself – something you are willing to give your life to? Without that, for you there will be no chance of greatness.” So, it is a matter of choice really; everyone has to make a choice between going in the same way that we ended up being or going beyond that so that the purpose of our lives, our careers, schooling, and our relationships is about something bigger than ourselves. Equally important, when given the opportunity to lead, one must recognize the personal concerns of those we lead and appreciate how important these concerns appear to be for them. It is ineffective to make these concerns wrong. As a leader, you will be better starting with the commitments of the people you are leading. Then, you may lead them to something greater. Most of us may spend great part of our lives seeking, for the purpose of our careers or our schooling, to be something bigger than ourselves. In doing so we may experience hopelessness or inadequacies from time to time. Unfortunately the longer this takes the more difficult it will be to free ourselves of such feelings and then it may be too late. Therefore, we must be careful, since being committed to something bigger than ourselves may be the only thing that will make us move beyond who we ended up being. We must work hard to identify what is it that we need to be committed to that will make us great. “What is your life about, and what are your career or schooling or relationships currently about – that is, what is your purpose in life, and what is the purpose of your career or schooling or relationships?” In order to answer these questions, you must be ruthlessly honest about your willingness to do the work to be bigger than the way you wound up being – leadership begins with leading yourself! Just be honest with yourself about what your life and your career or schooling and your relationships are about, and do it without any evaluations or judgments – that is, without making it wrong or right in any way. The material we are sharing with the reader in this chapter is a rather succinct version of the process necessary to provide individuals with a real opportunity to create for themselves a standing for something bigger than their own concerns. The methodology mastered by the creators of this material is designed to make these opportunities possible.

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3.3.4 Being Cause–in-the-Matter The fourth element that constitutes the foundation for being a leader and exercising leadership is referred to here as being cause-in-the-matter of everything in our life as a stand we take from ourselves and life that is acting from that stand. This distinction may not appear as clear to us at the beginning; it is perhaps the distinction that lends itself for more than one depiction. So in an attempt to briefly expand on the meaning of being cause-in-the-matter, we will divide this discussion in two separate topics. The first one has to do with the stand we take in our lives, that is, where do I see myself in relation to everything else that is not me, how do I interact with life and other people. The second aspect of being cause-in-the-matter has to do with the degree of awareness that I have, or that I may need to develop, in order to realize all that needs to be realized, discovered, and dealt with for me to be free to act and interact with life and everything else that is not me. A profound dissertation on the philosophical foundations of existentialism and the thinking of Heidegger as the father of the study of being and the ontological bases of existing are beyond the scope of this chapter [15]. A great deal of the material and the writings by those who mastered the ontological bases of leadership are available to us; however, for the purpose of this chapter we will limit ourselves to distinguish a few thoughts about the meaning of being aware of and the way we interact with all that is not us in life, so that leaders can exercise leadership [4]. There are several aspects that deal with the neuroscience principles that are at the center of the role we play in both of these aspects (i.e., our awareness and our interactions). These subjects are discussed with some detail elsewhere [16, 17]. Therefore, we will not describe them here. We will simply say that no human being is fully aware. While the brain processes millions of bits of sensory input every second, we are consciously aware of only a tiny fraction of them. The brain is constantly anticipating events that are the result of what we have in our memory and that have evolved from millions of years [18]. In fact, the brain’s mental constructs are built from deeply ingrained and internalized assumptions and generalizations that are constantly influencing how we interact in our lives and what we filter or move aside [19]. Revealing the hidden and unchallenged assumptions, beliefs, and frames of reference that compromise our worldview is critical to effective leadership. Because of the many limitations and distortions that these biases create in our way of being, we may not be able to authentically listen to others, and by doing so, we constrain the otherwise endless possibilities available to us for leading effectively. Dr. Souba writes: “Our mental models are not so much views and beliefs that we hold tightly as they are views and beliefs that tightly hold us.” [8] He goes on to say, “All leaders dwell in already made clearings, some of which have become cluttered with antiquated worldviews, cognitive maps, and other hidden cultural baggage.” Effective leadership requires that one be a cause-in-the-matter by cleaning up and freeing ourselves from these constraints in order to create the optimal conditions for unrestricted possibilities of being a leader.

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What is meant by the term cause-in-the-matter is not any of the following: fault, blame, shame, guilt, burden, obligation, credit, or praise. For many people having caused something (“you did it”) cannot be seen as anything other than fault and the like, or credit and the like. It is important to distinguish that the term cause-in-thematter used within the context of the ontological bases for leadership has no relation to assigning blame or credit, who is at fault, or who made it happen (i.e., who should be rewarded). The term cause-in-the-matter must be used as a declaration for which one is willing to stand, a declaration made on a commitment that gives us an empowering perspective from which to view some condition. In exercising leadership, who is at fault or to blame, or who gets the credit, or even who actually did it conveys no power to anyone. In fact, it is more likely to be disempowering [4]. Ultimately, the stand you have taken in the matter is a new, separate, distinct place from which to view the facts of the condition you may be confronted with. By doing so you will be able to see opportunities to be effective that you simply could not see with any other context. Conversely, when our way of being and acting prevents us from, and stands in the way of, being cause-in-the-matter then we are at the effect of any given situation. The resulting effect is that we lack power. We’re not saying that, because we lack power, that the situation is bad or that we are bad; we’re just saying that to the degree we are at effect, we lack power. Power is always an exercise of something. Power equals the size of your intentions divided by the time it takes for your intentions to get realized. When I do not honor my word, I diminish power. The less authenticity I have the less power I have. When I am committed to myself I have little power. When I am at the effect I have no power. When you have as your foundation being a person of integrity, being authentic, being committed to something bigger than yourself, and being-cause-inthe-matter, you have given yourself a foundation that is truly powerful. Reich in 1928 wrote about power: “Anything that comes out of you and goes out into the world is power and in addition to that, the ability to be open, to appreciate, to receive love, to respond to others, to listen to music, to understand literature, all of that is power. When you “lead” someone against their will, that is not power at all, that is force, and force is the negation of power.” [17]

3.4 The Contextual Framework We have so far reviewed the four foundational elements required for effective leadership. In the next section we will briefly summarize what the writers on the ontology of leadership refer to as the contextual framework. Before describing how the contextual framework is built, we need to remember the original methodology of the ontological bases of leadership and the specific approach to leadership based in what we called transformational learning. This methodology is used to provide individuals with an opportunity to examine and

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eliminate the grip of their everyday common-sense worldview and their existing frames of reference (received ideas, beliefs, and unexamined assumptions) relative to leader and leadership. Then, the methodology provides individuals with an opportunity to create for themselves a context for leader and leadership that shapes and colors any leadership situation they deal with, such that their natural selfexpression (their naturally correlated way of being and acting) in dealing with that situation is one of being a leader and exercising leadership effectively. How do you create a context? It will not be possible for us to enter into a comprehensive discussion about this methodology here. Perhaps a simple example quoted directly from the material on the ontology of leadership will help the reader to see how a context can be empowering and change everything by the way we react to a specific situation at any given moment and time.

3.5 The Power of a Context and Its Impact on Way of Being and Acting An example of the power of a context: playing the violin in a subway. “Dressed in jeans and a baseball cap, a 39 year-old ‘fiddler’ stood against a wall next to a trash can at the L’Enfant Plaza metro station in Washington D.C. He looked like any other street musician trying to make a buck. During the 43 minutes that he played his violin, researchers watched 1,097 people pass by during the morning rush hour. It took 3 minutes before someone even gazed in his direction, and even longer before any money was thrown into his violin case. Most people did not notice the musician. Some were talking on cell phones, others listened to iPods. Masterful pieces such as Bach’s “Chaconne”, Franz Schubert’s “Ave Maria”, and Manuel Ponce’s “Estrellita”, were passed off as nothing more than “generic classical music” (Weingarten, 2007). That day, the fiddler made $32.17, or 75 cents a minute. When situated within an upscale concert hall dressed in black, the same 39 yearold ‘fiddler’, Joshua Bell, on the same $3.5 million Stradivari violin, commands up to $1,000 a minute playing the exact same masterpieces. This elite musician is said to be “one of the finest classical musicians in the world, playing some of the most elegant music ever written on one of the most valuable violins ever made” (Weingarten, 2007).” [20] Within the context of a subway street musician, a measly seven people were moved to stop and listen before walking by. Within the context of a famous concert hall musician, thousands of listeners invest significant money to hear and be moved by Bell’s music. The context uses you in that it shapes your way of being, which includes your perceptions, imagination, emotions, and thinking, and as a consequence the context shapes your actions. One of the most interesting aspects about the ontological bases of leadership is the ability to connect how our brain works (based on the current knowledge derived from neuroscientists and their experiments depicted within the material) and how

