Letter to the Editor: What Happened to Surgical Leadership?

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To the Editor:
I read with interest the recent publication of Ledgerwood's1 American Surgical Association presidential address, “What Happened to Surgical Leadership,” and appreciate the author's firm commitment to quality improvement (QI) and leadership. As a surgical resident, I would like to offer an expansion of one area discussed in the manuscript, specifically: “surgical leadership and residency training.” Given the importance of QI and leadership to surgeons of all levels, I would propose that the development of QI and leadership skills should be seen as a critical component of surgical training, and deliberately integrated into residency curricula.
Quality improvement and leadership are often emphasized as important physician competencies.1,2 To this end, the Accreditation Council for Graduate Medical Education now mandates that all residents participate in QI efforts; increasingly, residents are also expected to demonstrate leadership in clinical teams.3
Yet, trainees—much like experienced surgeons—must acquire foundational skills in QI and leadership to maximize our effectiveness at applying these skills. Just as trainees learn how to operate competently through deliberate practice, so too could we practice QI and leadership by applying well-established systems-science and leadership principles. Foundational QI skills might include, for example, design and implementation of a quality improvement project, and determination of when systems change represents a meaningful improvement. Similarly, foundational leadership skills might include self-awareness, emotional intelligence, conflict resolution, interprofessional collaboration, negotiation, and change management. Opportunities for real-life applications of these skills frequently arise during the course of trainees’ daily routines.
Contrary to popular belief, leadership skills can be taught and learned.4 Many of the most successful organizations across a broad range of industries commit to leadership training throughout their ranks. Similarly, the military devotes substantial resources to leadership training owing to the belief that leadership skills development drives performance improvement. These examples complement a vast literature within and outside of health care describing the effectiveness of leadership development programs.4
In recent years, efforts to incorporate QI and leadership development into graduate medical education (GME) programs have accelerated.5,6 Yet, these programs remain fragmented and suffer from lack of consensus regarding appropriate teaching and evaluation methods. Furthermore, only a small fraction of the training programs referenced in these published reviews are surgical programs. Some surgical trainees have taken advantage of extracurricular opportunities such as the American College of Surgeons’ Residents as Teachers and Leaders course to hone their skills. This course alone cannot ensure that all surgical trainees achieve competence in QI and leadership. In recent years, my residency program has begun to build longitudinal QI and leadership curricula; I wonder if similar, local efforts exist around the country and to what extent they have been successful. Should such efforts be organized more systematically across institutions? If so, how and by whom?
The author reminds us that surgical quality in today's environment is often adjudicated by nonsurgeons. It is particularly frustrating when this “cook-book” approach ignores relevant contextual details, sometimes even acting in opposition to high-quality care. In this era of accountable care organizations, cost control, and quality benchmarking, external forces such as these will likely continue to impact surgeons, including trainees who will enter practice in the near future. To prove the merits of complementary efforts designed and led by skilled surgeons, we must equip ourselves with the skills to lead the changes we desire.
The ad hoc approach to leadership development common in today's health care system may not be desirable in the long run. Instead, dedicated efforts to provide formative education in QI and leadership skills could transform both our education as surgeons and consequently our efforts to optimize surgical care.
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