Keywords

Introduction

In 1994, for the first time in the history of the American College of Surgeons (ACS), an individual who was not born in the United States (US) and had not trained in the US, was elected President. In his Presidential address delivered during the 78th Convocation of the ACS on October 13, 1994 Dr. Alexander J. Walt stated: “I stand here as the first foreign medical graduate (FMG) to be President of this College……. The election of a FMG testifies to the great generosity of our American Society, to its warmth, tolerance, acceptance of strangers, willingness to experiment, and its disdain for artificial barriers……” [1]. Nineteen years later, on October 6, 2013 another FMG, Carlos A. Pellegrini, gave his Presidential address in front of 1622 new fellows of the College as the 94th President. Of the 1622 initiates, 346 (21.3%) were from 55 countries around the world. Even though Dr. Walt and Dr. Pellegrini are examples that are difficult to follow, their stories have a lot in common and show that foreign-born individuals do serve in leadership roles in surgery.

Foreign Medical Graduates (FMG)

In 2017, a study based on the National Residency Matching Program statistics, published the trends in the proportion of students who matched into categorical general surgery (GS) residency positions. During the period between 1994 and 2014, they showed a steadily decrease (at a rate of one-half percentage point each year) of GS postgraduate-first year (PGY1) positions occupied by US seniors. However, during the same period, they proved that these GS positions have been filled by US FMG and non-US FMG applicants [2].

While some of them were American citizens, the majority were born and educated abroad. It is very important to separate these two groups. Generally, American citizens attended school and college in the US and then enrolled in a medical school abroad, mostly because they could not secure a position in one of the 151 accredited medical degree programs in the US. After graduation, and after passing the required exams (i.e., the United States Medical Licensing Examination [USMLE]), they eventually obtained a residency position in the US. In contrast, the majority of FMGs were born and raised abroad, and went to school, college, medical school and sometimes even completed a residency in their own countries. For them the path to a residency position in the US is very cumbersome, as it involves learning a new language, passing the USMLE exams, and often doing a couple of years of research in the US before applying for a residency position. In fact, there is no reciprocal recognition of training between the US and the rest of the world, so that even surgeons who are board certified in their own countries must complete a residency in the US in order to be eligible for board certification and independent practice [3, 4]. It is a long and hard process that requires many sacrifices: 1) leaving their own country, their family, and their friends; 2) facing expenses for the multiple examinations (around $3000) that are often equivalent to a 1 year salary in many underdeveloped countries [5]; and finally, 3) being immersed in an social and professional environment that is often radically different from their own. Language, beliefs, and family structure are unique to the American culture. For instance, in many other countries the role of the doctor is completely different, more “god-like”. Similarly, the role of nurses and other health care professionals, the concepts of informed consent, confidentiality, and documentation are unique to the American health care system [6].

So why are so many individuals willing to undergo this long process and make considerable sacrifices? There are indeed some very strong personal and professional reasons. The US is still seen as a land of opportunity. It is seen as a unique place in the world where an immigrant can become educated and wealthy, and where meritocracy is still the norm rather than the exception. Thus, there is a strong desire for many to try to achieve a comfortable economic situation, guaranteeing an education and a better future for their own children. In addition, there are some characteristics of the surgical education in the US that are absolutely distinctive: it is a system that is open minded, flexible, grants graded responsibility, and practices a hands-on approach. In contrast to many other countries where training periods extend to 10–15 years before a surgeon is considered ready for independent practice, in the US a general surgeon is produced in 5 years, a neurosurgeon in 7 years, and a cardio-thoracic surgeon in 7–8 years. And contrary to many other countries, employment is a certainty after completion of training.

Due to the shortage of American-born applicants to General Surgery programs, the number of FMGs will increase overtime. It is therefore important to understand and respect the cultural differences that exist. For the world of surgery it is a unique opportunity to create a work force characterized by the blending of many different cultures that will better serve a country blossoming with diversity.

In this chapter, we will focus on the influence of culture on leadership. We will use the term FMG to indicate individuals who were born and educated abroad before doing their residency in the US.

Leadership

There are many definitions of leadership. Wikipedia defines leadership “… as a process of social influence in which one person can enlist the aid and support of others in the accomplishment of a common task….” [7]. Patel et al. identified qualities that are essential for leaders in the area of surgery [8]:

  • Professionalism. Leaders must be honest, ethical and serve as a role model for their team.