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we respond to different situations in our daily lives and in dealing with others that would require from us being effective leaders. Recent findings in the area of neuroscience have established that neural patterns of perception (phenomenologically speaking, the way something occurs to a person) and the neural patterns that give rise to a person’s way of being and acting are virtually always, as neuroscientists term it, “networked” together in the brain. This means that the neural patterns that give rise to a person’s way of being are networked together with neural patterns of perception (including stored neural perception patterns – memory); and likewise the neural patterns that give rise to action are also networked with those neural patterns of perception. This is what Libet [21], in his book Neurophysiology of Consciousness, summarize as follows – “ : : : the brain ‘decides’ to initiate or, at least, to prepare to initiate the acts before there is any reportable subjective awareness that such a decision has taken place.” Both, Clancey [22] in 1993 and later Hawkins and Blakeslee [23] in 2004 arrived at the same conclusion: “Perceiving, thinking, and moving always occur together as coherent coordination of activity,” in other words, as if “perception and behavior are almost one in the same.” For the purposes of bringing this point across and in order to make practical sense of it, let’s assume for a moment that a “leadership situation” could be defined simply as: a situation in which the current circumstances, and the possible futures (outcomes) that can be realized in the prevailing context for those circumstances, are unacceptable or non-optimal. As we said before, a person’s way of being and acting in any leadership situation is correlated with the way in which the situation they are dealing with occurs for them. Therefore, for a person to be a leader and to exercise leadership effectively, the situation they are dealing with must occur for them such that their naturally correlated way of being and acting is that of actually being a leader and exercising leadership effectively. Given that in any leadership situation a person’s way of being and acting is a correlation of the way the situation occurs for them, the way in which the situation occurs for them is the actionable access to the being of being a leader and the actions of the effective exercise of leadership as their natural selfexpression. And put simply, the actionable access to the way in which a leadership situation occurs for a person is the context that person brings to or creates for leadership situations. It is plausible that if we were to dedicate some time during the formative years of the residency program (and beyond) to specifically use these ontological methods so that young individuals training to be surgeons could at the same time experience a shift of what it really means to be a leader, then a different context about leadership could be created. A context in which the individual is committed to something bigger than his or her own agenda, a context that “uses” the individual and allows for a new will to challenge deeply held assumptions or a habitual way of being, then the possibility for a meaningful transformation becomes real. As Souba writes, “Ontologically, this leadership approach entails an inward journey of self-discovery and reinvention. In the cognitive, affective, and behavioral

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neuroscience realm, it is about letting go of our obsolete or predetermined mental maps that hold us back from exercising more effective leadership. Electrophysiologically, this new learning involves re-wiring of neural circuits. Functionally, this leadership journey enhances our workability, performance, and joy in life” [8]. Anyone interested in being a leader as his or her natural self-expression, must practice every day in order to rewire those circuits that Souba is referring to in the previous paragraph. The prevailing tendency in our brain is to go for the default set of solutions (or contexts); after all that has worked out well for human beings from an evolutionary view point. A leader must be aware of the challenges ahead so that the context to be created is not just another default context. Leaders fail when the future they are trying to create becomes just an enhanced, augmented or improved version of the SAME future. If one can see possibilities for resolving a situation in the prevailing context, there is no need for leadership. All that this requires is competent management. While people may consciously have hopes and dreams, and worries and doubts, and goals and strivings regarding the future, the brain, below the level of consciousness, only has patterns from the past from which to predict the future. The brain shapes a person’s way of being and action in the present to be consistent with realizing the brain’s predicted future. As we have already described, neuroscience studies confirm that brain activity selects an action even before the person experiences consciously choosing that action [21, 23]. This explains in part, why life for most people is “business as usual”. They may do more of what they have done, but that is just more of the past. Or, they may do what they have done in the past, but better. However, “better than the past” is still more of the past; “better than the past” is only a reshaping of what they have done in the past. In fact, neuroscientists consider that the evolutionary survival value of the brain’s storing memories of the past is purely their value in predicting the future. The brain initiates those ways of being and acting in the present that are most likely to ensure success, which for the brain is the realization of that past-derived predicted future. This is the way our brains evolved to best ensure survival. Consistent with this, MRI studies show that virtually the same regions of the brain are active both when we think about the past and when we think about the future [24]. It is intuitive to state that if all of our behaviors are evolutionarily conserved then this concept should apply not only for all of our behavioral traits but also for the traits that go along with making a good leader. Without excellent leaders our species would not have survived and evolved. You may think then that our hope for change, specifically in our ability to create or educate other people about a new context for leadership, may be dismal. The facts indicate that the prevailing context is the future people are living into, and the future that people are living into is by default derived from and shaped by the past. Remember, the context is decisive. That means that, in the default context, people’s being and action in the present will result in more of the same. It may be more, better, different, or a change, but it will still be some variation of the past.

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3.6 How Can We Break This Cycle? In order to break this cycle, that is to create an intervention that is capable of bringing about a discontinuous future, a future that is not a continuation of the past, we have only one option: language. It is through language that we can bring forth something that revises one’s worldview, frame of reference, or context. In fact, language is our path into what is revealed about the nature and function of human beings from the perspective of being. When you see someone being a leader or exercising leadership, or when you have experienced being led, you see someone functioning in the sphere of language. And, more pointedly when you are being a leader and exercising leadership you will be functioning in the sphere of language. Creating a Created Future is a linguistic act, a speech act. To create and realize futures that were not going to happen, we need to be able to successfully utilize speech beyond a simple representation of the world. Language gives us the freedom to provide us with an infinite set of possibilities for leadership. There may be surprising examples that may help us distinguish when being a leader exists as a leader in a realm of possibilities: There are instances in which you can only be effective as a leader by being a follower. There are instances in which you can only be effective as a leader by being a bystander, and there are frequent instances in which you can only be effective as a leader by saying and doing nothing, just listening in a certain way. That certain way of listening means to listen authentically; it is critical to be aware of our listening as W Erhard states, “ : : : to exercise leadership effectively, one must be masterful in empowering others to see for themselves actual errors in their thinking, and masterful in enhancing their valid thinking : : : ”. Kantor reflects on the leaders effective communication description of the 4-factor model of conversation/interaction: 1. 2. 3. 4.

Mover: initiates objectives and actions Opposer: challenges the proposed objectives and actions Follower: supports the suggested objectives and actions Bystander: reflects on the conversations, suggests objectives and actions

Counter-intuitively, in actual practice you will see that there are times as a leader when you can only get something done by being a bystander or a follower. If there are any ways of being and acting that are excluded from your opportunity set of being and acting, you will be handicapped as a leader [25]. Another path to master the distinction of leadership as a realm of possibility is by exercising leadership as questions that we are determined to dwell on rather than answers that we already have. This may not be that easy; after all, we all have a bunch of ideas and preconceived notions and taken for granted assumptions about what leadership must be. Getting “unstuck” from these theories or models of leadership is a way accessing a clearing of virtually unlimited possibilities for leadership.

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As linguistic abstractions, leader and leadership create leader and leadership as realms of possibility in which when we are being leaders, all possible ways of being are available to us, and when we are exercising leadership, all possible actions are available to us. The point is: mastering leader and leadership as realms of possibility leaves us free to be and free to act, rather than being constrained by notions about what it is to be a leader and what it is to exercise leadership effectively. When one’s focus is on fulfilling a commitment rather than acting in a particular style, all ways of being and acting are available. The idea that reality is constituted in language is core to an ontological approach to leadership. Language allows us to reframe what we observe. By changing the way we think and speak, we create new possibilities and thus a new reality becomes available to us. Shifts in our mental maps generate new possibilities for desired actions and outcomes not previously accessible. If we were building a leader in a similar way as we would build a house, then once the foundation is completed, the contextual framework could be distinguished by the four walls that will be resting on this foundation. By completing the contextual frame work we will end up having almost an entire structure. The four “walls” that formed the contextual framework are: 1. 2. 3. 4.

Leadership as a linguistic abstraction, Leadership as phenomena, Leadership as a concept Leadership as a term. Directly quoted from the ontology of leadership original material [4]: As linguistic abstractions, leader and leadership create leader and leadership as realms of possibility in which when you are being a leader all possible ways of being are available to you, and when you are exercising leadership all possible actions are available to you. As phenomena, leader and leadership exist in the sphere of language, whether that be literally speaking, or speaking in the form of writing, or speaking and listening to yourself, that is, thinking, or the speaking of your actions, as in “actions speak louder than words”, or in providing a certain kind of listening. As concepts, leader and leadership exist in the temporal domain of a created future, a future that fulfills the concerns of the relevant parties, that the leader and those being led come to live into, which future gives them being and action in the present consistent with realizing that future. As a term, being a leader is defined as, committed to realizing a future that wasn’t going to happen that fulfills the concerns of the relevant parties, and with the availability of an unlimited opportunity set for being and action, being the kind of clearing for leader and leadership that shapes the way the circumstances you are dealing with occur for you such that your naturally correlated way of being and acting is one of being a leader and exercising leadership effectively.

The fundamental building block or basic brick for these walls to be erected lies within our language – the words (or actions) – with which we communicate. It is through language, that we can create all possibilities with the words that are available to us. A single brick may not represent any form in your brain beyond what a brick looks like, yet the right combination of bricks open infinite possibilities for us to build whatever we can possibly build.

