Keywords

Introduction

For the first edition of this monograph I was quite flattered when asked to contribute to a textbook on surgical leadership, until I was told I was invited to write the chapter about leadership mistakes. After an initial hesitation and false sense of insult, I decided “yes!” because over my past two decades of leadership in academic surgery I have unquestionably made a great deal of mistakes. Mistakes are valuable because you can only learn from them, and if shared, others may learn from them too. If you are not making mistakes, you are not trying hard enough. I decided, with the use of a few important references, to provide what I believe are the top mistakes that a surgical leader, or perhaps any leader, may make. I assure you that I have made them all, and unfortunately, I will unquestionably commit at least a few more during the remainder of my career. I ask the readers to review the reference list of classic articles and textbooks that are worthy of their study if they aspire to successful surgical leadership careers. For this second edition, I have asked my colleague and co-author, a newly minted Professor and Chairman, to add his perspective and expertise.

First, leadership matters! In Joseph Simone’s words:” What makes great leaders is not a secret-they not only have grace under pressure, which means both courage and character, they remain focused on the important aspects of an issue in the midst of chaos, and they repeatedly articulate a consistent, simple public vision.” It is also important to differentiate between leadership and management. It is often said that management means doing things right, whereas leadership is doing the right thing, and much more difficult. As a surgical leader you will need to be both a manager and a leader. Management issues tend to be urgent, the daily putting out of fires. They can be briefly satisfying in solving, but can and will get in the way of leadership issues, which are more important and often less immediately gratifying.

Peter F. Drucker was the most famous, prolific, and profound management thinker that ever lived. I recommend many of his works and will include them in my reference list. Many of his axioms can be applied to leadership.

The first and most important step in building leadership skills is to be self-aware of your own weaknesses and strengths, and to work on minimizing and improving them, respectively. Do not be afraid to seek counsel or coaching. Pursue feedback rather than waiting for it to happen. Ask yourself, when interviewing for a job, if your direct supervisor (Dean, Chair, CEO) is a mentoring individual. Often Chairs are hired without any support or promise for their own professional development. Perhaps there are a few natural leaders out there who do not need it, but not us. We have dozens of leadership and business school textbooks on our shelves, all of them read and highlighted. There are several more in our Amazon queues. None, however, has taught us as much as the one-on-one sessions we have had with the great mentors of our careers. Leadership, like surgery, is a lifelong learning experience. Embrace it. Both authors approached middle age by entering MBA programs.

In Halverson’s article it is wisely stated that leadership is two sides of the same coin: self-management and team management. Self-management is based on emotional intelligence, which is the ability to manage oneself and one’s relationships. We encourage you to read or review Daniel Goleman’s salient works about emotional intelligence. Briefly, emotional intelligence comprises four essential domains: Self-awareness, self-management, social awareness, and social skills. This topic is elaborated upon in another chapter of this book. Goleman further divides leadership styles into authoritative, coaching, affiliative, democratic, pacesetting, and commanding. Bing Rikkers, in his wonderful Presidential Address to the Central Surgical Association, comments that surgical leaders must be able to use multiple leadership styles depending on the situation. He likens these to the golf clubs in one’s bag that one appropriately deploys depending on the shot required. For example in the operating room, when there is a sudden injury to the right hepatic vein, a surgical leader would use a commanding leadership style, as using the democratic style or coaching style could be lethal. We continue to see many surgical leaders use the commanding, or “surgical mentality” style by default, in situations where affiliative or democratic leadership is far more appropriate.

Another important reference that we recommend to all serious readers and students of leadership is Rules by Donald Rumsfeld. Irrespective of whether you like his political beliefs and career, there are many pithy and profound rules that apply to business, government, military, and surgery. Many of them will be used in this chapter. So in the essence of brevity we would like to give you our Top 13 errors list. We apologize in advance for the curmudgeonly and frequent use of quotations. The 13 errors are not ranked in order of ignominy or priority, yet they also all interrelate at some level.