  • Technically competence. Leaders must be recognized by their team as competent surgeons.

  • Motivation. Leaders must have clear goals and expectations in order to motivate their team.

  • Innovation. Leaders should have a vision and be able to adopt new ideas.

  • Teamwork. Leaders should be able to create and lead a team with a common goal.

  • Communication skills. Leaders should be able to convey information to others so that they understand the goal.

  • Decision making. Leaders should be able to choose the best options and take responsibility, even when the situation is not certain.

  • Emotional competence. Leaders should be able to control his/her own emotions and those of others.

  • Resilience. A leader should be able to adjust and recover from setbacks and changes to achieve a designated goal.

  • Effective teaching. A leader should be able to transfer knowledge and skills to others.

Some feel that individuals are born with inherited traits which determine leadership [9], while others think that individuals can learn to become leaders through teaching and observation [10]. We believe that what makes a leader is probably a combination of the two. Leadership, in fact, is influenced by many factors:

  • Generations : Today, the majority of the individuals in leadership positions belong to the baby boom generation. Baby boomers are goal-oriented, hard-working, and driven to success. They value power, and believe in a hierarchical system. Members of generation X are very heterogeneous in terms of race, religion and ethnicity. They respect talent more than authority, and for them work-life balance is a priority. In contrast, generation Y (the leaders of the future) have a sense of entitlement, do not believe in hierarchy, and demand to be mentored and to achieve an ideal balance between work and private life.

  • Gender . Although medicine has historically been a male-dominated profession, the Association of American Medical Colleges (AAMC) reported that during the last years, female presence has been steadily increasing, with women representing half (50.1%) of medical school matriculates in 2017 [11]. Conversely, while the number of women entering medicine has been increasing, there is still a significant underrepresentation of women in faculty and leadership positions in medicine. In 2015, women made up 39% of faculty, but only 22% held full professorship, with 23% tenured [12].

  • Race . Health care disparities according to race and ethnicity remain a persistent and insidious problem. Despite efforts to promote diversity in surgery, Blacks and Hispanics continue to be underrepresented [13]. In 2017, Abelson JS et al. performed a cross-sectional and longitudinal analysis providing an updated description of diversity along the academic surgical pipeline. It was shown that in 2014–2015, 12.4% of the American citizens were represented by the black population. However, they represented only 5.7% of graduating medical students, 6.2% of general surgery trainees, 3.8% of assistant professors, 2.5% of associate professors and 2.0% of full professors. In addition, from 2005 to 2015, representation among Black associate professors has worsened (0.07%/year, p < 0.01) [14]. Thus, while the U.S. population is growing increasingly diverse, this study demonstrates that this increase is not reflected in our medical school graduates, surgical trainees, and academic surgical workforce.

  • Mentorship . Mentors can help facilitate professional and personal development with respect to leadership skills thorough an assessment of strengths and weakness, helping in tasks such as decision-making, diplomacy, and conflict resolution.

  • Upbringing . It is easier to become a leader when the focus of the educational process has been to eventually assume a position of leadership. This is based on solid role models, often within the same family, and constant positive reinforcement.

  • Culture . There is no question that culture influences leadership. While this is not an issue for individuals who are born and raised in the country where they work, it plays an important role for individuals who were born and raised in a country different from the one where they eventually decide to live and work.

Culture and Leadership

Culture stems from ethnicity, language, beliefs, religion, customs, and philosophy of life. Different groups of human beings who live in different areas of the world are distinguished from one another by cultural traits, and this determines cultural diversity. Two concepts are closely related to culture and leadership: ethnocentrism and prejudice.

  • Ethnocentrism is the tendency to favor one’s own culture (race or ethnicity) over others, valuing one’s own beliefs and attitudes over those of others. This is a major obstacle to effective leadership as it can prevent a leader from understanding and valuing other people’s cultures. It can also make individuals less tolerant of other people’s behaviors. For instance, a leader that grew up in a culture that respects hierarchy and authority may find it difficult to deal with somebody that challenges his/her authority

  • Prejudice is a negative attitude toward individuals or members of a group, based on one’s own beliefs and feelings rather than on objective facts. Prejudice results from having an ethnocentric behavior. Classic examples are prejudices about race, gender, sexual orientations, and religion.