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3.7 The Third Component Is the Ontological Constraints There are many constraints that constantly stand between us and our ability to best and naturally exercise effective leadership. These constraints relate directly to how we see the world that surrounds us and how things occur to us. It is not about the state of our minds, which is what we refer to under the psychological method. When distinguishing the ontological bases for leadership, it is fundamentally important to be able to establish the differences between the psychological method and the ontological method. Although both methods are available to us in order to deal with all that may interfere with a person’s effectiveness in life, the psychological methods deal with those “interferences” as problems of the mind (mental and emotional disorders). The psychological method therefore uses language with the ultimate goal of having an impact on the mind. Quite differently, when the ontological method is used, it should give us access through language so that we discover by ourselves the distortions in the meaningfulness or clarity of the way the world, others, and oneself occur for one. The strongest constraint that may interfere with our ability to interact with others as effective leaders is a perceptual constraint referred to as “already-alwayslistening”. This is the typical constraint that is already there in our listening before we hear anything. This constraint is powerful in the sense that it can distort not just what we listen to but also constrains and shapes what we get out of what we read or what we study. See Fig. 3.2.

Fig. 3.2 Already always listening to the most common perceptual constraint: this constraint is powerful in the sense that distorts not only what we listen to, but also constrains and shapes what we get out of our daily interactions with others

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As we said earlier, integrity is a mountain without a top and we are always striving to maintain it by continuously climbing such a mountain. The same occurs when dealing with our own constraints. We must also practice every day so that we are aware of the prevailing attitudes that allow our own already-always-listening behaviors. If we are unable to distinguish what those constraints are in our lives, then all that remains undistinguished ends up running our lives. (It literally functions without our awareness – it functions without our permission). Our functional constraints (set ways of being and acting) often seem justified and even rational at times, and are therefore difficult for us to recognize as a limitation on our opportunity set for being and action; while such limitations on our behavior are difficult for us to recognize, it is often apparent to those around us, both those we lead and those we follow.

3.8 Conclusion Let us finish by sharing with you a piece of one of the most beautiful writings about the new context that leadership needs to be. It comes from a “story” told by Dr. Souba entitled “The dream: A leadership fable” [26]. In it, the author compares our humanity with a worldwide corporation that has lost its compass and like our current world appears to be spinning out of control. A world where the context of leadership is so obtuse that members of the humanity corporation truly believe that leadership must be the sole possession of one person rather than something people create by working together. A world where petty self-interested people feel that they are more important that the other members of humanity. A world where the designated leaders are merely people in charge with the authority to call the shots and if necessary “kick butt.” Souba finishes by adding that the “humanity corporation” is at a critical juncture and that only through a new context in leadership, will every member of humanity be called to make life better. These are choices we all must make to build the kind of future that humanity and life were designed to have.

References 1. Bennis WG, Thomas RJ. Crucibles of leadership. Harv Bus Rev. 2002;80(9):39–45. 2. Heifetz R, Riley S. Managing the public’s problem solving, chapter 8. In: Robert R, editor. The power of public ideas. Cambridge: Ballinger; 1988. 3. Rost JC. Leadership for the twenty-first century. Westport: Praeger; 1993. 4. Erhard W, Jensen MC, Granger K. Introduction to being a leader and the effective exercise of leadership: an ontological model – the textbook. Harvard Business School Negotiation, Organizations and Markets Research Papers. Apr 2009. 5. Zaffron S, Logan D. The three laws of performance. San Francisco: Jossey-Bass; 2009.

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6. Vanto Group, Inc. (2008). Brochure. http://www.vantogroup.com/file_redirect.jsp? siteObjectID=103953&fname=Vantogroup_Brochure.pdf. 7. Erhard W, Jensen MC, Granger KL. Creating leaders: an ontological model (October 28, 2010). Forthcoming in: Snook S Nohria N, Khurana R, editors. The handbook for teaching leadership. Sage Publications; 2011. http://ssrn.com/abstrdsact=1681682. Harvard Business School NOM Unit Working Paper 11-037; Barbados Group Working Paper No. 10-10; Simon School Working Paper Series No. FR-10-30. 8. Souba WW. The being of leadership. Philos Ethics Humanit Med. 2011;6:5. 9. Being a leader and the effective exercise of leadership: an ontological model, 2014. www. beingaleader.net. 10. Jensen MC. Integrity: without it nothing works. Interview: by Karen Christensen, from Rotman: The Magazine of the Rotman School of Management, 2009, p. 16–20. Revised Apr 2014. 11. Argyris C. Teaching smart people how to learn. Harv Bus Rev. 1991;69(3):99–109. 12. Erhard W, Jensen MC, Zaffron S. Integrity: a positive model that incorporates the normative phenomena of morality, ethics and legality. 2008. http://ssrn.com/abstract=920625. 13. Tillich P. The courage to be. New Haven: Yale University Press; 1952. 14. Gardner J. Self-renewal. New York: WW Norton and Company; 1981. 15. Heidegger M. What is metaphysics? Chicago: Existence and Being Henry Regnery Co; 1949. 16. Dijksterhuis A, Bargh J. The perception-behavior expressway: automatic effects of social perception on social behavior. In: Zanna M, editor. Advances in experimental social psychology, vol. 33. New York: Academic; 2001. 17. Reich CA. The greening of America (25th anniversary edition). New York: Three Rivers Press; 1995. ISBN 0-517-88636-7. 18. Soon S, Chun MB, Heinze H-J, Haynes J-D. Unconscious determinants of free decisions in the human brain. Nat Neurosci. 2008;11:543–5. 19. Waldholz M. Mapping the mind – panic pathway: study of fear shows emotion can alter ‘wiring’ of the brain. Wall Street J, 29 Sept 1993, p. A1. 20. Weingarten G. Pearls before breakfast. Washington Post. 2007. Retrieved 25 June 2009, from http://www.washingtonpost.com/wp-dyn/content/article/2007/04/04/AR2007040401721. html. 21. Libet B. Mind time: the temporal factor in consciousness (perspectives in cognitive neuroscience). President and Fellows of Harvard College. 2004. 22. Clancey WJ. Situated action: a neurophysiological response to Vera and Simon. Cognit Sci. 1993;17:87–116. 23. Hawkins J, Blakeslee S. On intelligence. New York: Henry Holt; 2004. 24. Szpunar KK, Watson JM, McDermott KB. Neural substrates of envisioning the future. Proc Natl Acad Sci. 2007;104(2):642–7. 25. Kantor D, Lehr W. Inside the family. 1st ed. San Francisco: Jossey-Bass; 1975. 26. Souba WW. The dream: a leadership fable. J Surg Res. 2013;179(1):e53–6.

Chapter 4

Leadership Theories and Styles Melina R. Kibbe

4.1 Introduction In order to become an effective leader, one must understand the core leadership theories and the styles that emerged from them, how they evolved, and how to implement different styles of leadership depending on the environment, situation, or need of the leader. Physicians, and more specifically surgeons, are natural leaders as they are used to quick decision-making and tend to be authoritative. However, due to the nature of the work of a surgeon, this can also breed leaders with autocratic leadership styles, a style not conducive to the success of a current day surgical department. Over time, as generational changes have occurred, the traditional autocratic leadership style, so natural of surgeons from the Silent Generation, no longer resonates well with today’s Generation X and Generation Y surgery faculty and trainees. In addition to understanding the needs of the organization, it is important to understand the needs of the personnel being lead. Below, the core leadership theories are discussed, followed by a description of some of the common leadership styles. Lastly, a discussion of leadership in surgery with respect to these different leadership styles is presented.

4.2 Leadership Theories Trait Theories Trait theories argue that effective leaders share common personality traits or characteristics. These include traits and qualities such as integrity, honesty, assertiveness, decisiveness, motivation, innovation, vision, intelligence, M.R. Kibbe, MD, FACS, FAHA () Department of Surgery, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair, Suite 650, Chicago, IL 60611, USA e-mail: [email protected] © Springer International Publishing Switzerland 2015 M.R. Kibbe, H. Chen (eds.), Leadership in Surgery, Success in Academic Surgery, DOI 10.1007/978-3-319-11107-0_4

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persuasiveness, etc. Early trait theories posed that leadership traits are innate and that one is born to be a leader. Trait theories have now evolved and pose that one can learn leadership traits, and that positive leadership traits can be developed through training and education. Many studies on leadership traits have been conducted in an attempt to identify traits of successful leaders. The Forbes top 10 qualities that make a great leader include: honesty, creativity, intuition, confidence, commitment, ability to inspire, delegate, and communicate, a sense of humor, and positive attitude [1]. While many of the above traits are associated with great leaders, it should be noted that the converse does not necessarily hold true, i.e. that having these traits or a combination of these traits guarantees that one will be a successful leader. Chapter 5 in this textbook explores leadership trait theories in-depth as well as some of the common traits of successful leaders. Behavioral Theories Behavioral theories focus on how a leader behaves. In the early 1930s, Kurt Lewin presented a framework based on the behaviors of leaders [2]. He described three types of leadership behaviors: (1) autocratic; (2) democratic; and (3) laissez-faire. Autocratic leaders are described as making decisions without consulting their teams. This type of leadership is appropriate when quick decisions need to be made, when there is no need for agreement, or when agreement from the team is not necessary in order for a successful outcome to be achieved. Democratic leaders take into consideration input from the team before making a decision. The degree of input considered will vary from leader to leader. This type of leadership is appropriate when team agreement is important for the final outcome. However, this style of leadership can be difficult to manage when a wide variety of opinions, perspectives, and ideas exist among the team members. Laissezfaire leaders typically do not interfere with the decision-making process. These leaders allow the individuals in the team to make most of the decisions. This type of leadership is appropriate when the teams consist of highly competent, skilled, motivated and capable individuals that require little supervision. This leadership style can fail when it is born out of laziness on the part of the leader. Since the description of these three leadership styles, many more styles have emerged. A description of the most common leadership styles follows below. Contingency or Situational Theories Contingency or situational leadership theories pose that no one leadership style is the correct style. Instead, the best leadership style is the one dictated by the situation or circumstance (i.e., situational leadership). For example, if a quick decision is required, the autocratic leadership style might be best. If the full support of all team members is required, the democratic leadership style might be best. Contingent leadership theories also pose that the best leadership style depends on characteristics of the team members. For instance, the HerseyBlanchard Situational Leadership Theory proposes that successful leaders should change their leadership styles based on the maturity of the people on the team and the details of the task [3]. Hersey and Blanchard describe four leadership styles for this theory (i.e., telling, selling, participating, and delegating) and four maturity levels. The use of each style is dictated by the maturity level of the team members.

