Leadership and Training in Pediatric Urology

This chapter will take approximately 17 minutes to read.

By Duncan T. Wilcox, MBBS, MD ^{1, 2} & Pedro-José López, MD ^{3, 4}

Department of Pediatric Urology, Children's Hospital Colorado, Aurora, CO, USA
Department of Surgery, Division of Urology, University of Colorado, School of Medicine, Aurora, CO, USA
Department of Paediatric Urology, Hospital Exequiel González Cortés & Clinica Alemana , Santiago, Chile
Universidad de Chile, Santiago, Chile

Introduction

A frequently asked question of medical leaders and in particular surgical leaders is why would you give up some of your surgical practice to attend meetings. With sometimes a not too subtle subtext, some might imply perhaps you went into administration because you were unable to do surgery! While certainly that was considered true decades ago, for the authors who have over 20 years of administrative experience, we certainly hope that is not the case today.

In general, a surgeon’s career can be divided into 3 parts: after completing training the first part consists of honing ones skill, developing your own particular techniques, style and creating, in many peoples’ practice a clinical and or research niche. The second is when you are comfortable in your skill you have a definite competency and can provide excellent care and pass on your knowledge to others. Then there is the third—for some this is a continuation of excellent clinical care or research and for others it is the business side of medicine, especially if the surgeon is in private practice. For those less fortunate it is biding time until retirement. But one option available is to go into medical leadership.

The purpose of this chapter is to outline some of the reasons and benefits and give some guidance as to the necessary roles and skills of a good surgical leader. It is important to realize that being a “good leader” does not necessarily mean that the leader has an official title or position, although it can. A good leader is someone who exercises the quality of a leader in their daily practice within the team. These qualities are vital for a successful career in surgery regardless of whether the person chooses to take on a more formal leadership role. After all, a surgeon acts as the leader (or should act as the leader) every time they are in the operating room.

This is one chapter and not meant to be the definitive text on the matter. In fact there have been books written on almost every section outlined in this chapter and consequently there is an additional reading list at the end of this chapter that we recommend to interested readers.

“Never doubt that a small group of thoughtful, concerned citizens can change the world. Indeed it is the only thing that ever has.” —Margaret Mead

Why become a surgical leader

Before addressing the reasons for becoming a surgical leader with a formal title, it is important to realize that all surgeons, in practice, have a leadership role. Whenever a surgeon runs a clinic or has patients undergoing surgery then they are part of a very complex and highly qualified team. There is no doubt that the surgeon acts as the leader of that team, and the culture, vision and communication that the surgeon portrays, and models are vital to the outcomes those patients achieve. Consequently, all surgeons should understand the principles of good leadership, and this is the reason why many medical schools and surgical trainee programs now have official leadership courses in their curriculum.

There are many reasons to become a surgical leader when you have mastered being a competent clinical surgeon, but a many may not realize it gives you an opportunity to continue to develop and learn new skills. Leadership is like most skills, while some people are naturally better than others, everyone can improve by concentrating, learning and developing. Probably the most common reason why people choose to become a surgical leader is to help develop new programs and mentor less experienced faculty. There can be few greater work achievements than watching a novel program come to fruition that you had a hand in helping to foster. Or seeing a colleague develop and go on to have greater individual success. A good surgical leader can have enormous influence on the success of the team and the people within the team. In addition, by developing successful programs a surgical leader can significantly improve the care of patients to a much greater degree than individually treating patients. A good example of this is the formation of a robust quality and safety program. By creating a process that reduces surgical site infections by only 1% you could improve the care of hundreds of patients every year, which is difficult to do in one’s own surgical practice alone.

The one reason that is unacceptable to want to go into medical leadership is the desire to have a new (more important) title. If this is the reason you are considering surgical leadership you will be unhappy, and the people you are there to serve will be equally unhappy.

What value do clinicians have as leaders for a hospital

Often medical leaders undervalue their role in a hospital, perhaps because they have trained for many years to perfect the skills necessary to become a physician but do not appreciate what that brings to hospital management. In fact, many leaders feel intimidated by the new technical terms, abbreviations, and huge spreadsheets that they are presented with. Every profession has its own language and hospital administration is no different, but it is relatively easy to pick up. But even before you have mastered this, clinicians have a vital role to play in running a hospital. Certainly, the most successful hospitals have a strong collaborative relationship between clinical leaders and hospital leaders. After all, both are striving to provide greater and better care to the patients and community they serve. Increasingly, physicians are leading hospitals as their CEO.