Number One: Failure to Appreciate that Institutions Do Not Love You Back

This is the first rule from Joseph V. Simone’s classic and “a must read” manuscript entitled “Understanding Academic Medical Centers: Simone’s Maxims “. Although at first blush this may sound cynical, one simply cannot presume the same respect or appreciation from an enterprise that one would from a friend or family member. You will be astonished that even the most wizened senior faculty believes that they somehow merit special dispensation because of their longevity, or past productivity, or sworn allegiance to an organization. Repeat after us: “What have you done for me, lately?” Simone refers to a colleague who opines that the only true job security is the ability to move to another position, because of professional independence. In these days of rotating Chief Executive Officers and Deans, it is sad to say that institutional loyalty to an individual, especially a chair, cannot be counted upon. Institutional lifespans are long, ours is ephemeral in comparison.

Although we will discuss this later, the concept of “tickets, or chits” should be mentioned here. Jerry Shuck, in his presidential address to the Central Surgical Association, presented the hypothesis that an individual is given a certain and fixed number of tickets when granted a leadership position. The number of tickets granted is a carefully guarded secret that this individual never knows until the last one is spent. The purpose of this digression is that when there is a change in leadership at the Dean or CEO level, the chair’s reserve of tickets may precipitously decrease or disappear.

Number Two: Failure to Appreciate that Not Everyone in the Room Is as Interested in Team Success

Transitions are the riskiest time for the new leader, yet potentially can yield the greatest rewards. Much is written about the first 90 days of any transition and the need to learn about the culture of the new organization, as well as the need for transparency, clarity and repetitive delivery of the new message. There is much emphasis on the early definitive wins and the identification of allies who will help you carry that message forward. Remember: culture is the most fundamental framework of teamwork and reflects the heart and soul of the team. Culture can be good or bad. Do not underestimate the power of the pre-existing culture for it has persisted for a reason. Do not assume it is for the good of the team. As Peter Drucker was fond of saying “Culture eats strategy for breakfast.”

Yes, we are surgeons who thrive on the art and science of medicine and would do anything for a colleague, patient or family in need. But, do not always assume that everyone on that new team shares your most fundamental values, good will, and resolute understanding of the power of teamwork. Failure to realize that you cannot convince some that change is needed will continue to plague the most fundamental improvements.

Some members of the team will never admit that change is needed nor have an alternate plan for the organization. These individuals may spread anarchy for the sake of anarchy. This is often surreptitiously performed through a carefully crafted pre-existing subcultural labyrinth. Such conduits are ideal for the speedy delivery of misunderstandings, “fake news”, and outright lies sent out as sound bites to test the worthiness, transmissibility, and impact factor of these packets of vaporware on the intended recipients. Periodic micro-insults, which only need sensitive recipient ears, will stymie the best-intentioned forward motion of a team. Once discovered, these subterranean tunnels must be plugged aggressively and declared unworthy of further human habitation, akin to clearing the wound of infection before healing may begin.

Number Three: Failure to Respect that Leadership Cycles Have a Natural Ebb and Flow

As Joseph Simone famously said “for academic leaders, the last ten percent of job accomplishment may take as much time as the first ninety percent, and may be not worth the effort.” He then states that the average leadership duration should be 10 ± 3 years. Thomas Starzl reportedly said that surgical chair positions should have durations of 7 ± 2 years. We personally believe that the era of the chairmanship lasting until retirement is a dinosaur, like many of those who did such. New leadership at the Dean, Executive VP, or CEO levels are likely to bring in their own teams irrespective of the successes of the incumbents. Be prepared and try not to take it personally. In addition, it is important to have the insight that perhaps you no longer have the passion or institutional support to take your Division or Department to the next level. It is no service to anyone if you are just going through the motions, or as Rumsfeld says, “if you are coasting, you are going downhill.”

In saying this, we comment that it is not a good thing to be constantly on the search for a better opportunity. There are no well-kept secrets in academic surgery and if a sitting chair is looking at another position, he or she must be willing to accept the brinksmanship that may result at home. Also, you probably will only receive one retention package. Your second trip to this particular well may result in a firm handshake and best wishes. Simone states that you should consider an academic move only if there is an improvement in anticipated environment and opportunity of 50% or more. The grass may look greener but when you get there the verdure most assuredly will not be luxuriant as once believed.