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If the team members have a low maturity, the telling style works best. If the team members have high maturity, the delegating style works best. The Dunham and Pierce Leadership Process Model describes how four factors contribute to leadership success or failure [4]. These factors are: the leader, the followers, the context, and the outcome. All four variables are related to each other and affect each other. This model highlights that leadership is dynamic and that it is important to be flexible based on the context, the outcome, and the team. Power and Influence Theories Power and influence theories are based on the different ways in which leaders use their power and influence to get things done. These theories then examine the leadership styles that emerge as a result. For example, people tend to follow others who are powerful. When others follow that person, the person with power leads. But, there are different reasons why people have power. One of the best-known theories that describes this type of leadership is French and Raven’s Five Forms of Power [5]. John French and Bertram Raven described five forms of power: legitimate, reward, expert, referent, and coercive. Legitimate power comes from the belief that that person has the right to make demands and expect compliance, such as a CEO or president. Reward power is when someone has the power to compensate others for their actions (i.e., salary increase, bonus, etc.). Expert power comes from a person’s own superior skill or knowledge (i.e., recognized expertise). Referent power results from a person’s perceived worthiness, charm, charisma, or appeal, such as celebrities. Coercive power results when someone has the ability to punish others. When a person recognizes their source of power they are better able to lead for the best outcome. The positional power sources (i.e., legitimate, reward, and coercive) tend to be the least effective as they can easily fail, while the personal power sources (i.e., expert and referent) tend to be the most effective. Emotional Intelligence Emotional intelligence is having the ability to understand and manage your emotions as well as those of the people around you (direct reports, peers, and supervisors). Leaders with emotional intelligence tend to be calm, don’t lose their temper, and don’t get out of control, no matter what the situation or crisis is about. Leaders with emotional intelligence are able to recognize what they are feeling, what these emotions mean, how these emotions can impact others, and are able to modulate their leadership style based on this information. Having emotional intelligence is essential for a leader. First popularized by Daniel Goleman, five elements of emotional intelligence have been described: (1) self-awareness; (2) selfregulation; (3) motivation; (4) empathy; and (5) social skills [6]. The more a leader is able to understand how their emotions and actions impact others and is able to manage each of these five elements, the higher the emotional intelligence. The higher the emotional intelligence, the more successful he or she will be as a leader, as they will be able to relate to and work with others better. To learn more about emotional intelligence and these five elements, the reader is directed to Chap. 6 on emotional intelligence written by Drs. Harry Sax and Bruce Gewertz.

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4.3 Leadership Styles Many different leadership styles have been born from the core leadership theories described above. A brief description of some of the more common leadership styles is provided. Autocratic Leadership As described above, autocratic leadership is when the leader makes decisions without consulting their team. Autocratic leaders tend to have a lot of power over the people they lead. A benefit of this type of leadership is that it is very efficient. Thus, it is appropriate leadership when quick decisions need to be made, when there is no need for agreement, or when agreement from the team is not necessary in order for a successful outcome to be achieved. This type of leadership works well in situations of crisis where quick decisions must be made and followed. It works well for the military as it allows the troops to focus their attention and energy on performing the task at hand. It also works well for jobs that require routine tasks or involve unskilled labor. A disadvantage to this type of leadership is that most people resent being treated this way. It can result in high levels of job dissatisfaction and turnover. Autocratic leadership is an extreme form of transactional leadership, which is discussed below. Democratic or Participative Leadership Democratic leaders include the team members in the decision-making process but make the final decisions themselves. Democratic leaders encourage creativity, participation, and input from the team members. As a result, team members feel a greater sense of purpose toward the common mission and tend to be very engaged in the project, work and/or decision, and hence productive. Benefits of democratic leadership are many and include high job satisfaction among the team members and greater motivation of the workers since they feel a sense of inclusion and empowerment with the decision-making process. This type of leadership also tends to result in greater development of the skills of the team members, supporting even more engagement. This leadership style is most suitable for situations in which working as a team is necessary, and when quality is more important than productivity or efficiency. However, a distinct disadvantage of this type of leadership is that it takes time, especially compared to autocratic leadership. Thus, it can hinder speed and efficiency and would not be good during times of crisis. Lastly, this type of leadership only works well when the team members have the knowledge and/or expertise to contribute meaningfully to the decision-making process. Bureaucratic Leadership Bureaucratic leaders are rule followers and work “by the book”. They ensure that everyone follows the rules and procedures rigorously and precisely. Advantages of this leadership style are precision, efficiency, and predictable output. This style of leadership functions well for tasks that require a high degree of accuracy and safety, such as operating heavy machinery, working with caustic or explosive chemicals, or at extreme heights. It works well for jobs that handle large amounts of currency, such as cashiers, currency exchange personnel, and bankers. It is also ideal for activities that are very routine, such

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as manufacturing. Disadvantages of this leadership style are that creativity and innovation are stifled because of the rigid, inflexible framework. It can also create resentment among the team members if the leader obtains the position because of conformity and rule following and not because of qualifications or recognized expertise. Charismatic Leadership Charismatic leaders lead by inspiring enthusiasm in their team members. They are energetic leaders, motivating others to excel. The ability to create excitement and commitment among the team members has great benefit. In a way, this type of leadership can resemble transformational leadership which is discussed below. However, the main distinction between charismatic leadership and transformational leadership lies with the intent of the leader. Transformational leaders want to inspire change in their team members or organization. Charismatic leaders are often focused on themselves and do not necessarily want to lead change. An obvious disadvantage with this leadership style lies with the leader, as they are more interested in themselves than their team members or organization. Charismatic leaders also have a sense that they can do no wrong, even when others may point out to them the error of their ways. Due to their heightened sense of self-worth, charismatic leaders are often viewed as successful by their team members. Thus, from an organizational point of view, if a charismatic leader departs there is a great risk that the project, team, or organization will collapse given the inherent focus on the leader and not the team or organization. Laissez-Faire Leadership As discussed above, laissez-faire leaders, also known as passive-avoidant leaders, typically do not interfere with the decision-making process. These leaders allow the individuals in the team to make most of the decisions. These leaders typically allow the team members complete freedom to do their work when and how they like, and to set their deadlines. This type of leadership works best when the teams consist of highly competent, skilled, motivated, and capable individuals who require very little supervision. This leadership style also works well when the leaders monitor performance and provide regular feedback. One of the main advantages of this leadership style is that team members tend to have very high job satisfaction and productivity given the autonomy they are permitted. A disadvantage of this type of leadership style is when it emerges out of laziness on the part of the leader. In addition, this type of leadership style fails if the team members are not internally motivated, or don’t have the skill or knowledge to do their jobs. People-Oriented or Relations-Oriented Leadership People- or relationsoriented leaders are completely focused on developing, organizing, and supporting the people on the team. This leadership style requires participation and teamwork, and tends to support creativity and collaborations. People-oriented leaders tend to treat everyone on the team equally. They are usually very approachable and friendly leaders, and pay close attention to the welfare of all the team members. These leaders are also readily available in times of need by any team member. An advantage of this style of leadership is that people like to be on teams with

