Take It to the Limit
2014; Elsevier BV; Volume: 98; Issue: 6 Linguagem: Inglês
10.1016/j.athoracsur.2014.06.122
ISSN1552-6259
Autores Tópico(s)Dental Education, Practice, Research
ResumoFig 1“Taking it to the limit!” Finals of Thames Challenge Cup, Henley Royal Regatta, July 4, 1976 (The American Bicentennial). Harvard winning gold medal over favored British team.View Large Image Figure ViewerDownload (PPT)Taking it to the limit is what cardiothoracic surgery has done for the past 50 years and what The Society of Thoracic Surgeons has done on behalf of the specialty for that same half century. Our founders took it to the limit when they had the courage and the foresight to create a new specialty society, The Society of Thoracic Surgeons, to represent a fledgling specialty and to become a home for that specialty within North America (Fig 2). Pioneering surgeons were taking it to the limit when they tried new procedures in thoracic and cardiac surgery, forging a new specialty that would affect millions of lives for the better. The presidents of this society, volunteer leaders, and professional staff have been taking it to the limit to make our specialty the model of innovation, quality, and patient-centered care that is an example and paradigm for other medical specialties. The foresight of leaders like Richard Clark and Fred Grover in developing our databases, and Mark Orringer in leading us to self-management, are examples of our leaders and our society taking it to the limit on behalf of cardiothoracic surgeons and their patients.Fig 2Officers and Council at the founding of The Society of Thoracic Surgeons.(Reprinted from Ann Thorac Surg 2014;97:S2-4 [6Rainer G.W. Merrill W. Genesis and early growth of The Society of Thoracic Surgeons.Ann Thorac Surg. 2014; 97: S2-S4Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar], with permission.)View Large Image Figure ViewerDownload (PPT)Some of the things that made us successful in our first 50 years may not be as effective or may even be counterproductive in our next 50 years. If we are going to take it to the limit for the next 5 decades, we will need to continue to evolve as we have done in the past. Although this evolution will encompass areas that may not be appreciated today, I would like to highlight two themes that I think will be important for us and for our continued success. The first is to embrace a feminism in cardiothoracic surgery that has heretofore been distinctly absent. Indeed, we are a macho specialty, frequently described as “cowboys” for our improbable fearlessness, brashness, and swagger. But in feminism for the specialty I am not talking about the bra-burning, militant, gender wars of the 1960s and 1970s. Rather, I am referring to a feminism that recognizes that our future is dependent on the recruitment of brilliant and talented women into our specialty and promoting them into positions of leadership within our departments, our hospitals, and our specialty societies. And I do not intend to slight the men destined to be cardiothoracic surgeons. I equally want to attract and encourage these smart, innovative, and hard-driving men to our specialty. Certainly the men before them have laid a good groundwork for our future. However, more than half of our medical school graduates are engaged and creative women, and without them we lose half of the intellectual talent that will keep our specialty fresh, relevant, and progressive.The other theme where I see us at a turning point, a place where we can continue to take it to the limit, is a shift to a style of selfless leadership. This leadership style is more modern, effective, and accepted by people in our professional lives and in our communities. Part of the macho swagger of cardiothoracic surgery has been transactional and selfish leadership, focused on the leader’s ego and the submissive performance of the rest of the team. In the rough-and-tumble early days of cardiac surgery, this highly ordered and proscriptive style was effective and led to the virile growth of our specialty. This leadership style was also a cultural norm emanating from the surgeons of the depression and World War II era, who dominated the development and maturation of our specialty. However, this leadership and behavior style is also responsible for the widespread reputation of cardiothoracic surgeons as arrogant, condescending, and insufferable—a reputation that we have not yet shaken. Although this leadership was effective for its time, expectations have changed, and the culture and people that we deal with today are radically different than those in our first half century.It turns out that these two areas of feminism and selfless leadership are closely intertwined. The traits of selfless leadership that are likely to be the most effective for our future are likewise those traits that are feminine and more naturally attributed to women leaders. Today I