You will also be faced, as a leader, with faculty members who are constantly interviewing for another position. Often, they will tell you this during an early conversation after your arrival. Listen carefully, but make no promises or retention offers until you have done your due diligence as to the faculty member’s value and track record of such claims. If the individual was an internal candidate for your position, listen even more carefully and gauge whether he or she will be an ally, or a passive or aggressive impediment to your vision (see Number Two, above). It may be best to cut the cord and allow them a graceful exit. Beware of faculty who announce that they have another offer, and a better one, as your first introduction to their job hunting. Michael Zinner wisely opined that anyone can have a first interview, or “first date”, but once a second date is scheduled, it is appropriate and respectful to notify the chair.

Number Four: Failure to Remember that First Class People Recruit First-Class People; Second-Class People Recruit Third Class People, or as Rumsfeld Says A’s Hire A’s, B’s Hire C’s

The late William Longmire once commented that his secret to success as the first surgical chairman at UCLA was to hire great division chiefs and then get out of their way. Of course, he modestly simplified his success. We also later learned that this advice originally came from Theodore Roosevelt. Dr. Longmire provided his leaders with resources, support, and promoted them vigorously internally and nationally. He was neither afraid nor intimidated by their excellence. Michael Zinner, inarguably one of the greatest surgical leaders of our time, stated it this way, “learn to bask in the reflected glow.” After all, it really does not matter who gets the credit as long as the job gets done well. Rikkers says it this way “leadership need not be lonely, wise chieftains grant authority and responsibility to those they had delegated assignments”. Do not be afraid of hiring people who are smarter, more accomplished, or even better surgeons than you. Genghis Khan was an icon of political and military genius, but his greatest strength was in the ability to recognize and recruit excellent generals. Rikkers also state that the two most important roles of a leader are mentorship and recruitment. Mentorship leads to retention of those whom you have recruited. Rikkers also states truthfully that a lack of autonomy has been a driver for divisions of surgery to seek departmental status.

Saying this, you will make recruitment mistakes. We have made many of them and the senior author has often aggravated them by seemingly becoming an all you can eat buffet of second chances. After all, you put your pride and reputation on the line bringing in a physician or researcher who subsequently was found to be incompetent, dishonest, lazy, disruptive, or just a poor fit. Do your due diligence. The smallest red or yellow flag must be considered seriously, as should be its source. “Warm body” recruitments, especially in times of great clinical need, are to be avoided. Take your time, as removing someone from a faculty position can be extraordinarily time-consuming, litigious, and damaging. This is one of the reasons that we do not favor multiyear contracts to new recruits, despite their obligatory requests. We also believe that one should “excise the lesion” as soon as it becomes obvious that failure is present and a suitable attempt at rehabilitation is complete. Work with your human resources department and be prepared to keep meticulous records of interactions with the faculty member. Over the last two decades we do not believe that we have ever relieved a faculty member of his or her position without legal action being initiated.

Number Five: The Failure to Appreciate the Changing Priority of the Surgical Workforce

The failure to adhere to an occult progressive new paradigm of what’s in it for me (WIIFM) will limit your impact unless you recognize that for some it is money, lifestyle and work/life balance that serves as the leading edge of the new practice model. We have had some practitioners look at us as though we had three heads when we wax prophetically about the pleasure and pain of caring for the sickest patient, the receipt of the hand-written note of thanks from a patient’s relative, and the enduring pain that comes when surgical results are less than hoped and strived for- yet remain as indelible marks on your psyche. These are the best and the worst of experiences for a surgeon that defines us as human beings who are capable of a broad range of emotions. This is the life of service that prior generations thrived upon and that has created most medical advances. Although not the sole driver of some of those in medicine now, it remains as a powerful force that if unrecognized cannot be understood and utilized. If unacknowledged it will serve as a barrier as potent as the Berlin wall to any change. We implore you as the leader to take that difficult stand and face those pervasive issues in today’s world with the ethical leadership that has defined medicine for the millennia. Remember to never forget that this is more than a job. Once it becomes a job then we are on a slippery slope for society and run the risk of merging with any of the multitude of occupations competing for the lead in the blind pursuit of financial bliss.