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people-oriented leaders. Team members led in this way tend to be productive and are more willing to take risks because they know the leader will support them if they need it. This leadership style tends to be the opposite of task-oriented leadership which is discussed below. A disadvantage of this leadership style is when the leader goes too far and prioritizes the development of the team above the task, project, or organization. Task-Oriented Leadership Task-oriented leaders focus on getting the task or job done. These leaders share some traits with autocratic and bureaucratic leaders. Task-oriented leaders define the work to be done, the roles required of the team members, put structure in place to complete the task, plan and organize how the work will get done, and monitor the output. These leaders are excellent at creating and maintaining performance standards. An advantage of this style of leadership is that the task will be completed in a timely manner. This style is also helpful for team members who need lots of direction and do not manage their time well. Disadvantages of this leadership style are low job satisfaction and morale which can lead to high turnover with low retention rates among team members. Servant Leadership A servant leader is someone who leads by simply meeting the needs of the team at large. They often don’t recognize themselves as the leader and serve in this capacity more out of duty and by leading through example. Servant leaders tend to stay away from the limelight and glory of leading. They prefer to get the work done and have the team receive the recognition, not themselves as leaders. Given these characteristics, these leaders tend to have very high integrity and generosity. Servant leadership is a form of democratic leadership since the entire team is involved in the decision-making process. This type of leadership is useful for tasks or projects that place emphasis on values. In fact, servant leaders tend to move up the ladder based on their values. Under the power and influence theory, this would be most similar to expert power, as servant leaders gain power because of their values, ideals, and ethics in addition to knowledge, skills and expertise. Servant leadership also tends to create a positive team and corporate attitude with high morale. A disadvantage of servant leadership is the time required to master this type of leadership, and the time required to complete tasks and projects. Similar to democratic leadership, it can take a lot of time for the team members to make decisions. Thus, this leadership style is less conducive for situations that require quick decisions or have tight deadlines. Another disadvantage of this leadership style relates to competitive leadership positions. Servant leaders tend to trail behind leaders using other styles in competitive situations. Transactional Leadership Transactional leadership implies that a worker or team member is paid or compensated in some manner for their work product or services (i.e., a transaction). If the work is not done, the leader has the right to be punitive. Thus, team members are motivated by reward and punishment, and transactional leadership can be described as having two components: (1) contingent reward and (2) management by exception. This style of leadership is similar to having coercive power as the source of power described from the power and influence theories. An

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advantage of this type of leadership is that everyone’s roles and responsibilities are clearly delineated. In addition, people who are ambitious tend to excel with this type of leadership since performance by individual team members is evaluated and considered and not that of the team. A disadvantage of this leadership style is the potential for low job satisfaction. Team members can do little to change their job situation which can lead to high employee turnover. This type of leadership is typical of managerial positions. It is not conducive to situations that require creativity and innovation. Some would argue that this is not a leadership style at all, as the focus is on completion of task. However, others argue that this leadership style is similar to task-oriented leadership. Transformational Leadership Transformational leaders inspire workers and team members with a shared vision of the future. It is a vision that is usually ambitious yet rich, exciting, and attainable. Transformational leaders set clear goals, inspire people to work toward those goals, and manage delivery of the vision. These leaders also coach and develop the team members by recognizing the potential of their team members and engaging them intellectually to achieve their full potential. They provide regular feedback and serve as good mentors. Transformational leaders also tend to have very high integrity and outstanding communication skills. Given all of these attributes, transformational leadership has been described as having four components: (1) idealized influence; (2) inspirational motivation; (3) intellectual stimulation; and (4) individualized consideration. Currently, this is one of the most successful types of leadership in the business world. An advantage of this type of leadership is that because these leaders tend to expect the very best of the team members, team members are highly satisfied, productive, and engaged. Thus, job turnover is lower compared to other types of leadership. A disadvantage of this type of leadership is inherently linked to the enthusiasm of the leader – they tend to need support from the detail people. This is why one often observes transformational leaders being supported by transactional leaders (i.e., the managers), with the latter being the individuals who will get the work done. Adaptive Leadership Adaptive leaders employ several of the leadership styles described above. The role of an adaptive leader is to guide the team members through problem solving, rather than solving the problem themselves. Adaptive leaders engage the team members, empower and motivate them to solve the adaptive problem on their own. This process requires thoughtful direction on the part of the leader. An advantage of this style of leadership is that change is more likely to be sustainable than if it were decreed from an autocratic leadership style. The latter type of change is usually transient. This type of leadership style is good for organizations in need of culture change. A disadvantage of this style of leadership is that it can take time for the team members to solve the problem. This leadership style also requires that the team members have some knowledge, skill, and expertise with the problem being addressed. This strategy can be helpful in the health care industry when physicians are leading physicians and the desire is a sustainable culture change.

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4.4 Leadership in Surgery No one leadership style is right for everyone. Surgeons by nature, and due to our training paradigm, tend to exhibit autocratic, task-oriented, and transactional leadership styles. However, there are times when democratic, bureaucratic, servant, and definitely transformational leadership is required. Due to this, some would argue that situational leadership is the best theory, as it takes into account the needs of the team members, the organization, and tasks in determining the best leadership style that fits those needs. For example, in the operating room, a democratic team approach is needed between the anesthetists, nursing staff, and surgeons. However, in times of crisis, an autocratic style clearly works best. Similarly, in the clinics, a collaborative democratic approach is required between the scheduling clerks, nurses, and physicians. But, when it comes to managing a specific ailment, disease, or complications, the physician will need to take charge and be decisive. For a Chair of a Department of Surgery, depending on the needs of the institution and the need for change management, a transformational leadership style may work best. When consensus is needed, a democratic approach is helpful. Yet, surgeons also still require some form of transactional leadership in the sense of reward and punishment. The later especially applies to matters of compensation. Many studies have been conducted examining leadership styles in the health care industry. Xirasagar et al. [7] surveyed executive directors of community health care centers using a Likert-type scale. They found that transformational leadership was used most often. The executives found it most effective and felt that it resulted in the greatest subordinate satisfaction and effort. Transactional leadership closely followed transformational leadership, and laissez-faire leadership trailed a distant third. An examination of rural primary care physicians by Hana and Kirkhaug revealed that physicians used change style leadership (i.e., transformational) the most, followed by task style (i.e., task-oriented), and then relation style [8]. Interestingly, lead physicians were noted to use mostly change style, whereas age was negatively correlated with the use of change and relation style. A survey of physician medical and executive directors of health care systems also revealed the highest scores for transformational leadership as compared to transactional and laissez-faire [9]. A similar survey of deans of nursing programs showed that 77 % of the deans scored highest with transformational leadership, 21 % for transactional leadership, and 2 % for passive-avoidant leadership [10]. Thus, it is clear that a good leader should be well-versed in the different styles of leadership and use them appropriately, as dictated by the need.

4.5 Conclusion Several different leadership core theories exist. These theories have evolved over time but take into account leadership traits, leadership behavior, the situation (i.e., contingency theory), the source of power and influence, and emotional

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intelligence. From these, many leadership styles have emerged to describe how leaders function to achieve a successful outcome. These styles include autocratic, democratic, bureaucratic, charismatic, laissez-faire, people or relations-oriented, task-oriented, servant, transactional, transformational, and adaptive leadership. No one leadership style is right for one person or one situation. However, studies on leadership in the health care arena reveal that the most effective leaders have adopted a significant portion of their leadership style as transformational, a style very popular in the business world. Varying contributions of other styles also comprise a good leader’s armamentarium and it is important to understand when one style is better over another. Surgeons are uniquely positioned to be leaders. However, it is imperative that surgeons recognize that their training paradigm has a tendency to produce an autocratic leadership style, a style rarely effective in the health care industry. Through education and training about the various leadership theories and styles, a surgeon can be well-positioned to lead.

References 1. Prive T. Top 10 qualities that make a great leader. 2012. Forbes http://www.forbes.com/sites/ tanyaprive/2012/12/19/top-10-qualities-that-make-a-great-leader/ Accessed 25 June 2014. 2. Lewin K, Lippitt R, White RK. Patterns of aggressive behavior in experimentally created social climates. Journal of Social Psychology. 1939;10:271–301. 3. Hersey P, Blanchard KH, Johnson DE. Management of organizational behavior: utilizing human resources. 7th ed. Upper Saddle River: Prentice Hall; 1996. p. 188–223. 4. Pierce JL, Dunham RB. Managing. Chicago: Scott Foresman & Co; 1990. 5. French Jr JRP, Raven BH. The bases of social power. In: Cartwright D, editor. Studies in social power. Ann Arbor: Institute for Social Research; 1959. p. 150–67. 6. Goleman D. Leadership that gets results. Harv Bus Rev. 2000;78(2):78–90. 7. Xirasagar S, Samuels ME, Stoskopf CH. Physician leadership styles and effectiveness: an empirical study. Medical Care Research and Review. 2005;62(6):720–40. 8. Hana J, Kirkhaug R. Physicians’ leadership styles in rural primary medical care: how are they perceived by staff? Scandinavian Journal of Primary Health Care. 2014;32:4–10. 9. Xirasagar S, Samuels ME, Curtin TF. Management training of physician executives, their leadership style, and care management performance: an empirical study. 2006. AJMC. http://www. ajmc.com/publications/issue/2006/2006-02-vol12-n2/feb06-2252p101-108. Accessed 16 June 2014. 10. Broome ME. Self-reported leadership styles of deans of baccalaureate and higher degree nursing programs in the United States. J Prof Nurs. 2013;29(6):323–9.