would also like to celebrate and honor the inherent qualities of leadership present in those who choose to be cardiothoracic surgeons: leadership that results in everyday heroism, leadership that extends beyond feats in the operating room, leadership of quiet colleagues who are heroes in their community, for their country, and dedicated to helping others. We are fortunate to have many amazing models of selfless leadership in our specialty and among our peers whom we work beside each day. They are not necessarily the most famous, but if you think of those colleagues that you most admire, you are probably identifying a selfless leader. It is someone that you admire for integrity, humility, generosity, and altruism rather than for technical or academic prowess.One hundred years before the founding of STS, almost to the day, the British ship Grafton, led by Captain Thomas Musgrave, shipwrecked in a vicious storm on the southern portion of Auckland Island. Four months later, another ship, the Scottish square rigger Invercauld, captained by George Dalgarno, wrecked on the northern portion of the same island. Auckland Island is a remote godforsaken place in the fierce expanse of ocean between New Zealand and Antarctica. Year-round freezing rain and howling wind and lack of adjacent shipping make Auckland Island one of the most remote and forbidding places on earth. To be shipwrecked there meant almost certain death.Although only 20 miles apart, the two crews were unaware of each other’s existence, and yet with almost identical circumstances suffered diametrically opposite outcomes, highlighted beautifully in a book by the New Zealand maritime historian Joan Druett entitled Island of the Lost [1Druett J. Island of the Lost: Shipwrecked at the Edge of the World. Algonquin Books, Chapel Hill, NC2007Google Scholar]. The crews endured relentless cold, wet, and windy weather with no shelter and negligible resources. However, Captain Musgrave inspired his crew, who banded together in a common quest for survival. They salvaged material from the wrecked Grafton, built a cabin, developed techniques for harvesting seals for food and oil, tanned seal hides for clothing, and ultimately built a forge and furnace. Encouraged by Musgrave, the men cooperated in procuring food, rotating duties, and nursing each other; they shared duties of hunting and maintaining a fire; they even crafted a chess set and card game for recreation and organized classes that included teaching the illiterate sailors to read. They adapted to a new type of discipline, bonded by camaraderie developed from mutual respect and support. Finally, after 20 months of incredible survival, Captain Musgrave and his crew fashioned a small seaworthy dinghy and crossed the open ocean, needing to constantly pump seawater out of the leaky craft for days before they ultimately made it to the civilization of Stewart Island in New Zealand.In the meantime, at the other end of Auckland Island, Captain Dalgarno and the crew of the Invercauld survived the wreck itself, but chaos ensued. Attempts by Captain Dalgarno and his officers to maintain the hierarchy and discipline of the ship failed. Witness testimony and diaries describe Dalgarno trying to maintain the chain of command, requiring the sailors to forage for food for the officers, and prioritizing his own privilege for shelter, sleeping arrangements, and sustenance. However, Captain Dalgarno failed to inspire his men and was unable to maintain credibility, respect, or control. There was no camaraderie to bind them, and even the crisis before them did not provoke a common purpose or an ability to work together. Ultimately, only three survived to be rescued by a passing ship a year later.Six years ago, in my address to the Western Thoracic Surgical Association, I briefly outlined this story [2Wood D.E. Cardiothoracic surgery: a specialty divided or as one.J Thorac Cardiovasc Surg. 2009; 137: 1-9Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. Yet, 6 years ago, I simply concluded that Captain Musgrave displayed leadership and Captain Dalgarno did not, but as I have learned myself over the past several years, the difference is probably much more nuanced than a simple presence or absence of leadership. There is no evidence that Captain Dalgarno was a weak or ineffective leader. On the contrary, Dalgarno had a distinguished career and was a highly respected ship captain when he embarked on the expedition with the Invercauld. The tragic outcome is more likely due to Captain Dalgarno maintaining a leadership style that he was accustomed to and that had been successful throughout his career, yet did not pertain to a radically altered environment. A drastic change of circumstance required a similarly drastic change in leadership in order to rally his men to the camaraderie and commonality of purpose that was necessary for their survival. This is where the “randomized trial” on Auckland Island becomes so illustrative. In contrast to Dalgarno, Captain Musgrave completely altered his approach to leadership after the shipwreck. Musgrave flattened the hierarchy that had been important for structure and discipline on the ship and threw his lot in with his men, sharing even the most menial duties, leading by example rather than by command, and establishing respect and leadership among his men. Both of these men were faced with nearly identical challenges on the same island at the same time. One of these leaders failed in spite of his clear track record of successful leadership. He and his crew deteriorated into chaos and anarchy, with the ultimate loss of human dignity and human life. However, the other inspired his team while enduring the same harsh conditions, maintaining a high standard of social structure and resulting in the survival of all of his crew.Changing times dictate the need for change in leadership style. Cardiothoracic surgeons are natural leaders who influence their teams, their departments and hospitals, their communities, and public policy. Yet, effective or acceptable leadership style has progressively changed significantly over the course of most of our careers. This change is not as sudden as a shipwreck, but it is no less profound. Although most of us have familiarity and proficiency with a hierarchic or authoritarian leadership style, similar to that exercised by a captain on a ship, the worlds and environments that we now face are almost always more responsive to selfless leaders with integrity and emotional intelligence. These leaders motivate people with a shared vision of the future, and they communicate well. They are also typically self-aware, authentic, empathetic, and humble—characteristics not routinely considered the strong suit of cardiothoracic surgeons.Leadership principles are common fodder for presidential addresses, and it is hard to contemplate covering new territory that has not been better considered or presented by previous presidents. However, as I have considered these remarkable contrasts between the two captains stranded on Auckland Island, I see changes and challenges that require us to rethink our leadership style and principles. As cardiothoracic surgeons we are accustomed to being the captain of our own ship, directing our surgical team in the operating room and our clinical team in the hospital. But in all aspects of our specialty we are increasingly reliant on collaborative partnerships with other specialties and our allied health care colleagues. Although these collaborations have always been present, they have been changing so rapidly in the past few years that they have created a new paradigm for practice in nearly all areas of cardiothoracic surgery.As cardiothoracic surgeons we like data: data that inform what we do and validate our outcomes. Data exist for the preferred characteristics of leaders in the modern world, which appear to parallel the successful transition to an adaptive and selfless leadership style that helped Captain Musgrave be successful on Auckland island. The social scientists John Gerzema and Michael D’Antonio recently surveyed 60,000 people in 25 countries that represented 65% of the world’s gross domestic product. The authors identified 125 different human behavioral traits and were able to show that across age, gender, and culture, people around the world believe that feminine traits correlate strongly with making the world better place [3Gerzema J. D’Antonio M. The Athena Doctrine: How Women (And the Men Who Think Like Them) Will Rule the Future. Jossey-Bass, San Francisco2013Google Scholar]. They found that traditionally feminine attributes and values are now more strongly related to leadership than the macho paradigm of the past and that people are frustrated by a world dominated by codes of male thinking and behavior—codes of control, aggression, and black-and-white thinking (Fig 3).Fig 3Masculine and feminine attributed leadership traits showing a strong correlation and preference for feminine style leadership.(Used with permission of BAV Consulting, 3 Columbus Circle, New York, NY, 10019.)View Large Image Figure ViewerDownload (PPT)Unfortunately, the modern preference for feminine values, characteristics, and leadership places our specialty of cardiothoracic surgery at a distinct disadvantage. It only takes a casual glance around the room to confirm that 95% of cardiothoracic surgeons are encumbered with the foibles of masculine leadership. Gerzema and D’Antonio have written a book outlining the impact of feminine traits on leadership [3Gerzema J. D’Antonio M. The Athena Doctrine: How Women (And the Men Who Think Like Them) Will Rule the Future. Jossey-Bass, San Francisco2013Google Scholar]. Fortunately, the authors parenthetically note that men who think like women can be successful leaders, too. But we are burdened