Number Six: Failure to Understand that the Leadership of Change Will Be Your Hardest Task

Machiavelli said that “there is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, and when you take the lead in the introduction of a new order of things.” You were recruited to your new position because change was seen as necessary and you will be the driver and public face of that change. Hence prepare for criticism, inertia, and even insubordination from the few who are not willing to see the path ahead of them. The path is the key. Get your leadership team involved early, on the takeoff rather than the landing. Being crystal clear as you articulate your vision where your department, division, unit, or center should be is essential. Encourage feedback and be willing to amend, but never compromise on what is the right thing. Surgery is not a democracy.

If you do not have failures then you are not trying hard enough. If your shortcomings do not become visible then you are not out of your comfort zone and you are not growing yourself or your organization. If your true north tells you that something must change for the long-term goals of improved patient care and improved teamwork, then as Admiral David Farragut is oft quoted during the Civil War battle of Mobile Bay “damn the torpedoes, full steam ahead.” Nothing should prevent your ethical leadership and moral compass from improving the lot of mankind, no matter how small an increment, as long as it is forward and with honorable intention. Should your effort appear to prove fruitless to those outside looking in, the reward is truly the learning experience from the failed process and further insight into oneself. That so-called “benefit” may initially be opaque and remain that way for the longest time; however, when it is least expected the learning might reappear as experience and guide in unexpected ways.

As Teddy Roosevelt so aptly stated “Far better is it to dare mighty things, to win glorious triumphs, even though checkered by failure … than to rank with those poor spirits who neither enjoy nor suffer much, because they live in a gray twilight that knows not victory nor defeat.”

Be sure to join an organization that allows the new leader to create a new culture or pursue a worthwhile avenue, and in the process, understands that some changes take time and “mistakes”, often made, must be recognized as part of the cost of doing business. You want to make sure that the organization is healthy enough that it does not adhere to the principle in which it is really easy to avoid all surgical complications by not operating at all!

A good salesman knows that the first thing to sell is yourself; the product (or vision or policies) are sold second. You must be clear, consistent, and above all honest first before expecting the right “others” to jump into the bus with you, or the wrongs to disembark.

A few quotes: General Eric Shenseki famously said “if you don’t like change, you are going to like irrelevance even less.” Rumsfeld says “dogs don’t bark at parked cars” i.e. if you are not being criticized, you may not be doing much. Margaret Thatcher stated that “there is nothing more obstinate than a fashionable consensus. “Charles Darwin put this in evolutionary terms by saying that “It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”

Finally, remember that the place you landed was still standing when you arrived. They were doing some things right, including their decision to hire you. Do not throw the proverbial baby out with the bathwater. Build on the existing strengths and relationships even as you create your vision for new ones. Entire textbooks have been written about the leadership of change and change management. We have read quite a few and remember a little. Some of our favorites are placed in the reading list at the end of this chapter.

Number Seven: The Failure to Repeatedly Ask Yourself If What You Propose Is Fair, Is Clear for All to Understand, and Is What You Would Want for Yourself

This is the failure to ask yourself repeatedly if your message is appropriate for the task at hand or is simply the case of a square peg in a round hole. If so, it prevents the team from acceptance and rowing at the same cadence and in the same direction. The leader must be introspective at every step to understand who the team is, what it would like to become, and perhaps what it is capable of handling. As James Comey pointed out “doubt is wisdom.” This should almost become a daily event and eventually will lead to a clearer understanding of the leaders’ almost automatic response to a patient in distress, a family in need of consolation or any one of a number of crises and will ultimately reflect one’s true north. Gates’ rule number 32 is “never do anything to a patient you would not want done to yourself” also applies to the individual teammates. There will be many instances of external queries about the effects of change and your role within that organizational change. As long as one has been through the process of self-doubt, reflection and reassessment as to the true motivation beyond self, the leader will reconfirm the needed change and the wisdom to press on in the face of unstable times. The failure to anticipate those queries may derail your efforts but if the leader has done his/her internal measurement and homework ahead of time, then it will not be long before they are back on track.