Many studies have focused on national culture and on what distinguishes one society or a nation from another, the so called “dimensions of culture” [15, 16]. Geert Hofstede identified five dimensions that distinguish societies [15]:

  1. 1.

    Power distance index. The extent to which members of an organization accept that power is not distributed equally.

  2. 2.

    Individualism vs. collectivism. The degree by which people prefers to act as individuals rather than group members.

  3. 3.

    Masculinity vs. femininity. The degree by which ideals such as competition and success (masculine ideals) are valued over caring for others and quality of life, traditionally considered “feminine” ideals.

  4. 4.

    Uncertainty avoidance. The degree by which a group uses norms and procedures to make the future more certain.

  5. 5.

    Long-term orientation. The degree by which goals are set for long-term objectives rather than for immediate gratification.

Another very important cross-cultural comparison study was the so called Global Leadership and Organizational Behavior Effectiveness (GLOBE) project [16]. The data in this study came from questionnaire responses from 17,000 managers in 62 countries. Globe identified nine cultural dimensions, adding four to the work of Hofstede.

  1. 6.

    Gender egalitarianism. The degree by which a group minimizes gender inequality.

  2. 7.

    Assertiveness. The level of confrontation and aggressiveness versus harmony and solidarity.

  3. 8.

    Performance orientation. The degree by which individuals in a group are rewarded for improvement and excellence.

  4. 9.

    In-group collectivism. The degree by which individuals express pride and loyalty to the organization and family.

Based on similarities in these dimensions, GLOBE divided nations into ten main cultural clusters, based on the belief that cultures are formed around regions that share common historical, political, economic and environmental backgrounds (Table 16.1). The study clearly identified differences among these ten cultural clusters. For instance, while in the Nordic Europe cluster gender egalitarianism and institutional collectivism were very strong, in the Middle East cluster gender egalitarianism was very low as women are usually afforded less status than men and are rarely in a position of leadership.

Table 16.1 Cultural clusters
Full size table

The goal of the GLOBE project was to see how different cultures determined different approaches to leadership. Six different leadership styles were identified:

  • Charismatic. Leadership reflects the ability to inspire and motivate.

  • Team oriented. Leadership emphasizes team building and common goals.

  • Participative. Leadership emphasizes involvement of others in decision making and a non-autocratic behavior.

  • Human-oriented. Leadership that is characterized by compassion, generosity, and sensitivity to other people’s needs.

  • Autonomous. Leadership that is individualistic and autocratic.

  • Self-protective. Self-centered leadership, status conscious and face saving.

Relating to the clusters described before, it is easy to identify a leadership style for each cluster. For instance, a Confucian Asia leadership style is team oriented but at the same time the leader uses status and position to make decisions independently, without the input of others. In contrast, in Anglo countries the leaders want to be non-autocratic, team-oriented and considerate of others. And they believe that face saving represents ineffective leadership.

Overall the study identified positive leadership attributes (confidence building, honesty, excellence-oriented, and motivational) and negative attributes (autocratic, non-cooperative, asocial, irritable). Clearly people from most cultures think that good leadership is based on integrity, charisma, and interpersonal skills.

In summary, this study underlines the intricacies of leadership and how it is influenced by culture. Furthermore, the GLOBE project stresses the importance of abandoning our ethnocentric behavior and opening our mind to different perspectives, with the goal of developing a richer understanding of the leadership process.

The FMG and the American Training System

As mentioned before, the path is very long for a FMG to get into an American residency program, often the end-result of a process that can take anywhere between 3 and 7 years. Most FMGs enjoy tremendously the training period. Even if they have completed a residency in surgery before, they treasure the teaching in pre- and post-operative care, the multi-disciplinary approach to the care of the patient, the progressive independency in the operating room, the evolving role as teachers for those who come after them. There is no question that at the beginning of the training, the FMGs feel a sense of pressure, the need to prove to themselves and the people that put their trust in them that it was not a mistake. The completion of training brings a unique sense of relief, the realization that it was possible to function at the same level as an American medical graduate and succeed in a different system.