by the culture in which most of us were trained and by some of the masculine traits identified in the work by Gerzema and D’Antonio—traits such as dominant, strong, ambitious, hard-working, assertive, and competitive—but unfortunately also by such pejorative traits as arrogant, rigid, overbearing, and selfish.It might be easy to characterize this recent research by Gerzema and D’Antonio as an isolated and provocative effort to market books. However, similar credible researchers in leadership theory have confirmed the desirable principles of feminine leadership in our organizations today. The leadership consultants Zenger/Folkman recently published a study of more than 7,000 executive to middle management leaders in the Harvard Business Review. As one might expect, men outnumbered women in senior leadership positions by nearly four to one. However, on a leadership effectiveness index, women scored definitively better than men. And out of 16 important traits of leadership, women scored higher in 12 of these 16 traits, including such traditionally masculine traits as “taking initiative,” “driving for results,” and “establishing stretch goals.” But just as importantly, feminine leadership traits identified by Gerzema and D’Antonio and by others were highly important in the study from Zenger/Folkman: traits such as “displaying high integrity and honesty,” “developing others,” “building relationships,” and “collaboration and teamwork” [4http://zengerfolkman.com/wp-content/uploads/2013/07/WomenBetterThanMen.pdf (accessed Jan 1, 2014).Google Scholar].We have understood for many years the importance of increasing the number of women in cardiothoracic surgery, but these data provide further incentive for recognizing and promoting female leadership within our organizations. Advancing women within our specialty provides individuals with a set of leadership styles that are suited to our current practice environments and to the culture and expectations of the millennium generation and those that follow. Women have a more natural tendency to be what are known as selfless leaders, that is, leaders who understand that the cornerstone of honorable leadership is to serve those we lead. I encourage our program directors to look for ways to make our training programs and our practices more attractive to women, and I encourage leaders in our specialty to look for opportunities to mentor, encourage, and promote the female cardiothoracic surgeons around them. It can only serve to make us better.The success of Captain Musgrave and the success of women leaders in the 21st century are linked by the principle of selfless leadership that is often ascribed to those individuals who we consider our greatest heroes. These selfless leaders are attuned to the concerns of their followers and empathize with them, making others better by their presence.Carolyn Reed was one of these remarkable people and leaders in our specialty. I feel privileged to have been counted as a friend and colleague and to have stood behind Carolyn in whatever she was doing. Carolyn was a pioneer who was the first woman chair of the American Board of Thoracic Surgery and the first woman president of one of our cardiothoracic societies. She was also the first president of this society but was never privileged to serve because her life was cut short by cancer. Carolyn was an example of the best that we can strive for as cardiothoracic surgeons in our daily practice and care of patients as well as in education, mentorship, and leadership of the younger generation. Carolyn inspired and still inspires me, and we have all benefited from her selfless leadership (Fig 4).Fig 4Dr Carolyn Reed, a pioneering leader, mentor, and educator in cardiothoracic surgery, and the first woman president of The Society of Thoracic Surgeons.(Photo used with permission of The Society of Thoracic Surgeons.)View Large Image Figure ViewerDownload (PPT)The characteristics of these selfless leaders emphasize trust, empathy, and the capacity to listen and to relate to others. More than ever before, leadership is about the expression of tolerance combined with integrity and confidence. It requires courage to be both vulnerable and connected to others, and it requires humility to accept mutual dependence and an acknowledgement of one’s own weaknesses and vulnerabilities.This modern or feminine style of leadership is not about competition. It is not about raising yourself up above the others around you and certainly not about pulling down those around you. Modern leadership is about elevating the people around you, and perhaps people not even noticing that you were the reason. We are a competitive group—competitive with one another and competitive with ourselves. This competition has served most of us well in sports and in accomplishments in our professional lives. In a masculine construct, winning is typically considered a zero-sum