Chapter 5

Leadership Traits: Are People Born to Lead? Jeffrey B. Matthews

5.1 Introduction Be not afraid of greatness: some are born great, some achieve greatness and some have greatness thrust upon them. William Shakespeare, Twelfth Night

The notion of the “born leader” has been deeply rooted in popular imagination since ancient times, whether reflected in historical political structures that bestowed power to monarchs by virtue of their bloodline, or in cultural legends that attribute the triumphs of heroes to circumstances of birth and their innate superior skills. From antiquity, it has been assumed that leaders displayed certain personal characteristics that distinguish them from their followers. Plato believed that leaders possessed superior reasoning capacity and wisdom, whereas Machiavelli emphasized the inherent ability of the successful leader to understand and to manipulate social situations [1, 2]. Thomas Jefferson believed there was a natural aristocracy among men, reflected in the elements of genius and virtue [2]. Behavioral scientists still debate whether leaders are born or made. Indeed, in scholarly circles, the pendulum of opinion has swung from nature to nurture and back again over the past century. From everyday experience, it seems intuitively obvious that leaders are different than followers, that leaders possess something that, for lack of a better term, might be called “the right stuff” [2, 3]. To some, leadership is almost entirely an acquired skill, and they see only a very limited role for genetics or inherited traits. Others contend that potential leaders are endowed with certain fundamental talents not possessed by those who follow.

J.B. Matthews, MD, FACS () Department of Surgery, The University of Chicago, Chicago, IL, USA e-mail: [email protected] © Springer International Publishing Switzerland 2015 M.R. Kibbe, H. Chen (eds.), Leadership in Surgery, Success in Academic Surgery, DOI 10.1007/978-3-319-11107-0_5

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5.2 Great Man Theories In the nineteenth century, “great man” theories asserted that the personal qualities that define leadership were inherited and that these attributes were mostly associated with an upper class lineage [3]. Galton [4] is often credited as the first to methodically investigate the inherited basis of leadership. In his 1869 treatise Hereditary Genius: an inquiry into its laws and consequences, he introduced concepts that later generations of scholars would come to find highly controversial and even racially charged. Galton studied generations of leaders and believed that superior intelligence was the key, and that this attribute was inherited, not acquired [4]. His work formed an intellectual rationalization for eugenics or selective mating as a way for society to breed its most qualified leaders [1]. Prominent sociologists including William James saw a hereditary basis for the appearance of Great Men within a society, in essence the product of Darwinian selection, wherein the “peculiar gifts” of the leader interact with the environment and social circumstances of the moment to push those individuals into action [5, 6].

5.3 Origins of Leadership Trait Theory Great Man theories and the inherited leadership ideas espoused by Galton drove much of the research in this field in the early decades of the twentieth century. Scholarship was directed towards the identification of those specific or general personality characteristics, motives, and behaviors – leadership traits – that differentiated leaders from non-leaders, irrespective of whether those leadership traits were inherited or acquired [3]. Whereas Great Man theories held that the course of history was determined by the actions of a small number of extraordinary men possessing extraordinary inherited skills, leadership trait theory attempted to define and validate a list of traits that acted singly or in combination to produce leaders [7]. As a scientific approach was adopted by the emerging disciplines of psychology and sociology, a number of methodological issues with leadership trait theory became evident. Cowley, working at the University of Chicago, noted three specific concerns [8]. The first problem was the difficulty of establishing a clear definition of leadership, specifically the challenge of distinguishing “actual and unquestionable leaders” from those he termed “headmen”, individuals who are called leaders because they have a certain pedigree or certain characteristics that allow them to occupy positions of leadership (leadership role occupancy) but who do not in fact have true leadership qualities, outstanding motives, or clear direction. The second concern noted by Cowley was that individual traits associated with a given leadership (or headship) role seemed to vary from situation to situation. At one level, these situational differences merely reflected the specific job qualifications needed for leadership role occupancy. For example, in order to lead (or head) a department of surgery, one must have completed medical school and surgical

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residency training, passed board examinations, and so on. At a deeper level, it became clear that individual personality traits and skills possessed by leaders could not be defined independently of the requirements of the specific situation; certain traits appeared to be valued more highly in certain circumstances whereas they might be of little value in others. Thus, a study of leadership could not be confined to leadership traits in isolation but must also take into account the context of the specific leadership situation. This led to the third concern identified by Cowley, which was the challenge of defining that subset of generalizable leadership traits that were applicable in all situations. Cowley approached these three concerns through experimentation. For example, he administered standardized psychological tests to leaders and followers in three different settings, comparing officers and privates in the U.S. army, criminal leaders and gang members in a state penitentiary, and student leaders and student followers at the University of Chicago. He found that while standardized tests could reasonably discriminate leaders and followers within the same environmental situation, leadership traits appeared to differ considerably between situations. Leadership trait theory began to fall out of favor due to the many inconsistencies in the evidence base. In the decades that followed Stogdill’s notable 1948 review, most psychology and sociology textbooks de-emphasized or outright rejected leadership trait theory [3, 7, 9]. Amid increasing skepticism that the essence of leadership could be captured solely in the possession of specific character traits, behavioral theories of leadership that emphasized situation-specific factors began to emerge. As summarized by Fielder [10], a number of important conceptual advances were made during this period. Among these was the idea of emergent leadership, in which individuals possessing the right degree of visibility and the right combination of skills and resources that matched the needs or goals of a group would be the most likely to emerge as acceptable leaders. In this view, there is no universal set of traits or personality that determine leadership of a group; good leaders in one situation may just as easily be good followers in another. Another important advance was the debunking of gender and race differences in leadership. Other insights included the recognition of the importance of group dynamics, including the behavior of leaders towards subordinates, the structure of group roles, and the explicit or implicit attribution of motives to leaders and followers. Leadership was increasingly conceived as a more transactional framework, reflecting the complex interactions that occur among individuals within a group as well as the specific situational context.

5.4 Modern View of Leadership Trait Theories Leadership trait theory has made somewhat of a comeback in recent years [1, 11]. Models of charismatic and transformational leadership that emerged in the 1980s, while acknowledging the importance of situational context, began to refocus attention on the personal qualities and attributes of leaders that enabled their

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effectiveness [7]. It is now generally accepted that while no single set of traits or personality type can reliably predict which individuals will become leaders, certain personal characteristics and qualities under a given set of circumstances do positively (or negatively) contribute to the likelihood of leader success [1, 3, 11, 12]. A number of conceptual difficulties with modern leadership trait theory remain to be resolved. Much of the earlier work on leadership took a univariate approach, failing to consider the importance of combinations of traits and attributes [7, 13]. However, even when multivariate analysis is attempted, there remain significant challenges in quantifying the relative expression of a given trait or combination of traits. Moreover, the relationship of a given trait to leadership may not be linear, and the contribution of multiple traits may or may not be additive. The relative contributions of leadership traits may differ with respect to leader emergence, leadership role occupancy, or leadership effectiveness. It may also be difficult to distinguish effective leaders from other high-performing individuals [7]. A persistent problem with leadership trait theory has been the lack of a uniformly accepted taxonomic framework [13]. Different researchers have used different terminologies to describe different aspects of personality and other attributes that might relate to leadership. For example, Stogdill’s influential review [9] listed eight traits that correlated with leadership: dependability, sociability, initiative, persistence, self-confidence, alertness, cooperativeness, and adaptability. On the other hand, Mann listed five different traits: adjustment, extroversion, dominance, masculinity, and conservatism [14]. Part of the challenge stems from ambiguities in the definition of “trait” itself, a term that is applied in various ways to personality, temperament, abilities, and even individual physical and demographic attributes [1]. The term trait is most narrowly applied to describe habitual, consistent, predictable patterns of behavior that are independent of the situational context. In this sense, leadership traits might be best defined as a coherent combination of personal characteristics that foster leadership effectiveness across a variety of groups and situations [7]. Leadership traits reflect not only personality but also a variety of other qualities that are expressed to differing degrees in leaders and non-leaders. Some of these traits may be innate while others may be acquired or developed. As such, one must accept an inevitable degree of overlap between personal attributes and the various skills, competencies, and expertise that are necessary for successful leadership [7].

5.5 Leadership Traits Kirkpatrick and Locke [3], in reviewing several decades of writings on leadership, outlined six categories of traits that appeared to differentiate leaders from nonleaders: drive, the desire to lead, honesty/integrity, self-confidence, cognitive ability, and knowledge of the business. Later, Zaccaro [1, 7] developed a more refined model that grouped leader attributes into integrated sets that depended to differing degrees on the situational context (Table 5.1): cognitive abilities, personality and

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Table 5.1 Leadership attributes [1, 7] Cognitive capacities General intelligence, cognitive complexity, creativity Personality and disposition Adaptability, neuroticism, extroversion, tolerance for risk, openness Motivation and values Need for power or achievement, motivation to lead, drive, tenacity Social capacities Social intelligence, emotional intelligence, persuasion and negotiation skills Leader expertise and tacit knowledge Metacognition, problem construction, solution generation Table 5.2 “Big five” model of personality traits [12]

Neuroticism Extroversion Openness to experience Agreeableness Conscientiousness

disposition, motivation and values, social capacities, and leader expertise and tacit knowledge. Some of these attributes, such as cognitive abilities, are envisioned as more foundational and less amenable to development or training. Others, such as social capacities, or expertise and tacit knowledge, are seen as experiential and learned. Cognitive capacities (which include not only general intelligence but also elements such as reasoning) strongly correlate with various measures of leadership and leadership effectiveness across a wide variety of situations [1, 7]. Studies that specifically test intelligence consistently show higher performance by leaders, and this correlation stands as an independent factor when evaluated by multivariable analysis. In isolation, the correlation between intellectual abilities and leadership performance is imperfect. For example, in studies of military leaders, high intelligence was undermined under circumstances of high stress or emergencies [10]. General intelligence is most associated with leadership performance when linked with at least one other leadership attribute, and the association is stronger when more complex measures of analytical ability are factored in. Creative thinking appears to be a particularly important leadership trait in situations that require complex problem-solving [1]. The role of personality in leader emergence or leader effectiveness has been more effectively evaluated through the development of standardized frameworks such as the so-called Big Five model and Myers-Briggs Type Indicators [1]. All of the big five major categories of personality traits (Table 5.2) have been found to be associated with leadership to some degree [12]. Neuroticism (manifest as anxiety, insecurity, and sometimes irritability and hostility) negatively correlates with leadership [12, 13]. On the other hand, per-