Number Eight: Quitting Your Day Job

We can only hope that you did not enter medical school or complete a surgical residency with the ultimate aspiration of being a division chief or the chair of a department of surgery. (Even worse, if your primordial aspiration was to become a Dean!) Oh sure, you may have known that you were something special and a natural leader based on those glowing letters of recommendation received as an undergraduate and medical student. Nevertheless, your first and singular task was to learn how to be the best operating surgeon; one with expert technical skills, great patient empathy, and of course an intellectual curiosity. The days of the surgical chairman only occasionally operating with the help of a junior faculty or a fellow are now extinct, like their analogous dinosaurs. We have been visiting professors at a number of institutions where, when the Chair’s surgical practice is mentioned, eyes roll and the conversation become funereal.

Even if you are one of those rare triple threat individuals with a funded laboratory and an international reputation, your junior faculty and residents need to see you in the Operating Room, blood and/or pus on your scrubs. This is especially true at night and weekends, as you must also take some call—and not the (once per month) “symbolic call” lorded over us by many senior egoist chairs at their multiple national meetings. Try to become an expert in one field and attain regional or national recognition in your ability to treat that disease surgically. It is difficult for a chair to have a busy tertiary practice with complex sick and often festering patients nowadays with all the administrative efforts and time sinks from the hospital and medical school. However, our 2 days a week in the operating room are usually our favorite and most rewarding days of the week. On the drive home, after a day in the operating room, one feels tired- an earned exhaustion. Compare that to the existential fatigue experienced after a day of meetings! Try to avoid having meetings scheduled late on your OR day or between cases so as to avoid any distractions. It is also important to scrub with junior residents, and be completely and utterly honest about your own complications at the surgical morbidity and mortality conference. In most cases you will be expected to be the grandmaster at this conference. Walk the walk.

A caveat: you will be watched, especially when new to the job. Other surgeons will wander through your operating room, seemingly to inquire how things are going or to wish you well, all in the subterfuge of really seeing how good you are as a technical surgeon. Like the cowboys of old, you must lead from the saddle. Be on time, get your own informed consents, and never malign the operating room publicly. If you are applying for a Chairmanship, insist on being Surgeon-in-Chief so as to be part of the solutions, not the problems, inherent in any academic operating suite.

Finally, do not appear aloof or unapproachable, even if you are busy and time conflicted. Make sure you sit in the OR lounge from time to time, telling a few bad jokes, but mostly listening on the fly to the concerns of all who work there. Host the departmental Holiday Party at your home and perhaps even a summer team-sporting event. When meeting with faculty, try to do so in their office. You can learn a lot by looking at the pictures and papers that adorn their walls. We have quarterly full Department meetings, and make sure a light supper is served.

This rule also applies because chairmanships may be ephemeral and you will need to rely on your hands and surgical skills if a change in leadership occurs. The ability to operate with skill and compassion will keep you employed, valued, and a candidate for other positions should this unlikely event occur.

Number Nine: Not Choosing Your Battles Wisely

You will be constantly faced with dealing with the urgent rather than the important. This is more than just time management; it is deciding where your scarcest resource, your time, is most effectively used. As a new chair your office will be flooded with faculty members with problems that have existed for years. You will be expected to solve these, in exchange for their undying trust and respect. (Don’t believe it.) Listen carefully, but before you promise, do your homework. Be especially cautious if your predecessor is blamed for the problem’s perpetuity. There is always more than one side to the story and usually a very good reason why this problem has been unsolvable for so long. Although getting a few quick wins under your belt is important, do not waste valuable energy or resources on the unwinnable or undoable. Sadly, these quick wins are often followed by a “what has he done for me lately?” Avoid the “tyranny of the urgent”.

It is important to seek counsel of others. A “kitchen cabinet” or Division Chiefs meeting should be held regularly, at least monthly. Here, many of these skirmishes can be discussed with those who have longer institutional and departmental memories. Insist upon absolute confidentiality from these meetings, however, and be wary of, and confront early, any leaks. The Chair has a lonely job, so consider strongly hiring a deputy, or Vice-Chair, whom you can trust, and develop a succession plan for yourself and all of your leaders.

