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Commentary: The behavior of leaders

      Figure thumbnail fx1
      Navyatha Mohan, MD, MPH, and Ikenna Okereke, MD
      The behavior and approach to learning that trainees adopt will influence their learning. Similarly, the behavior of their attendings will affect the learning environment.
      See Article page e257.
      We read the article from Dr Pasque regarding surgical training with great interest.
      • Pasque M.K.
      Getting the most from your cardiothoracic surgical training: it's all about behavior.
      Dr Pasque has provided excellent advice for trainees regarding preparation, development of lifelong learning habits, handling uncomfortable learning opportunities, and being kind to staff and fellow trainees.
      We disagree, however, with the thoughts expressed in the section titled “You Are a Lightning Rod.” In the manuscript it says that “even the nicest CT surgeon” can become abusive while venting stress. Physical, emotional, and mental duress are part of our profession. How surgeons behave in moments of stress is a litmus test of character. Surgeons at all levels must be held to high standards of thoughtful and rational behavior under duress. Such behavior is indeed an integral part of what makes a great surgeon and leader.
      We oppose the idea that trainees need to “suck it up and take the hit” when faced with abusive behavior. No trainee should consider abusive behavior to be a requirement of surgical education. In our current environment, trainees do not report most episodes of abusive behavior against them.
      • Pei K.Y.
      • Hafler J.
      • Alseidi A.
      • Slade M.D.
      • Klingensmith M.
      • Cochran A.
      National assessment of workplace bullying among academic surgeons in the United States.
      ,
      • Gostlow H.
      • Vega C.
      • Marlow N.
      • Babidge W.
      • Maddern G.
      Do surgeons react? A retrospective analysis of surgeons' response to harassment of a colleague during simulated operating theatre scenarios.
      The idea that abuse builds character and is necessary is a misconception that needs to be set aside. Trainees who are abused are incurring repetitive aggression that will in fact hinder their ability to learn. In addition, repetitive abuse of trainees has been shown to increase the risk of burnout, attrition, and suicidal ideation.
      • Hu Y.
      • Ellis R.
      • Hewitt D.
      • Yang A.
      • Cheung E.
      • Moskowitz J.
      • et al.
      Discrimination, abuse, harassment and burnout in surgical residency training.
      ,
      • Shanafelt T.
      • Noseworthy J.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      We also disagree that derogatory attacks are not personal, and that silence is the best response. Minorities and female trainees tend to be bullied more frequently, indicating that there is probably some degree of a personal nature to the attacks.
      • Zhang L.
      • Ellis R.
      • Ma M.
      • Cheung E.
      • Hoyt D.
      • Bilimoria K.
      • et al.
      Prevalence, types and sources of bullying reported by United States general surgery residents in 2019.
      Also, a culture of silence has been shown to encourage further bullying.
      • Pei K.
      • Cochran A.
      Workplace bullying among surgeons—the perfect crime.
      We cannot expect residents to do the “hard work” of enduring abuse and then excel during their surgical training. Trainees who show decreased interest in working with an abusive surgeon are not exhibiting passive-aggressive behavior but instead self-protective behavior. Residents must be encouraged and empowered to respond firmly and calmly with a simple “That's inappropriate, sir or ma'am.” A simple yet effective response like this hopefully will stem the abusive behavior without causing significant disruption, even in the operating room. Patient care is the responsibility of the entire team. An attending surgeon who engages in such behavior is not acting as an effective leader to trainees. As attending surgeons, we want to teach our trainees to operate and take care of patients. However, we also want to teach them to be effective leaders who conduct themselves with honor and dignity. A technically excellent surgeon will not succeed if that surgeon fails to display professionalism repeatedly.
      We agree that surgical training is improved by being other-focused. Other-focused surgeons place the collective good above their own. But doing the uncomfortable work of speaking up against abuse is an example of other-focused behavior. Speaking up in an effective but nonconfrontational manner will create a more positive environment for everyone and help trainees in the future.

      References

        • Pasque M.K.
        Getting the most from your cardiothoracic surgical training: it's all about behavior.
        J Thorac Cardiovasc Surg. 2022; 164: e257-e262
        • Pei K.Y.
        • Hafler J.
        • Alseidi A.
        • Slade M.D.
        • Klingensmith M.
        • Cochran A.
        National assessment of workplace bullying among academic surgeons in the United States.
        JAMA. 2020; 155: 524-526
        • Gostlow H.
        • Vega C.
        • Marlow N.
        • Babidge W.
        • Maddern G.
        Do surgeons react? A retrospective analysis of surgeons' response to harassment of a colleague during simulated operating theatre scenarios.
        Ann Surg. 2018; 268: 277-281
        • Hu Y.
        • Ellis R.
        • Hewitt D.
        • Yang A.
        • Cheung E.
        • Moskowitz J.
        • et al.
        Discrimination, abuse, harassment and burnout in surgical residency training.
        N Engl J Med. 2019; 381: 1741-1752
        • Shanafelt T.
        • Noseworthy J.
        Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
        Mayo Clin Proc. 2017; 92: 129-146
        • Zhang L.
        • Ellis R.
        • Ma M.
        • Cheung E.
        • Hoyt D.
        • Bilimoria K.
        • et al.
        Prevalence, types and sources of bullying reported by United States general surgery residents in 2019.
        JAMA. 2020; 323: 2093-2095
        • Pei K.
        • Cochran A.
        Workplace bullying among surgeons—the perfect crime.
        Ann Surg. 2019; 269: 43-44

      Linked Article

      • Getting the most from your cardiothoracic surgical training: It's all about behavior
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
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          The Accreditation Council for Graduate Medical Education works diligently to ensure that educational metric thresholds are consistently met in all cardiothoracic (CT) surgical training programs. You can be assured that an outstanding educational experience is available in yours. So, why do some trainees exit with so much more than others? The good news is that much is left in your hands. Although all trainees start out with the best intentions, it is behavior, not intention, that determines outcome (Figure 1).
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