Ensuring excellence in patient care, research, and education: thoughts on leadership and teamwork
=================================================================================================

* David A Spain

## Abstract

There are many ways to develop your leadership skills and many ways to be an effective leader. This is one perspective. The best style is the one that works for you and your environment. I would encourage you to spend some time and effort exploring your leadership style, develop new leadership skills, and look for opportunities to serve others.

*   editorial
*   education
*   quality improvement

## Introduction (slides 1–8)

Several years ago, Michael Sise, then trauma medical director at Scripps Mercy Hospital in San Diego assigned me this topic as a guest speaker at their annual trauma conference. I viewed this basically as a “tell us how awesome you are” talk. I called him and said “Mike, that is one thing I’m not awesome at”. He told me to do it anyway … and it did force me to stop and think. What are my goals as leader? What is my leadership style? What are the principles that guide my decisions? How can I help our team do a good job? Apologies in advance: this contains the words ‘I’ and ‘me’ a lot more than I am comfortable with, but it is a personal perspective (online supplemental file 1).

### Supplementary data

[[tsaco-2022-001027supp001.pdf]](pending:yes)

In the Doctor Crisis, Cochran and Kenney assert that “Real leadership starts from a proposition that you do not seek or accept a leadership designation because it pays better or because you get more recognition, but because you hunger for the responsibility of making a difference”.1 When reflecting on the most effective leaders I have known, this rings true. It is never about them. It is about making a difference. So, when a leadership opportunity arises, you should stop and ask why you would want to do this. What would be your motivation for pursuing this? How could you use this opportunity to make a difference?

Many leaders are very intentional. They develop a clear vision of where they want to go and a very detailed strategy on how to get there. Everything their team does is designed to advance that goal. I must admit to not always being the most intentional leader—more of a ‘fly by the seat of your pants’ style. But both me personally and our program have done well, so there had to be some structure to support this.2–7 As I put this talk together, a quote on Twitter struck a chord (figure 1).8

![Figure 1](http://tsaco.bmj.com/https://tsaco.bmj.com/content/tsaco/8/1/e001027/F1.medium.gif)

[Figure 1](http://tsaco.bmj.com/content/8/1/e001027/F1)

Figure 1 
Screen shot from Twitter (TM).

I realized that although the approach may be flexible, I had three very clear goals for our program:

*   Excellent patient care:
    
    *   *Nothing else matters if you do not have this.*

*   Contribute new knowledge:
    
    *   *This is why we do research and teach.*

*   Develop a place where people could flourish—in the way they want:
    
    *   *This is why I sought leadership roles.*

So, if these are the goals, what are the underlying principles that guide decision-making? How do I set the tone and make sure our environment helps people flourish? As I thought through this, nine principles that guide my decision-making became clear.

## Nine guiding principles of leadership

### Principle #1: hard work is more important than talent (slides 9–11)

Hard work is the underpinning of most of what I have been able to accomplish in my career. But you also must trust that hard work has its own reward. You work hard to provide great care, develop a new care pathway, or assess your outcomes because it is the right thing to do for your patients, not because you will get some recognition. It is also important to remember that hard work does not just mean long hours. You must be smart and efficient with your time and efforts. And you must work equally as hard for those things outside of medicine that are important to you—family, friends, exercise, hobbies, etc. This is a common mistake and one that must be assiduously avoided. The best, most accomplished doctors I know have rich, full lives outside of medicine too.

### Principle #2: integrity is everything (slides 12–14)

I use two functional definitions of integrity that I have learned along the way. The first is the ability to be honest with yourself about yourself. This requires some self-awareness and emotional intelligence. Over the years, I have engaged with professional coaches who can be very valuable in helping to see yourself better, both good and bad. Their feedback and coaching can be very valuable in your growth as a leader. But you do not have to hire a coach to get feedback. Encourage your colleagues to speak up and share opinions and give feedback. The second definition of integrity is doing the right thing, even when no one is looking and especially if it will cause you pain. Sometimes this means speaking up and saying what needs to be said, even if it is unpopular. Because as Lt. General David Morrison said, “The standard you walk past is the standard you accept”.9

### Principle #3: teamwork is a necessity (slides 15–19)

We all know when it comes to patient care, teamwork is an absolute necessity. As an acute care surgery leader, your job is to build a great team. How do you do that?

*   Hire great people.

*   Give them meaningful work to do.

*   Give them the support (and protection) they need to do it.

*   Give them the all the recognition and credit when they succeed.

*   Converse: take all the responsibility when something does not work out.

### Principle #4: never stop learning (slides 20–24)

As a leader, you can never stop learning. Most of us continually work at expanding our clinical knowledge and research expertise. But it is also crucial you expand your leadership knowledge. There is a whole cottage industry of books out there. Find some that resonate with you (many will not), read them, and refer back to them often to remind yourself of what you learned. My two all-time favorites are *the Contrarian’s Guide to Leadership* by Steven Samples10 and *The Five Dysfunctions of a Team* by Patrick Lencioni.11 Podcasts can be another source of good ideas.