Perhaps a leaders’ greatest strength should be “artful listening”, as per Steven Sample. Your inner circle should be constructed on trust and understanding. You should assemble a team committed to what is best for the institution and the department, and be willing to exchange in free and often no-holds-barred conversation, in private. Disagreements should be encouraged, but a decision is made, all must support it as a team.

Early on, become colleagues and friends with your corresponding chairs of Medicine and Anesthesiology. You are joined with them at the hip clinically and academically. Larger battles, and those engaging your Dean or CEO, may result in a win, but also a loss of a precious ticket, as per Jerry Shuck. Choose these carefully and make sure they really benefit the greater good of your faculty or patients, as it may become a Pyrrhic victory.

Number Ten: Poor Management of Meetings and Committees

Someone once told us that a good week is when you have more cases than meetings. If that were true, we have very few good weeks. As a surgical leader you will have meetings and committees populating your calendar with evangelical abandon. Many of these you will need to attend, after all, you most likely will be the only one there representing the field of surgery, or having the voice of reason. Sometimes real money or resources are discussed; to be absent is to lose your turn at the till. You do not have to attend all of them, however. Be prepared, review the agenda, and if there is none, suggest that there be one at the next convening. Speak up and express your concerns, comments, or advice, but do not feel the need to interrupt every silence with your own words, unless they improve the silence. Occasionally take the opportunity to publicly complement another chair or department. (Not the dean, as to avoid appearing sycophantic). If in doubt as to the importance or necessity of the meeting, arrange for your Executive Assistant to page you 30 min into it, to allow for a graceful early exit, seemingly for an urgent clinical matter. For after hours’ meetings, consider setting your smart phone to alarm 30–45 min into the meeting; you can always hit the snooze button if you want to stay.

The first consideration for your own meetings, according to Rumsfeld, is whether to call one at all. Can it be avoided with just a few phone calls or emails? Your direct reports are busy, as you want them to be, so be respectful of their time. Do not set a time or place that only works for your schedule. Send out an agenda, early, with time limits set for each item to keep all on track. If it is a regularly scheduled meeting, as with your Division Chiefs, invite agenda items, or at least have time allotted for open discussion. We strongly believe that no meeting should exceed an hour; 50 min is better. Do not let meetings be purely informational as that can be accomplished with just an email or document. Encourage discussion, even dissent, but keep things civil.

Start on time, and do not recapitulate for those who arrive late. It is disrespectful to the majority who were on time. Do not allow the use of smart phones by the attendees, unless it is to answer a call, and follow this rule yourself assiduously. Make sure everyone present is asked their opinion, and respect and explore differing views. Finally, the closing questions of any meeting should be: what was good or bad about this meeting, what have we missed, and what are the next steps? For the latter, assign responsibility. Avoid the formation of committees and subcommittees as a solution to a meeting’s unsolved problems.

For individual meetings the two most common mistakes are surprise and location. If you ask to arrange a meeting with a faculty member, make sure they know roughly what it is about. No one likes surprises, and no one expects good surprises. If a formal meeting, such as one for evaluations, negotiation, or criticism, use your office. If informal, congratulatory, or just to check in, visit them on their home court.

Committee work is the bête noire of the academic surgeon. Remember that only about a third of committee members will actually work at it, whereas an equal proportion is “idiots and troublemakers” (Simone). The rest probably will not show up. If appointed or conscripted to a committee, try to be in that good 30%, despite the other claims on your time. When establishing committees, remember that less is more. In fact, like a cardiac arrest, their success is inversely proportional to the number of people in the room. Make them small, representing all stakeholders of the issue, and establish goals and a timeline.

Finally, it is all about time management. David Logan, of Tribal Leadership fame, says it succinctly: Don’t let anyone commoditize your time. Here is a personal example: If paged, and I answer promptly, and I am then put on hold, I hang up (unless it is from a referring physician). Why? Well, when someone pages you they are essentially saying “stop what you are doing, and answer me now.” If they cannot make themselves available for that return call, they are commoditizing your time. When you are re-paged, gently notify them of this simple rule of etiquette.