game—one wins; the other loses. But in our environments of heart teams and multidisciplinary care, winning is plural. Sustainable improvements depend on collaboration and agreement. Over the longer time horizon we will see that the real winners are those who invoke the skills of sharing credit and consensus building to achieve shared success. Our careers will ultimately be a reflection of our character, how we treat others, how we work with people, and the strength of our integrity. Even though it may not come naturally to the hard-charging and high-achieving men who make up a majority of our specialty, feminine traits that are admired today suggest that we would all benefit from diminishing our ego and striving more for modesty and kindness. Vulnerability can be our new strength. Instead of covering up failure and pointing fingers, openness and humility are gateways to improved relationships and opportunities and to seeing the world in new ways that may be the most important agents of change management.Colonel Eric Kail served as the course director for military leadership at West Point until his untimely death earlier this year from cancer. Colonel Kail identified six leadership characteristics and focused on those successful requirements for the modern leader. These are remarkably consistent with the feminine leadership characteristics identified by Gerzema and D’Antonio and by the Zenger/Folkman researchers (Fig 5) [5Kail E. Leadership character: A six-part series by West Point’s Col. Eric Kail http://www.washingtonpost.com/blogs/guest-insights/post/leadership-character-a-six-part-series-by-west-points-col-eric-kail/2011/04/04/AGSg1DPH_blog.html (accessed Dec 23, 2013).Google Scholar]. When one considers the most influential people in your life—individuals who have had the greatest impact—what was it that made such a difference? Was it their skills, accomplishments, or abilities that left such an impression, or their character? Kail suggest that it is character, not accomplishments, that makes an individual stand apart as an exceptional leader. He identifies courage, integrity, humility, selflessness, empathy, and collaboration as providing the foundation for that character.Fig 5The six primary characteristics of selfless leadership.(Modified from Kail E. Leadership character: A six-part series by West Point's Col. Eric Kail. http://www.washingtonpost.com/blogs/guest-insights/post/leadership-character-a-six-part-series-by-west-points-col-eric-kail/2011/04/04/AGSg1DPH_blog.html [accessed Dec 23, 2013].)View Large Image Figure ViewerDownload (PPT)The role of courage is more about conviction to moral principles than taking risks in dangerous settings. In cardiothoracic surgery we have tremendous examples of courage all around us. We have celebrated the founders of this society today who had the courage and vision to create a new specialty society. We recognize this courage today in those who expand the boundaries of traditional cardiothoracic surgery with endovascular, hybrid, and minimally invasive techniques and who have the courage and strength of character to share this with our allies, the cardiologists, in contrast to the self-protective turf battles from the past. We owe a debt of gratitude to the courage of STS leaders like former presidents Sid Levitsky and Ranny Chitwood, and Director at Large Joe Bavaria.We have a group of surgeons with military service here today who should inspire us with their daily courage: courage not just in the face of risk of injury or death, but courage to put their careers on hold and to leave their families in the service of our country and our injured soldiers. Cardiothoracic surgeons are the ultimate surgeon’s surgeon, trained in general surgery, specialized in the technical aspects of cardiovascular and thoracic surgery, and adept in caring for critically ill patients. The cardiothoracic surgeons who have served overseas have saved untold lives while they and their families have made enormous sacrifices.Of course, for every one of these surgeons there is an individual story of service and leadership to inspire us. But I would like to choose just one because he is illustrative of the everyday heroes—not just who serve in the military but who fill this auditorium. Many of you know Cam Wright, a senior thoracic surgeon at Massachusetts General Hospital and a professor of surgery at Harvard. Cam is a soft-spoken, humble, and understated man in spite of his remarkable accomplishments as a surgeon, educator, and leader (Fig 6). Cam is not only a Director at Large for our society but is also the Vice Chair of the American Board of Thoracic Surgery. Cam was at a comfortable stage of his career with no existing military commitment when he joined the Army reserves in 2007. At the time, Cam’s son was deployed and serving in the Marine Corps in Iraq. He knew that if his son was injured he would want him to be cared for by the best possible surgeons, and in an act of remarkable courage and loyalty, he volunteered for service and has now been deployed three times to Iraq and Afghanistan in support of our troops. Cam, I have always admired you, but you set an example of courage and service to inspire us all—courage to step out of the safety and comfort of your secure position at MGH to care for the soldiers who are serving our country.Fig 6Dr Cameron Wright, an “everyday hero” cardiothoracic surgeon volunteering to support the troops in Iraq and Afghanistan.