Clinicians have insight into clinical problems and how to prioritize clinical conditions and treatments. Every hospital would love to provide all the resources necessary for every program, but all too often, difficult choices are necessary and clinicians can guide this. Clinical leaders act as a bridge between providers and administration and are advocates for staff, faculty, and patients to ensure that resources go to the most appropriate place. Importantly, a good clinical leader will have clinical credibility, so that when difficult decisions have to be made, such as which elective surgical patient needs to be cancelled because there are insufficient intensive care beds today, although patients will not be happy it will be based on clinically-relevant criteria.

How can you become a surgical leader

“The most dangerous leadership myth is that leader are born—that there is a genetic factor to leadership. That’s nonsense; in fact, the opposite is true. Leaders are made rather than born.” —Warren Bennis

Having made the decision to pursue a career as a surgical leader, how can you realize this ambition? There are many ways to go about this. Firstly, and probably most importantly on the job experience is vital. This will mean, even before taking up a position, being involved and actively contributing to committee work. Frequently, physicians will attend a committee because it is “good for your CV” or “will help with promotion” but not actually contribute—responding to emails, being available, answering questions and providing input to the committee. If you have aspirations for leadership, it is important to be active and add value to the committee. By being involved in committee work you will gain insight into the administrative workings of the hospital and hopefully be able to observe good leaders in action and learn from them. Furthermore, you may well have the experience to help solve important problems in the process! What are the attributes that make this person successful and not another?

In addition to on-the-job experience, there are a few more didactic ways to develop the necessary skills. Most hospitals and Universities will offer a series of leadership courses, and they may cover such areas as successful mentoring, financial education, or human resource work (specifically communication skills). Increasingly, leaders and potential leaders are offered executive coaching, this is normally a one hour a month of one on one conversations with a coach who can help you work through difficult problems and provide guidance. Be warned though a good coach will not tell you what to do but will ask you questions until you have the appropriate approach to deal with the current problem. Finally, there are degree courses, such as an Masters of Business Administration (MBA) or a Masters in Health Care. While these degrees will certainly provide a good education, they are not essential to landing a leadership position. They can certainly indicate a strong desire for leadership. We would reinforce the idea that leadership is a skill that is best improved by practice.

Frequently, people are striving to determine the specific characteristics associated with being a good leader, and in truth there is no one set of characteristics that make a great leader. Effective leaders can be quiet and introverted or eloquent and extroverted. They can be people who enjoy the limelight at presentations, and they can be happy in the shadows. It is important to follow your own character, but be clear and consistent in your communication and actions.

How to Lead

Once in a new leadership position, what are the areas that need to be addressed, and how can you best develop and promote your team and prepare the whole team for success? There appear to be several very important aspects to this covered in the following sections.

Changing Culture

“What you do has far greater impact that what you say.” —Stephen Covey

One of the most important first things in a role is to develop the culture of the team. How do you want the team to behave and to present itself? What are the behaviors that need to be promoted and what are the things that should be reduced? There are many aspects to developing a culture: Firstly, it is vital to communicate what you want to achieve, and this should be restated time and time again in almost every communication method that is available. It is not enough though to preach without practicing, but it is more important the leader should personally practice that behavior. For example, if you want the team to be respectful of each other, then the leader needs to treat everyone in the whole team with respect all the time. Creating a good culture takes time, but one or two bad acts by a leader can destroy a good culture in hours. In addition to preaching and practicing the culture, it is necessary to manage and correct behavior that is not in alignment with the culture. If someone, especially a senior person is seen or believed to be “getting away with it” or “above the law,” then all the work to create a good culture will be lost. Once a culture has been created (and this can be very quickly achieved with concerted effort) then it constantly needs attention and management.

One area that consistently seems to be important but is actually difficult to do is creating a culture that is consistent and, as much as possible, transparent. For example, if there are limited resources available for a set number of planned surgical procedures, deciding how to prioritize said resouces in a manner that is known by everyone (transparency) and applying this in a consistent approach will make the decision making process easier. Even though the people who did not get the resources will be disappointed, they will know why they did not get them and what they have to do to be more successful in the future. This is true for all decisions, if the criteria for success is openly communicated, and the results of the decisions are equally communicated then everyone will know how the system works. Little can be more destructive to a culture than “back room deals” or a feeling that the system is stacked against you or unfair.

Creating the appropriate culture cannot be overstated. There are many examples when a new CEO starts or a new coach leads a team, and within days or weeks, the success and direction of the team has completed changed.