Number Eleven: Forgetting that You Need to Be More Catholic Than the Pope

The senior author’s first academic leadership position was as Division Chief of General Surgery at UCLA. The laconic and underrated E. Carmack Holmes was my Chairman and mentor. Along with a lot of other good advice, he cautioned me to always be more Catholic than the Pope. In other words, you need to be above reproach in all matters clinical, ethical, and professional. The Department certainly had its share of outliers in those days, and he did not want his first leadership appointment to fall from Grace. Although I was initially affronted by this advice, I realized its importance early on, as I watched other surgical leaders, both at home and on the road, ignore it. Although some special dispensations or perquisites come with the leadership territory, they must be deployed with grace and humility, and as infrequently as possible.

This also means that you must expect this self-discipline from your direct reports and faculty members, without exception. Looking the other way for an individual, perhaps because of their busy clinical practice or grant funding, is an unforgiveable slippery slope. Needless to say, these conversations must be held in private, and documented. Chip Souba’s classic, and factually based, article about Brock Star, a hugely profitable but disruptive cardiac surgeon, is an epitome of this caveat.

A corollary of this rule is the axiom: just stay put. John Cameron once stated that there were two kinds of Chairs, those who went to meetings, and those who took care of patients. It is important to go to regional and national meetings, and attain some leadership in them, but limit your time on the road as much as you can. Your faculty will most likely have limited travel time and money, and many silently (or not) resent your travels, especially if they are left covering your patients. Use national meetings to support your faculty and residents by nominating them to membership and committees. We personally do not attend meetings for over a two nights’ stay, with rare exception. Chances are, if there is a black-tie event, we have already left the building.

Number Twelve: Poor Credit or Blame Assignment Mistakes

As mentioned earlier, learn to bask in the reflected glow of your faculty. The corollary of this was disclosed by Mike Zinner, when he said to not expect a lot of “thank you’s” in return. It is difficult to sit at a meeting and watch someone take full credit for your work, or suggestion, or resources supplied, but it is best to stay silent. Forgive, but remember. Be generous with praise and credit, but beware those who begin to believe in their own press. To paraphrase Bear Bryant, if anything goes bad, you did it. If anything is semi-good, we did it. Finally, if anything goes really good, then they did it. Send emails out to the faculty publicly congratulating someone for a publication, or promotion, or acceptance into a surgical society. The obverse and deadly sin is taking the credit when it is not truly yours. A venal example of this is padding your CV with the work of your faculty.

For the most part, you should criticize in private and praise publicly, unless an act is so egregious that a rapid response is mandatory. Remember the words of Simone, “muck flows uphill … and fast” contrary to the laws of physics. In academics the leader must, at first whiff of a conflict, error, or other significant problem, avoid the response of burying one’s head in the sand. Successful bullet dodging is rare. If you ignore it, it will not go away. Get the facts quickly for the rare horrendous surgical or research outcome, inform the Dean if necessary, and prepare a course of reparation. Consult your institution’s legal team, and be wary of the press.

Number Thirteen: Failing to Keep Your Priorities

It is often said that the opportunity costs of leadership are precious, and usually include family and personal time. After all, these priorities often complain the latest, and the softest … until it is too late. This is the mistake we make the most frequently. The senior author has never left a position where he did not have a full bank of unused vacation days. His young children rarely saw him before noon on Saturdays, and unless they went to church, before noon on Sundays. These were his “catch up” days for writing and administrating. He was lucky to have a most understanding family, and still managed to attend almost all sporting events and dance recitals. Saturday night dinners out were a family tradition, although now we nearly empty nesters tend to have it delivered. But we know that we could have done a whole lot better except for ambition and ego, and it could have easily gone the other path of counseling, separation, and divorce. Make your family a top priority. Chip Souba wisely stated that “your family never reads your CV”, and the old saw that no one ever lies on their deathbed wishing they spent more time at the office is a certainty. Try to go off the grid on vacations.

Do not fail to prepare for retirement, financially and personally. Maximize your pre-tax savings from day one. Have disability insurance. Counsel your junior faculty to do the same. Do not assume your health will be perfect forever, or that you can save for retirement after your kids finish college. Finally, do not ignore your own personal and spiritual health. Read, exercise regularly, and thank God every day that you have been blessed to be a surgeon.