As the end of the residency gets closer, however, the FMG has to make an important decision, something that has a tremendous impact in his/her future, both personally and professionally. It is the difficult choice between securing a job in the US and starting a path toward citizenship versus going back to the country of origin. Clearly it is a balance between different powerful forces. On one side, there is the realization that working in the US is very gratifying. As shown by the example of others who have reached the pinnacle of American surgery, the US system allows the individual to reach his/her full potential and to be rewarded for hard and high quality work. Along with the professional satisfaction, there is the certainty of an economically safe life, with the possibility of providing opportunities and an education to their own children, something often not possible in their country of origin. On the other hand, there is the realization that staying in the US means to be away from family, friends, habits, and life style as it was. In a way, it depends on the degree of assimilation that has occurred during the years of training. Some FMGs have chosen integration, the conscious decision to accept different rules as a need to function in a culture different from their own, a culture that is not embraced, with preservation of their own values. This is typified by the FMG that goes home after work and spend time only with members of his/her own cultural group, speaking the language of their childhood, trying to raise his/her own children if they were not in the US. In such a situation the individual feels a tremendous pressure and lives a dichotomous life, American while at work, foreigner when at home. For other FMGs a slow process of assimilation occurs during training. It is based on the acceptance of new values, different beliefs, and a different life style. For a person who has only reached a state of integration, there is often the regret of “what life could have been” if he/she went back to their country of origin after completion of training in the US. However, the person who has been slowly and consciously assimilated into the US culture lives without regrets, enjoying the newly acquired status.

Clearly these different emotional situations have a very profound effect on the way the person will behave if in a position of leadership. The person who tries to hold on his/her own culture will try to impose the values and characteristics of two different worlds, often failing and creating tension in the work place environment.

In contrast, the individual fully or partially assimilated in the American system will show a leadership style that conforms to the “Anglo cluster” previously described. This person enjoys his/her acquired position and is grateful to the system, frequently trying to help others along the same difficult path.

Some of these concepts are better explained by personal examples.

From Italy to the US

I was born and raised in Catania, a town on the east coast of Sicily. After completing high school (there is no college in Italy), at age 18 I enrolled in medical school, one of 1500 new students who aspired to become physicians. I completed medical school at the top of my class, and I was accepted in the General Surgery program at the Vittorio Emanuele II hospital in Catania. Needless to say, I was enthusiastic about this choice. I was motivated by the desire to become a competent surgeon and by the ability of making a difference in other people’s lives. The enthusiasm and the dreams, however, were short lived as I soon realized that the system was not designed to prepare one for an independent practice before age 45–50. The Chairman of the Department of Surgery performed all the difficult cases, leaving very little to other faculty members and residents. Interestingly, he had trained in the United States where he had enjoyed very much the educational system. Back in Sicily, however, he felt he could not change the culture of the place and went back to the dictatorial and autocratic system that he had left (please note that I always refer to male figures as there were no female faculty or female residents). There was no formal mentoring or teaching, and we mostly learned by observing, reading, and performing simple cases. Needless to say, I soon became disillusioned and I looked for a way to escape this reality. This presented in the form of a fellowship that supported research abroad. With the blessing of my Chairman, I applied and was accepted for a 1-year research position at the University of California San Francisco (UCSF). There I worked under the guidance of Lawrence W. Way and Carlos A. Pellegrini. I have to confess that the cultural shock was tremendous, and I am not only talking about the different language. Professionally, I soon realized I was in another world. Even though both Drs. Way and Pellegrini were very busy surgeons, they were always available for meetings during which they took the time to teach the intricacies of research, from formulating a hypothesis to designing an experiment to test it. But what struck me even more was the way resident education was structured. Interns and junior residents were taken through simple cases, while senior and chief residents were performing complex procedures. Residents were given progressive responsibility for patient care and Chief residents managed their services and were treated as junior colleagues by the faculty. This world was present and close, but yet incredibly far away for a foreigner. One year of research became 3 years, and after passing the required examinations, I applied through the National Residency Matching Program. In June of 1986, I started all over again as an intern in General Surgery at UCSF.

I have wonderful memories of the years I spent training: it was hard work but it was incredibly gratifying. Every day I felt I was learning something new, becoming a better physician. After graduation I was sent by Dr. Haile Debas (the Chairman at UCSF at that time) to train at the Queen Mary Hospital in Hong Kong with Professor John Wong. I went with one of the Chief Residents who graduated with me in 1993. Still, today, I remember my colleague’s reaction to being immersed in a very hierarchical and autocratic system, and how he demanded things rather than earning them. While for him it was a real cultural shock, I adapted really fast and enjoyed my time!