### Principle #5: multitasking is a myth (slides 25–27)

I firmly believe that multitasking is a myth. Actually, it is really not possible for the human brain to do two things at once.12 I think most of the time it is just a lame excuse to ‘look busy and important’. Atchley argues

> make an effort to do tasks one at a time. Stick with one item until completion if you can. If attention starts to wane (typically after about 18 minutes), you can switch to a new task, but take a moment to leave yourself a note about where you were with the first one.12

Remember this old proverb as mentioned in figure 2.

![Figure 2](http://tsaco.bmj.com/https://tsaco.bmj.com/content/tsaco/8/1/e001027/F2.medium.gif)

[Figure 2](http://tsaco.bmj.com/content/8/1/e001027/F2)

Figure 2 
Screen shot from Twitter (TM).

As a leader you must *have presence*—have ‘boots on the ground’, take call, be in the operating room at 02:00 hours, etc—but you also must *be present*. My advice: stop ‘multitasking’ and *do what you are doing*.

### Principle #6: humility solves most problems (slides 28–29)

Humility can solve most problems because if you are humble, you can truly listen to others, you can consider new ideas, you can say you are sorry (one of the most powerful tools you have as a leader), and you can serve others (the true purpose of leadership). As Merryman reported in 2016, the “intellectually humble have a constant desire to learn and improve. They embrace ambiguity and the unknown. They like getting new information. They even enjoy finding out when they are wrong. And when in trouble, they are more willing to accept help”.13 “Humble leaders are more likely to have diverse teams. They disperse power and give their teams more opportunities to lead and innovate. Humble leaders have less employee turnover, higher employee satisfaction, and they improve the company’s overall performance.”13 As she notes, this can only happen when someone has an accurate assessment of both their strengths and weaknesses.

### Principle #7: you have to take some risks (slides 30–31)

As a leader you should take some risks; support that new research idea that may not pan out but could have a major impact if it does, hire that candidate who has a lot of potential but maybe has not had the support yet to develop a track-record, or volunteer to take over that quality improvement initiative that everyone has been struggling with. Remember what Muhammad Ali said that those who are ‘not courageous enough to take some risks will accomplish nothing in life’. Moving to Stanford and building a trauma program from scratch entailed some big risks, but there was strong support from leadership and huge opportunity.

### Principle #8: enjoy the journey (slide 32–38)

The work we do is hard—both physically and psychologically. We work long hours and bear witness to a lot of human suffering. The journey is long, so it is best to enjoy it along the way. Often, we get to save lives, restore health, and help makes families whole again. We get to train the next generation of surgeons and help mentor them into productive careers that amplify what we have done. Keep every thank you card and accolade you receive—and look through them on those days you doubt yourself.

### Principle #9: always remember your true North—excellence in patient care and education (slides 38–39)

Finally, the last several years have been especially challenging. But in those situations where things are confusing and you are not sure what to do next: always remember your true North—excellence in patient care and education. Let these be your guide.

## Lessons learned

Recently, I had the opportunity to put some of these principles to use. We frequently discuss the skills needed to be an effective leader. But one thing that almost never gets discussed is how to know when it is time to let others have an opportunity to lead. I recently decided to step down as Chief of Acute Care Surgery and Trauma Director after 21 years. This was a positive decision on my part, although I think I am still effective, it felt like I was starting to ‘lose steam’ and enthusiasm for things I needed to do for the team. When dealing with a minor issue, the thought crossed my mind that “if I have to be doing this a year from now, I might resent it”. The minute that happened, I realized my team deserves better than that. So, literally the next day, I announced plans to step down as soon as a new chief was recruited. We have all heard of, or even experienced, leaders who held onto the title but were not doing the work anymore. You did not want to be that person. It takes some self-awareness (integrity and humility) to know when to step down before it is ‘too late’. Have a mechanism in place to assess your performance:

*   Do an annual self-check-in: schedule a day away from work to reflect on how you are feeling, what is your level of engagement, how can you improve if low, what new skills do I want to work on this coming year, which bad habits can I try to jettison, etc. Do I have enough ‘joy’ in my role to carry on another year?

*   Have a close colleague (maybe in another division or department) give you honest feedback. Give them your ‘yellow card’ and encourage them to give you a warning if they see your efforts waning.

*   Engage a professional coach. I have used one off and on (with some periods on increased intensity depending on the situation) for the last 10 years and it has been incredibly beneficial.

We are all high-achievers and doer, and if we are being honest, we enjoy the benefits those entail. Stepping out of the ‘limelight’ can be hard but we owe it to our teams. And we owe it to the next leader to support and promote them as they set their new vision and agenda for the program. On the plus side, reducing administrative responsibilities may allow you more time for excellence in patient care and education.

Regardless of position or rank or title, all of us who take care of acute care surgery patients are leaders in some respects—you are leading a resuscitation, an operation, rounds, or a quality improvement project. Others will look to you often for guidance and reassurance. As mentioned, this is one perspective on how to lead. There are many ways to develop your skills and many ways to be an effective leader. The best one is the one that works for you. I encourage you to spend some deliberate time and effort exploring your leadership style, developing new leadership skills, and looking for opportunities to serve others.

## Ethics statements

### Patient consent for publication

Not applicable.

### Ethics approval

Not applicable.

## Footnotes

*   Contributors I am solely responsible for the manuscript.

*   Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

*   Competing interests None declared.

*   Provenance and peer review Not commissioned; internally peer reviewed.

*   Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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