Developing Leaders in Anesthesiology

THE call for more effective leadership in medicine, and specifically in anesthesiology, is not new. In 1999, Dr. Francis M. James III, in his Rovenstine lecture, outlined both the importance of leadership in medicine as well as the breadth of leadership opportunities available both inside and outside anesthesiology.1Eleven years later, Dr. Peter J. Pronovost, also in his Rovenstine lecture, turned up the volume by setting out an agenda focused on accountability, performance measurement, teamwork, peer-to-peer reviews, and the need for participation from anesthesiologist-leaders in change initiatives within and outside the specialty.2Driven by a heightened focus on cost reduction, quality improvement, patient safety, performance measurement, and technological innovation, anesthesiology is going through a period of upheaval. Effective leadership is essential to the success of this transformation, because leadership is all about envisioning and guiding people through change. If anesthesiology is to continue to thrive as a medical specialty within a rapidly evolving healthcare system, anesthesiologists will need to envision and manifest change beyond simply providing efficient care.The specialty is confronting what has been coined an “adaptive” challenge, i.e. , a challenge for which there is no preexisting solution.3Furthermore, there is evidence both inside and outside of medicine that organizations that focus exclusively on cost reduction and efficiency during times of rapid change ultimately do not fare well.4–6As a result, anesthesiologists need to become change agents who envision, lead, and implement initiatives that ultimately result in greater patient safety, better patient outcomes, improved quality, and sustainable finances.Medicine, however, as a whole underinvests in leadership development because, according to Dr. Wiley W. Souba, a surgeon and a prolific writer about leadership, the profession is not sure where to invest or how to “prepare people for the practice of leadership.”3He points out that although leadership training is available, the focus on “managerial skills” fails to get at the heart of leadership.3More recently, a qualitative study of emergency medicine residents at a major academic center found that the approaches to learning leadership are underdeveloped, resulting in a narrow view of leadership.7What is still missing is a roadmap for cultivating leadership behaviors in clinicians and relevant tools to guide their actions. In this article, with the help of a case scenario, we propose a practical framework for turning anesthesiologists into leaders.The anesthesiology department of a large academic medical center has recently implemented a series of operating room and anesthesia efficiency measures designed to improve on-time starts, reduce turnover, and manage patient preoperative times. These measures will be used to set targets and to measure the performance of providers.A junior anesthesiologist, now in her second year as an attending, views achieving the targets as important in meeting her aspirations to become a leader in the department. She is very focused on being as efficient as possible when running her cases. She feels that during her first year as an attending she was able to establish herself as a good clinician and an effective teacher. But during the last several months, she has begun to struggle with supervising and teaching residents. For a period of a few months, this attending notices that some of the residents she oversees demonstrate less initiative than she would expect, appear unenthusiastic about their work, and do not seem to take the newly implemented efficiency initiatives seriously. Her reviews from residents who had been very good have fallen below average, which is causing her to feel disappointed in her relationship with residents. She has always seen herself as a good mentor and teacher, and despite the added pressures toward efficiency, she still has a strong desire to have a positive impact on the next generation of anesthesiologists.Becoming more and more frustrated with the situation, she begins to blame this dynamic on “the new generation,” a group of younger residents who, to her mind, are much less dedicated and hard-working than when she was a resident. Reflecting on her own residency, she believes herself to have been the exact opposite: She was extremely enthusiastic and respectful of her superiors, and was always interested and engaged.Taking no action to address the situation, get feedback, or to question her own assumptions, over time this attending becomes more alienated and disengaged from her students, and finally reaches a point where she is always on the lookout for clues in resident behavior that will reinforce her stance. She knows she is “right”: Residents are simply not as good as they were when she was one.This situation might not immediately appear to be an issue of leadership. After all, the attending is relatively junior and has no formal leadership position in the department, and supervising/teaching residents is traditionally not viewed as a formal leadership role. Leadership is normally viewed as a top-down function, where a department head or division chief is responsible for change efforts that result in improved quality, effectiveness, and performance of an organization. Yet, where do these so-called change efforts begin? Whether directed from the top or empowered from within, all leadership starts with the individual.8During the past four decades, the traditional locus of activity for most organizational leaders was on the abstract – mission, strategy, processes, and policies, conceptual frameworks that undergird an organization. This emphasis upon process and structure evolved within the fields of management science and organizational development as a result of research that had a specific goal: to control the mechanics and reduce the vagaries of the human enterprise. This reductionist and linear view of organizational practices attempted to improve quality and efficiency by automating processes wherever possible and circumscribing workers' span of control down to repeatable, repetitive activities.Yet, given the need for creativity, flexibility, and rapid adaptability, this rigid, hierarchical, paradigm from earlier, more stable, and slower periods of human enterprise is increasingly becoming obsolete. The problem for leaders in the fast-paced, rapidly changing context of today's world is that the so-called “human element” that management theorists initially dismissed as inherently messy, hard to corral, or difficult to control turns out to be an essential component of organizational success. Dealing with humans as creative, generative, and emotionally alive beings is often referred to as the “soft” stuff, but it is truly the “hard” stuff.Disciplines such as cognitive psychology, social psychology and neuroscience are extending our knowledge about how people make decisions, regulate behavior, create mental maps, and divine meaning within fast-changing environmental contexts. For example, the work of Damasio and Dodge points to the critical role of emotions in behavior regulation, information-processing, and decision-making.9,10This is a radical departure from the traditional management science, where rational, logical thinking was king, and emotions were viewed as something to eliminate from behavior and decision-making. In addition, Goleman and Boyatzis are exploring the linkage between neural circuit activity and effective interpersonal competencies.11These findings are starting to validate within scientific circles what is emerging in the business