Creating a Vision

For new surgical leaders having to create a vision seems very intimidating, but it does not need to be. What are you hoping to achieve? Is it to be the best clinical department in the country, to have the safest patient care, to develop a world class research team, or to provide excellent clinical care for your community. Do you want the team to be known as a great place and supportive place to work? What are your priorities? Once you have this in mind then you need to let your team know and keep telling them. It can seem ridiculous to repeat the same things every time you meet or have a staff meeting but everyone needs to know that making sure every patient gets great care every time is still the team’s main priority. Think of a good politician every time they get an interview, on the stump or in front of voters: they say the same thing and stress the same points over and over again, and a good leader needs to do the same thing. The team should never be in any doubt what the vision and goals of the team are.

When informing the group about a vision or goals, it is not possible to over communicate. Use every tool you have: meetings, one on ones, texts, emails, and retreats. However frequently you communicate, there will always be at least one person who has not heard or understood what you are hoping to achieve.

Once you have communicated your vision, this naturally leads to creating goals, both long term and short term. For example, if the vision is to become the best surgical program in the country then it is likely going to take 5–10 years to achieve this. So your long term goals are going to probably include: Developing world class programs, starting a robust quality and safety program, fostering a renowned teaching program, and creating a highly-funded research program. From these long-term goals, short-term goals can be created that can actually be achieved within a year. So that a goal may be to recruit a new surgeon scientist or develop quality dashboards. Having a clear vision, including long-term and short-term goals that the whole team know and have bought into will make your chances of success much greater. By writing down the goals and publicizing them, it has been consistently shown that they are much more likely to be achieved. When you have developed these goals and achieved them, make sure the whole team is aware of those successes!

People

“The best executive is the one who has sense enough to pick good people to do what the leader wants done and self-restraint enough to keep from meddling with them while they do it.” —Theodore Roosevelt

In any hospital the most important asset and the most expensive asset are the people who work in it. So once you have the right culture and an appropriate vision concentrating on the people within the team is vital to success. In fact, without recruiting, retaining, and developing the people, a team will never be successful.

Recruitment and retainment

Recruiting the right people is notoriously difficult. Many psychological studies have shown that interviews are a very poor way of assessing how effective the candidate is going to be at their job. Currently, though it is the most widely used method. In order to have the best work force, it is necessary to be able to choose from the most diverse pool, and so having a strong commitment to diversity, equity and inclusion is vital today for success. To recruit a diverse workforce, it is important to have a recruitment committee that is diverse and reflects the community that you are serving. That way, individual biases both known and unknown can be minimized, a wider pool of candidates can be obtained and hopefully the best candidate chosen. Larger organizations have systems in place to assist in this process, but if not, then a deliberate and conscientious effort is needed to ensure that the team becomes more diverse, equitable and inclusive.

Once the right team is in place, keeping them is the next challenge. Team members should be constantly checked in with to make sure that they have the necessary opportunities and resources not only to manage their work but also to achieve their career goals. It is too late when someone comes with another job offer to start giving them new opportunities.

Mentorship

“Outstanding leaders go out of their way to boost the self-esteem of their personnel. If people believe in themselves, it’s amazing what they can accomplish.” —Sam Walton

An integral part of being a good leader is mentoring and developing your team. It is necessary to create specific time on a regular basis for this. It can be part of regular meetings or time set aside for mentoring. Mentoring is a difficult skill because it is often easy to slip in to just giving advice, and on occasion that may be necessary but in general mentoring is about carefully listening to your mentee, asking appropriate questions, so that they can think through the problems in their work or career and giving them gentle guidance. Mentoring people can help them develop new skills that are vital for the team. It is also important to push mentees to develop or take on new tasks so that they are always improving and challenging themselves. When appropriate make sure that the mentee is offered new opportunities to pursue that way the team will develop a reputation of creating advancement chances and so will start to attract the best candidates.

As a leader though it is important to continue to understand the need for guidance in the role. Frequently, leaders are continuing to lean on their own experienced mentors to offer guidance, suggestions and advice in multiple areas. In addition, there is now a growing body of evidence to suggest that surgical coaching has great value in continuing to improve a leader’s skills.

Feedback

“A ruler should be slow to punish and swift to reward.” —Ovid

Increasingly, the importance of feedback is being recognized and requested by the work force. Giving regular positive feedback as close to real time is vital. This will be make it clear what attributes and behavior are wanted in the hospital and will also enable more constructive feedback to be given when necessary. Historically, 3 pieces of positive feedback were given for every one of constructive feedback—the so called feedback sandwich. But more recently this has been increased to up to 9 positive for every constructive. When giving feedback, either positive or constructive, it is better to give very specific examples and to give the feedback as close to the event as possible. So rather than saying you did a great job in the OR today, it may be better to communicate that the trainee was really good at gently handling the tissue. In general it is alright to give positive feedback in front of others (everyone likes being praised) but to give constructive feedback in private. Creating an environment where feedback is expected is vital, as this allows everyone to freely communicate expectations and good results. It allows all the team members to improve. In top performing companies, feedback is being given both to team members and leaders. Giving and receiving good feedback tends to be easy but giving constructive feedback is more difficult and needs to be deliberate, thought through, and timely.