(Photo used with permission of The Society of Thoracic Surgeons.)View Large Image Figure ViewerDownload (PPT)The second character of leadership that I would like to emphasize is the role of integrity. This may be the most critical character for our leaders because it builds valuable trust between people, a trust that is necessary to build credibility, confidence, and an acceptance by our teams. Being a person of integrity does not mean you have not committed a moral or ethical violation; it means that you have the humble introspection and strength of character to learn from these mistakes and seek continual self-improvement. It is remarkable that the term “integrity” becomes very highly charged, with individuals accused of either having integrity or not, as if it were an all-or-none phenomenon in contrast to nearly all other human characteristics. Yet, integrity is an imperfect and incomplete quality like most others. It can be developed. It can be learned. It is something for us to strive for and improve rather than to declare present or absent. We recognize and respect integrity when we see it. Our goal should be to model these individuals and the traits that we respect. Many of us have individuals who serve as a moral compass or as our own examples of integrity that we aspire to. Those individuals for me are Doug Mathisen and Carlos Pellegrini (Figs 7A and 7B) Doug Mathisen is a mentor and friend, who provides the clearest example of anyone I know of the integrity and honesty of doing the right thing and doing it all the time. I know that when I am faced with an issue of moral uncertainty, a conversation with Doug affords me much clarity and greater confidence in making the right decision. Carlos Pellegrini is my boss; but more than a boss he is a daily example of integrity and emotional intelligence in his dealing with people and his leadership of organizations. Carlos holds a depth of human understanding and strength of moral character that I can only aspire to. But aspire to it I do, for I have this outstanding pillar of integrity to model and to work beside every day. We should all be so lucky as I feel that I am with colleagues like Doug and Carlos, and I would encourage each of us to seek out and to imitate those people that we so admire.Fig 7(A) Dr Carlos A. Pellegrini.(Photo used with permission.) (B) Dr Douglas J. Mathisen. Surgical leaders who demonstrate ideals of ethics and a moral compass for others to follow. (Photo used with permission of The Society of Thoracic Surgeons.)View Large Image Figure ViewerDownload (PPT)A third characteristic of the modern leader is humility, one of those female leadership traits that promote respect, loyalty, and trust in our modern team environments. I think it is fair to say that humility has not been a primary characteristic of cardiothoracic surgeons. Our leaders frequently have been bold and brash, sometimes to epic proportions, providing terrific stories and anecdotes that are often recounted at meetings like this. The stories are humorous in their recounting of outsized egos, self-admiration, and the hero worship that accompanied the beginnings and rapid growth of our specialty. But I am not criticizing our early leaders or the style that was effective and relevant at the time. Yet, our specialty and the world have evolved. We work in a better established, safer, yet increasingly diverse and complex team environment. The expectations of our teams and the rules of engagement between people promote a softer and more collaborative style of authority—the style modeled best by our women leaders and demonstrated by Captain Musgrave as he successfully navigated a radically changed leadership environment after his shipwreck on Auckland Island. Humility provides us with a clear perspective and respect for our place in context to others. It is the character that leads us to celebrate success in others more than in ourselves, and the humble recognition that our own successes are due to the substantial and cumulative influence of the people around us.As many of you know, having seen for myself some of the remarkable contributions of cardiothoracic surgeons to their community and to their country, I solicited from our members stories about some of these remarkable surgeons and ways that they are working to ma
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