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sonality traits that reflect a low degree of neuroticism such as self-esteem are predictive of leadership. Extroversion is the strongest and most consistent trait that has been positively linked to leadership, whereas agreeableness shows the weakest correlation. Studies that have used Myers-Brigg indicators confirm the association with extroversion. However, studies of military leaders have shown preferences for sensing, thinking, and judging, whereas business executives may also show a preference for intuition, which may correlate with communication style [1]. Among the challenges of the study of leadership traits is observer bias: the ability to distinguish self versus observer ratings of personality [12]. Another challenge is that of attribution bias, in the sense that the personality traits of individuals are assessed through stereotypical assumptions about the characteristics of leaders [13]. Drive (which includes achievement, ambition, energy, tenacity, and initiative) has been emphasized as a particularly important leadership trait [3]. Motivation to lead appears to reflect a need for power or dominance. The extent to which motivation and drive correlate with leader effectiveness or leader achievement varies from study to study, and appears to be difficult to isolate from the impact of cognitive abilities and personality profile [7]. Social appraisal and interpersonal skills are particularly critical leadership traits [1]. Also known as social intelligence, the ability to understand and respond effectively to the feelings, thoughts, and behaviors of members of a group consistently correlates with leader emergence and leader effectiveness across a range of both military and civilian settings. Emotional intelligence is a related social appraisal and interpersonal skill that comprises self-awareness and self-control. Emotional intelligence appears to strongly correlate with leadership, leader work outcome, and subordinate work outcome. The final category of leadership attributes is leader expertise and tacit knowledge. Practical intelligence, which by definition comes from experience, correlates closely with leadership emergence, but whether the ability to learn from experience is an innate or acquired leader quality has not been extensively investigated.

5.6 Genetic Evidence for Inherited Leadership Traits Behavioral research indicates, perhaps not surprisingly, that personality traits are dependent upon both genetic and environmental factors [5]. Galton reviewed the pedigree of 100 individuals he characterized as great men and concluded that greatness ran in families [4]. Over the next hundred years, substantial evidence was obtained in support of the heritability of certain personality traits. However, differentiation of genetically inherited traits from traits that develop because of inherited environmental factors (e.g., socioeconomic) may not be straightforward. Moreover, it is only relatively recently that genetic research methodologies have been more specifically applied to the study of leadership. One of the first such studies examined self-reported psychometric inventories relevant to leadership in monozygotic and same-sex dizygotic twins [5].

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Higher-level leadership factors showed significant heritability. The genetic influence was particularly strong for factors that reflected transformational leadership such as inspirational motivation, attributed charisma, idealized influence, intellectual stimulation, and individualized consideration. However, factors associated with transactional leadership such as active or passive management-by-exception and contingent awards also showed heritability. Subsequent studies have shown that all of the big five personality factors show genetic heritability [15]. Notably, genes involved in regulating brain dopamine levels appear to be associated with extroversion, a trait itself strongly associated with leadership. Overall, studies using classical twin methodology have estimated that about one third of the variance in leadership role occupancy (defined as holding a position or office with leadership functions) can be explained by genetic factors [16]. This degree of genetic variation is roughly equivalent between male and female populations [16]. Environmental, experiential, and other non-shared factors between twin pairs appear to account for the rest of the variation. These studies confirm the prevailing opinion of current leadership scholars that leadership represents a complex dynamic between inherited and acquired factors, a balance between “nature and nurture” [5, 16, 17]. However, the majority of such studies have examined leadership role occupancy rather than leader effectiveness. Recent data have extended initial observations of the heritability of leadership traits in twins to identify specific genes that correlate with leadership role occupancy [17]. Several thousand genetic markers known to impact brain development, neurotransmitter biology, and hormonal regulation were evaluated in a large twin cohort as well as an independent sample drawn from the Framingham Heart Study. A single nucleotide polymorphism (SNP) in the neuronal acetylcholine receptor gene CHRNB3 was found to correlate with occupancy of leadership positions. This particular gene was evaluated because of its known association with impulsive behavior and its ability to modulate midbrain dopamine release.

5.7 Conclusions Popular wisdom has held for centuries that certain individuals are “born to lead”. However, the scientific underpinnings of this concept, starting with Great Man Theories, have been weak from an evidentiary standpoint. Leadership trait theory, which emerged in the early part of the twentieth century, was largely eclipsed by behavioral and situational theories. Trait theory was undermined by a variety of methodological and theoretical challenges including difficulties in the definition of leadership traits, differences among leadership traits in different situational contexts, observer bias, and difficulties in objective measurement. In addition to the lack of experimental evidence, Great Man and leadership trait theories fell out of favor due to troubling sociopolitical implications of racism, sexism, and eugenics. The modern emphasis on leadership development – that “anybody” can become a leader given the right situation and the right training – became more

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socially acceptable in the post-WWII world. In recent years, the pendulum has swung back towards a more intermediate position with the emergence of genetic data suggesting that a modest amount of variation in leadership traits and leadership role occupancy can be accounted for by hereditary factors. However, the majority of the variation in leadership traits among individuals in a given population appear to reflect differences in experience, environment, and, perhaps, training.

References 1. Zaccaro SJ, Kemp C, Bader P. Leader traits and attributes. In: Antonakis J, Cianciano AT, Sternberg RJ, editors. The nature of leadership. Thousand Oaks: Sage; 2004. p. 101–24. 2. Cawthon DL. Leadership: the great man theory revisited. Bus Horiz. 1996;39:1–4. 3. Kirkpatick SA, Locke EA. Leadership: do traits matter? Executive. 1991;5:48–60. 4. Galton F. Hereditary genius. London: Macmillan and Company; 1869. 5. Johnson AM, Vernon PA, McCarthy JM, et al. Nature vs nurture: are leaders born or made? A behavior genetic investigation of leadership style. Twin Res. 1998;1:216–23. 6. James W. Great men, great thoughts, and their environment. Atlantic Monthly. 1880;46:441– 59. 7. Zaccaro SJ. Trait-based perspectives of leadership. Am Psychol. 2007;62:6–16. 8. Cowley WH. Three distinctions in the study of leaders. J Abnorm Soc Psychol. 1928;23:144– 57. 9. Stogdill RM. Personal factors associated with leadership: a survey of the literature. J Psychol. 1948;25:35–71. 10. Fiedler FE. Research on leadership selection and training: one view of the future. Adm Sci Q. 1996;41:241–50. 11. Day DV, Fleenor JW, Atwater LE, et al. Advances in leader and leadership development: a review of 25 years of research and theory. Leaders Q. 2014;25:63–82. 12. Colbert AE, Judge TA, Choi D, et al. Assessing the trait theory of leadership using self and observer ratings of personality: the mediating role of contributions to group success. Leaders Q. 2012;23:670–85. 13. Judge TA, Bono JE, Ilies R, et al. Personality and leadership: a qualitative and quantitative review. J Appl Psychol. 2002;87:765–80. 14. Mann RD. A review of the relationships between personality and performance in small groups. Psychol Bull. 1959;59:241–70. 15. Johnson AM, Vernon PA, Harris JA, et al. A behavior genetic investigation of the relationship between leadership and personality. Twin Res. 2004;7:27–32. 16. Arvey RD, Rotundo M, Johnson W, et al. The determinants of leadership role occupancy: genetic and personality factors. Leaders Q. 2006;17:1–20. 17. De Neve JE, Mikhaylov S, Dawes CT, et al. Born to lead? A twin design and genetic association study of leadership role occupancy. Leaders Q. 2013;24:45–60.