After going back to UCSF, I spent the following 14 years working at Moffitt-Long Hospital as junior partner to Dr. L. W. Way (Carlos Pellegrini had moved to Seattle to become Chair of the Department of Surgery). Looking back, I can only be incredibly grateful to Dr. Way for his mentoring. He took a well-trained but rough individual and overtime he transformed him into a surgeon. I also treasured the continuous, albeit long distance, mentorship that Dr. Carlos Pellegrini has provided over the years, making sure that I excelled in other aspects of academic surgery, such as scholarship and leadership in surgical societies.

In 2008, I accepted the offer of Dr. Jeff Matthews, and moved to the University of Chicago where I assumed the position of Director of the Center for Esophageal Diseases. This was indeed a major honor, as I was trying to continue the tradition of Drs. David Skinner and Tom DeMeester, resuscitating a program that had been slowly dying after their departure [17].

In 2013 I married Dr. Melina R. Kibbe, a vascular surgeons who was working at Northwestern University in Chicago. In 2016, when she became the Chair of Surgery at the University of North Carolina, I moved to Chapel Hill, the third institution in my academic journey. And here I am enjoying working in a great public Institution, in a department led by a dynamic and dedicated chair who is driven by a sincere desire to have her faculty excel in the tripartite mission of academic medicine—clinical, education and research. In addition, I am enjoying a different quality of life, confirming that (as I always thought), it is not about “work-life balance” but rather “work-life choices”.

Overall, if I look back and examine this 35-year journey, from Catania to Chapel Hill, what have I learned? How has this experience affected the way I lead other people?

  • I have learned the value of hard work and resilience.

  • I have learned to appreciate traits such as honesty and efficiency in delivering quality care to patients.

  • I have set high standards for myself and for the people with whom I work.

  • I have learned to recognize the importance of giving back, of mentoring others the way I was mentored. During the last 20 years, I have trained fellows from many continents. Some have gone back to their own country, while others have eventually followed my same path and remained in the US.

If I reflect on my own experience, I do not think that a complete process of assimilation has taken place, but rather the blending of two different cultures has occurred. From my original place of origin, I preserve the respect for authority, the respect for the elders, the gratitude for the tremendous opportunities I was given, and sometimes a feeling of annoyance when my authority is challenged by individuals who feel that things have to be given to them rather than earning them. From my country of adoption, I have learned the importance of embracing other cultures and be tolerant of differences, avoiding being ethnocentric, and be open to other people opinions with the goal of achieving a shared objective.

From Uruguay to the US

Although from Uruguay, I was a product of a mixture of the French and British system of medical training. In this type of system there is no college so that after high school (typically when 14–15 years old), you have to make a choice into a diversified pathway that is designed to lead you into a specific discipline. At this young age, many of my peers struggled with their decisions. For some reason, I always knew I wanted to be a Surgeon, so I chose the biological disciplines. Although the disadvantage of this system is that it forces people to make difficult and life-altering choices early on in their lives, it has the advantage of initiating profession-specific training at a much earlier age than in the US. Thus, it prepares you for life in Medical School and afterwards very effectively.

I entered Medical School in the top 3% and graduated from it in the top 1%. During my training years, I became an Instructor of Anatomy, a highly coveted position where a large number of students compete for one of ten positions available every year. The experiences of teaching Anatomy in Medical School at such a young age was a powerful influence in my career, as I learned early on that the best available way to learn is to teach others. After the required 6 years of Medical School training, I competed for one of the roughly 100 positions available in the country as an Intern, managing to enter in the top 3%. Eventually, I worked my way to a surgical House Staff officer position, where for 3 years I learned the intricacies of Surgery.

At this point, at the age of 25, I had to make a very difficult decision: stay home and fight an uphill battle, or leave my home country and come to the US. Like in Italy, Uruguay has a very autocratic and hierarchical system where you truly do not gain independence from your elders until your early to mid-forties. Not only that, but after so many years of relying on a competitive system to advance through the ranks, once you hit the job market, jobs in most private hospitals become very difficult to obtain without connections inside the system. Facing this reality, I married my lovely bride, Luisa, and we decided to come to the US for our grand adventure. We really did not have a clue as to what was in front of us, but there was no turning back.