Difficult conversations

“The growth and development of people is the highest calling of leadership.” —Harvey Firestone

On occasion it is necessary to have difficult or crucial conversations with team members especially if their behavior or work is not reaching expectations. No one likes having these conversations, but they are vital for people and for teams to improve. There is a tendency to put them off and find a “better” time, but they will always be difficult so it is best to get them done as soon as the need is understood. It is obviously best to have these in private and to ask the person about the event in question and what, in their words, happened and what they thought of it. Many times the person will realize their error and apologize without you needing to say anything except to work on a way to help the person so that it does not happen again. On occasion and more concerning the person may deny or gloss over the error, this requires more education and input from the leader. Many organizations now have specific offices that can help people improve their behavioral problems and sometimes the person has medical or social problems that we need to address first. If the team perceives that inappropriate behavior is not being addressed in an appropriate and timely manner, it may be taken that this behavior is accepted. Consequently, it is best to have these difficult conversations as quickly as possible assuming all the necessary information has been obtained first.

Opportunities

Giving team members opportunities within the team or organization is vital. This may seem like straight delegation but by offering people these opportunities either small (e.g., to arrange a meeting or retreat) or large (e.g., to develop a whole new program) sends a clear signal that you trust in them and believe they have the skills to do the job correctly. This has many advantages. It allows them to develop and to have confidence in their own ability, but it also allows you to move on to other projects that may be only you have the insight or information to successfully complete. By delegating appropriately team moral and confidence is greatly improved the team develop new skills and the leader greatly multiplies the work that can be achieved.

Money

Money can ruin everything! If people feel that others are better and unfairly compensated or that resources are not being fairly divided then this quickly leads to team disharmony. Wherever possible having a transparent system in place will allow people to know why decisions or compensation are different and what is necessary to improve the chances of better compensation. Where the system is opaque or murky people tend to assume that something underhand or unfair is happening even if it is not. In general, there are fewer complaints if people know and understand even if they are getting less money than others. Starting to develop transparency can be difficult though, as money is a difficult topic to bring up.

Continuous monitoring and reevaluating

To understand how the team is performing and whether you are achieving the goals the team have decided upon, it is critical to have prospective measurements. When you set a goal (for example, increasing research output), have metrics clearly defined before you start and measure them regularly. Publish them so everyone in the team knows if you are achieving those goals. Interestingly, team dynamics and the desire to improve can often significantly improve the data even without putting any new mechanisms in place. For example, just by documenting and publicizing what individual surgeons on time start rate is you will see an improvement as no one wants to be “below average.” Once you have these metrics in place, creating a dashboard and regularly reviewing the data will continue to lead to improvements. Also, by regularly reviewing the data you will be able to decide when it is time to move on and concentrate on something else.

Time

Finally, being a good administrator and leader takes time, it is not possible to continue having the same busy clinical practice and then taking on leading the whole team. You will need time to think, develop visions and goals, to meet regular with your direct reports, have time to mentor people. In addition, there will be many meetings with hospital leadership that it is vital to attend, so you are able to understand how the hospital works and what the current climate of the hospital. This will allow you to appropriately advocate for your team.

If you do not feel able or want to give up some of your practice, seriously consider if this is the right time to take on this position. If your organization is not prepared to compensate you appropriately for your time, once again consider if this is worth doing. Taking on a leadership role is incredibly rewarding: seeing new programs develop and team members taking on new opportunities is exciting and fulfilling, but if you are going to be annoyed by the lack of time or compensation it may not be the right time.

However, if you are given the right opportunities and resources, the satisfaction you gain from your new role can easily compensate for the reduction in your clinical work.

“There are three essentials to leadership: humility, clarity and courage.” —Fuchan Yuan

Key Points

Becoming a surgical leader provides new opportunities for learning about healthcare systems and to influence the care of a larger number of patients.
Start by getting involved in committee work and actively participating.
Leadership skills are best obtained through purposeful practice.
Creating a culture, defining your vision, and cultivating people and talent are key to a leader’s success.
Be purposeful, transparent, and available.

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