Chapter 6

Understanding Emotional Intelligence and Its Role in Leadership Harry C. Sax and Bruce L. Gewertz

6.1 Introduction Irrespective of our life paths, the ability to initiate and sustain effective interactions with others is a key determinant of success and fulfillment. As physicians, we must lead both formally and informally in a variety of roles – in medical systems, clinics and operating theatres. We are often challenged by the stress of practice and the need to achieve balance with family and friends. Conflicts occur on a regular basis hence a level of personal insight is vital to a healthy and productive life. The increased interest in emotional intelligence is supported by a growing compilation of data that demonstrate that enhanced social interactions improve personal performance in a wide range of settings. Boyatzis studied 2,000 supervisors and executives and found that 14 of 16 distinguishing traits for success were emotional not cognitive [1]. Spencer and Spencer defined job competencies in 286 organizations and noted that 18 of 21 competencies associated with high performance were emotionally based [2]. Comparing “star” performers to average performers in diverse industries, Goleman found that emotional advantages were noted twice as frequently in high performers and were a much better predictor of achievement than cognitive superiority [3]. In this chapter we will quantify the traits associated with emotional intelligence (EQ), examine the role of EQ in the medical environment, including the differences seen in surgeons, provide insights into the neurobiology of human emotion, address

H.C. Sax, MD, FACS, FACHE () Department of Surgery, Clinical Transformation Initiative, Cedars-Sinai Medical Center, 8700 Beverly Blvd NT 8215, Los Angeles, CA 90048, USA e-mail: [email protected] B.L. Gewertz, MD, FACS Department of Surgery, Interventional Services, Academic Affairs, Cedars-Sinai Medical Center, 8700 Beverly Blvd NT 8215, Los Angeles, CA 90048, USA © Springer International Publishing Switzerland 2015 M.R. Kibbe, H. Chen (eds.), Leadership in Surgery, Success in Academic Surgery, DOI 10.1007/978-3-319-11107-0_6

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how experiences shape our ability to interact with others, describe how emotional intelligence can be measured and quantified, and finally assess what one can do to improve EQ. We will tie emotional intelligence into styles of conflict resolution, and describe forms of feedback that can increase insight and enhance both professional performance and personal satisfaction.

6.2 The Scope of Emotional Intelligence The term “emotional intelligence” has been advanced to describe the set of personal attributes which enhance social and professional relationships. As developed by Goleman and others, the elements of emotional intelligence span the full range of interactions between individuals and society including self-awareness, selfregulation, social awareness, and relationship management [4, 5]. Self-awareness encompasses one’s openness to their own emotional experience and their ability to realistically appraise their skills and abilities and to integrate feedback for self-improvement. It involves the higher levels of functioning to see our emotions from the perspective of distance – to recognize that we are feeling anger, frustration, unbridled joy, or sorrow. It then allows us not to immediately react to those emotions (Goleman uses the term “hijacking”.) [4]. Rather, we recognize what we are feeling and how that can affect our perception of the situation and reality. Surgeons feel that they must have control over their emotions to deal with high stakes situations. Yet often, we are unclear of what we are truly feeling, which distorts our abilities to be “in the moment.” Those with insight into their emotions develop appropriate levels of confidence and self-esteem. They recognize anger triggers that lead to impulsive, negative reactions. With self-regulation, they remain above the fray. Self-regulation is the ability to modulate and manage emotions within the context of any situation. Although it is possible to have strong abilities in selfregulation without self-awareness, it becomes analogous to addicts who “white knuckle” their way through temptation. Self-regulation is about balance. It is not appropriate to suppress all emotion any more than it is to be carried away into paralyzing dark depths or manic dizzying heights. As surgeons and leaders, we cycle through emotions frequently throughout the day. Those with strong selfmanagement organize thoughts and actions, produce high quality work, and are adaptable. They exhibit high levels of integrity. They are able to remain optimistic in the face of failure and rejection, viewing the setback as additional data on which to set a future course. Self-regulation is perhaps the most important skill to master. Impulsivity in response to a situation, driven by anger or strong emotion, has derailed many. Pessimism paralyzes and inhibits forward motion. We will discuss shortly the neurobiology of impulsivity and pessimism and how maturation of pathways to the frontal lobe can be crafted throughout life. This includes scenario

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based training, where one can recognize the physiologic changes induced by strong emotions and develop alternative mechanisms to cope with them. Understanding ourselves is vital. We are social animals, characterized by the need to interact with others. While we can appreciate how we may be feeling at the moment, others rarely put their feelings into words. Up to 85 % of communication comes from nonverbal cues – facial expression, tone of voice, subtle body language [4, 6]. The ability to read these cues predicts success in human interaction. Social awareness behaviors include empathy, political acumen, organizational dynamics, and openness to opposing points of view. This level of attunement ideally begins in childhood by parents who are able to mirror their children’s feelings, creating an understanding of empathy. Throughout life, however, relationships provide new opportunities to learn empathy, nonverbal communication, and how to read situations. Those with strong skills in social awareness are seen as good “listeners,” demonstrating the ability to understand others thoughts feelings and motivations by picking up all the cues. Taken to an extreme, however, in an effort to be liked, they may rapidly change their reactions to the situation oftentimes losing their own sense of self and values. The final competency is the ability to manage relationships by taking into account the normal differences of opinions and conflict that exists within groups. It is not only having the social awareness to read nonverbal cues, but also the ability to connect and relate. This can be on a personal level or as an organizer of groups. In Tipping Point, Malcolm Gladwell identifies connectors as “people with a particular and rare set of social gifts” [7]. They know large numbers of people and are in the habit of making introductions. They usually know people across an array of social, cultural, professional, and economic circles, and make a habit of introducing people who work or live in different circles. They are people who “link us up with the world : : : people with a special gift for bringing the world together”. Those skilled in relationship management are able to respond to others in a way that creates a connection, using both verbal and nonverbal modes of communication. In his book “Flourish,” Seligman describes four ways to react to any situation: Active/Constructive, Passive/Constructive, Active/Destructive, and Passive/Destructive [8]. For example, on hearing of a raise and promotion, the active constructive response will show enthusiasm and interest, maintain eye contact, and ask questions to draw the teller in. A more passive response is to say, “Congratulations, you deserved it,” with little or no emotion. Actively destructive responses will remind the teller of increased responsibility, time away from home and higher taxes. They will exhibit negative nonverbal communication in tone of voice or facial expression. The passively destructive person won’t even acknowledge the news and may bring up an unrelated topic. How often in surgical training did we want to emulate the skilled clinician who could accurately and constructively help us improve? “After you set the needle at 45 degrees, the anastomosis went more smoothly,” as opposed to “I don’t know how you got through sewing that with your left hand, but it’s open : : : for now.”

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6.3 Nature Versus Nurture: The Biology of Emotion Early studies on the brain and emotion centered on observed changes in personality after stroke, trauma, or surgical resection. More primitive organisms required near instantaneous responses to threats in order to survive. Further basic regulation of physiologic function and movement was required. The brainstem and amygdala serve these functions, with the olfactory lobe as the main interaction with the surrounding environment. As our brains evolved, emotions developed before the recognition of emotions. Fight or flight was reflexive [9]. With the emergence of the limbic system came the ability to remember previous experiences and feel wider ranges of emotion. It remains our pleasure center. In psychopathology, the amygdala and limbic region have been implicated as a key neural region in emotional regulation. With evolution and the specialized functions of the ever enlarging neocortex, humans could now experience wide ranges of nuanced emotion. Concommitantly, neural pathways developed to modulate the primitive forebrain and the passionate amygdala. This region is essential to learning the emotional significance of cues in the environment. It is not static. The white matter of the frontal lobe grows through the end of adolescences and into early adulthood [10]. Liston and colleagues have shown that white matter tracts between prefrontal–basal ganglia and posterior fiber tracts continue to develop across childhood into adulthood, but only tracts between the prefrontal cortex and basal ganglia are correlated with impulse control. This may also explain why childhood experiences in learning to deal with impulses are important while neural pathway development catches up [11]. In some individuals, these pathways that lead to higher levels of control do not develop, and taken to the extreme can lead to sociopathic behavior. Functional magnetic resonance imaging (MRI) has given us even greater insight into the nuances of where emotional intelligence may lie. It is clear that the ability to recognize nonverbal cues (facial expression, tone of voice, word versus non word sound) requires integration of disparate stimuli. Kreifelts examined functional MRI in a series of healthy adults who presented with various words or non-word sounds, and human versus inanimate pictures [12]. In some cases, the words were presented in either a happy or angry tone. Degree of activation in multiple areas of the brain was correlated with results from prestudy EQ testing. Subjects with higher EQ showed more activity in right posterior middle temporal gyrus during periods where integration of voice and facial expression was required. Of interest, in all subjects, the amygdala responded strongly to images of human faces, but not to voice. What remains to be seen is how well brain plasticity through life enhances these pathways with training [13]. The traits of optimism and resilience are key to joy in life and success in surgery. Traumatic events of childhood clearly are correlated with later depression, yet not everyone with Early Life Stress (ELS) develops depression. Cisler mapped the emotion regulation network in a group of woman who had ELS, some that subsequently became clinical depressed, others with no history [14]. Higher activity

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in the prefrontal cortex was seen in the resilient group, and more activation in the primitive amygdala in those with depression. There was no control group with depression but no ELS. Surgeons deal with traumatic events daily. How they process these stimuli may be colored by early experiences and biology. Although one may feel doomed by biology, it is also clear that brain plasticity allows new neural pathways to form and mature throughout life.

6.4 Emotional Intelligence in Medical Practice and Leadership Roles While having greater insight into one’s feelings could be expected to correlate with success in leading others, supportive data in the medical field is not robust. Traditionally leaders in medicine have been selected on clinical or research accomplishments, not on their ability to manage themselves and mentor others. That said, one could easily argue that the need for such informed and consistent leadership has never been greater. There is recent information that would argue that physicians are experiencing considerable emotional stress due to a host of financial and other pressures that are dramatically changing both the practice of medicine and how doctors perceive their role in society. A survey of 1,951 full-time physicians and scientists from four geographically separated medical schools noted that 20 % had significant depressive symptoms [15]. Depression and anxiety scores were higher in young physicians (