literature: The recognition that mental reflexivity, self-awareness, and emotional flexibility, not just stoic rationality and charisma, are crucial components of successful leadership behavior.Recent research into high-performing organizations has shown a consistent shift away from top-down, authoritarian environments toward leadership cultures where everyone, at all levels, is required to be a role model and an agent of change. No longer will it suffice for a clinician leader to wait until he or she has been promoted to a formal position of power to start developing leadership skills. Leadership is now considered by most experts to be a collaborative, interpersonal endeavor that often takes place outside hierarchical lines and exists as a potential within everyone: male or female, junior or senior, titular boss or underling (fig. 1). In fact, there is now considerable evidence that effective leaders are not always grand visionaries but are just as likely to be humble, self-effacing, emotionally stable, diligent, and resolute, and that leadership is needed at every level of an organization.12,13These updated and evolving theories of leadership provide new ways to understand – and ultimately, to optimize – the potential of human collective action. What is at the foundational level of any group context turns out to be more complex and subtle than any defined set of processes or neatly mapped organizational chart. Today, leaders must emerge from within all levels of an organization. They should reach beyond the organization charts, process maps, prescribed roles and titles, and seek to connect real problems with real people in real time. Leadership itself then becomes a set of multi-dimensional, relational, and innovative behaviors accessible to and even expected from everyone.In this case, our attending's inability to shift her relationship with subordinates into something more productive represents a failure of leadership at the most basic level. She is in a classic leadership bind: Asked to routinize and accelerate anesthesia-related tasks for the purpose of cost and efficiency, she must simultaneously supervise and help junior professionals practice and develop their clinical skills – which takes time. Reconciling these seemingly contradictory goals – achieving efficiency, control, and speed while optimizing learning and practice – is inherently problematic. It can be a setup for failure, or perhaps a formative opportunity for leadership development.In addition, this attending's difficult relationship with residents is fundamentally inconsistent with the vision she has of herself as a clinical role model and an effective teacher. If she cannot tackle this basic leadership challenge, how can we expect her to tackle more complex issues later in her career? Despite her poor interaction with residents, she might still attain an official leadership position in her department – a role for which she may not be adequately prepared.In light of the critical and growing importance of leadership competency in anesthesiology, our case scenario presents a key question: What kind of intervention is likely to help our junior attending overcome this basic leadership challenge?One common approach would be to send her to a “leadership course,” where she could gain appreciation for key leadership attributes – communication, vision, and strategic thinking – and learn more about interpersonal skills and teamwork. But although such courses provide useful information, they may not be enough to change her attitude or behavior toward the residents because their focus is not on generating new behaviors in a specific context.Potential leaders, especially when facing challenging situations, require more than just “business management skills” or “off-the-shelf” training; they need opportunities to break through unproductive belief systems and to experiment with new behaviors and practices in a safe and nurturing context.14,15When faced with a leadership challenge like the one described in our case scenario, or when attempting to structure a leadership development program, a simple and practical way to organize the foundational elements of effective leadership can be framed around three central themes: self-awareness, creativity, and relationships (fig. 2). The use of this framework can facilitate and accelerate the development of leadership capabilities, as detailed in the rest of this article.The first step in meeting her leadership challenge is for our attending to ask herself a fundamental question: What if the untenable dynamic has something to do with me? Accepting personal accountability for the failed relationship – even if the residents' behaviors and attitudes are contributing factors – and dropping the “blame game” is the first step required to potentially turn this negative situation into an opportunity for learning and growth. Not coincidentally, this shift in mindset, away from projection onto others toward ownership of results both positive and negative, also represents a cornerstone moment in leadership development.The link between leadership and self-awareness can be traced back to Socrates, whose famous adage “know thyself” has been recognized as a foundational tenet of human wisdom for centuries. More recently, the subject of self-knowledge – and conscious awareness of self – has been investigated extensively in the context of effective leadership. In particular, Goleman has demonstrated that emotional intelligence, the core of which is self-awareness, is associated with effective leadership and measurably improved business results.11,16Although there are now variations in the definition of emotional intelligence, Salovey and Mayer first defined it as the ability to accurately appraise and express one's and others' emotions, to effectively regulate emotions in self and others, and to use emotions to guide one's thinking and actions.17Preeminent groups such as the Stanford Graduate School of Business's Advisory Council have identified self-awareness as the most important capability for leaders to develop.18In medicine, two recent studies have shown a significant correlation between personal growth and self-reflection.19,20If encouraged by a mentor, trusted colleague, or a coach to reflect and explore her own role in the strained relationship with residents, the attending in our case study may be motivated to seek feedback from senior faculty or from the residents themselves. She might come to recognize the benefit of exploring her own assumptions about her role, her expectations of residents, and her fears or insecurities about supervising, teaching, or meeting efficiency targets, all of which may be coloring her judgment. She may realize that she is struggling to strike a balance between meeting her efficiency targets and being a teacher. If she seeks feedback directly from the residents, she may discover that she has a tendency to micromanage, something not uncommon for junior attending physicians, especially when under production pressure. 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In fact, like the for greater efficiency and time and cost opportunities to start developing leadership, one at a time. The leadership development process and the of this framework can be in with the of or training and the and of these is beyond the of this article, the key to success is leadership competency a safe and where can and practice new skills and is that the leadership framework in this can as a for senior leaders and anesthesia to to the strategic for leadership by James and self-awareness, creativity, and relationships are the upon which can step up to their and take the to become leaders.