Why the US? Like so many other FMGs, I was attracted by a system that can be best described as a meritocracy, as opposed to the autocracy that I was used to. Simply put, in the US, if you are willing to sacrifice and commit to your development, you will have a shot at earning your way. That prospect was a very powerful driver that allowed us to push through what can be described as the trials of entrance into the US surgical training system, passing the NBME exams (today’s USMLE exams) and eventually the two FLEX exams (they do not exist anymore) in order to be licensed.

Since the ACGME does not recognize surgical training abroad, I also had to repeat my surgical training. The challenge was to find a spot as a surgical resident. I reasoned that despite scoring very highly in my entrance exams, I was facing an uphill battle. Therefore, I decided to apply for a Surgical Research Fellowship position. Dr. Joel Roslyn, who I had briefly met in Uruguay while he was lecturing there, and who was moving from UCLA to the Medical College of Pennsylvania as a freshly minted Surgery Chairman, offered me a position as a Research Fellow. Dr. Roslyn not only gave me the opportunity to get started in the US, but he also became the most influential mentor in my career development; I will be forever grateful for his kindness, mentorship, and support. Under his guidance, our research laboratory became extremely productive and I was able to obtain a PhD degree in Molecular Pathobiology. This time in the lab became the platform that allowed me to eventually become a categorical resident at MCP-Hahnemann and it effectively launched my career as an academic surgeon in the US.

I absolutely loved my time in training and embraced it wholeheartedly. I was fascinated by the concentrated exposure to difficult disciplines, the system of progressive responsibility, and the emphasis on perioperative management. Above all, I loved the camaraderie with my fellow residents and the strong spirit de corps that we developed. We were, in the truest of ways, a team, and I knew that this was where I belonged. Unfortunately, shortly after MCP-Hahnemann became part of the AHERF system, AHERF went bankrupt. Simultaneously, Dr. Roslyn became ill and died way too young, cutting short a spectacular career in Academic Surgery. The residency program descended into severe turmoil and we all faced a difficult decision: to stay or to leave. True to my Hispanic heritage, where loyalty is a very important trait, I felt an enormous debt of gratitude to Dr. Roslyn, and decided to stay and finish what I felt we had started together. This was a unique experience since we had the opportunity of working very closely with the new Program Director in re-shaping our residency training program. In the most unlikely of circumstances, we all learned the powerful value of teamwork and of working together as one.

After residency, I was accepted for a 2-year fellowship in Surgical Oncology at MD Anderson. It was at Anderson where I learned the value of multidisciplinary care. It was a dream come true to be able to learn from some of the very brightest minds in the world of Oncology. After Anderson, I took my first job as faculty at the Medical College of Georgia, where we helped start a Surgical Oncology program and also participated in the creation of an MD/PhD Program in Oncology.

After Georgia, I accepted a job at Baylor College of Medicine initially as the Associate Operative Care Line Director for Operating Room activities at the MEDVAMC. This was my first experience in helping develop a matrix organization in healthcare. As a result of this matrix development our hospital moved from worst in the country in NSQIP outcomes to first, a remarkable testament to the power of collaborative teamwork. I was eventually promoted as the Vice Chairman and Director for Surgical Network Development as well as the Chief of General Surgery and Surgical Oncology.

After nearly 15 years in Houston, I moved back to the Medical College of Georgia as the Director for the Operative Care Line. This was a dream opportunity that I could not resist, since it gave me the opportunity of expanding a matrix organization style of management across an entire Cancer Center, The experience was so successful that eventually I was promoted as the Chair of the Department of Surgery at MCG as well as the Surgeon In Chief of the Health System. This platform has allowed me to help develop a matrix organization that now oversees all of the Perioperative Services across our large health care system.

In reflecting in all of this, my Hispanic cultural background values connectivity and relationships greatly, and I think this cultural influence heavily gravitated me to this wonderful healthcare matrix structures, one that develops multidisciplinary integrated health systems that are predicated in collaborative leadership and work across multiple silos. Ironically, In the process, I became the first Hispanic Chair of Surgery in the State of Georgia. Needless to say, at MCG we have embraced a culture of inclusivity and diversity that has enriched not only our Department of Surgery and our Cancer Center but the entire organization as well.

Along the way, I was very fortunate to become the first Hispanic president of the Association for Academic Surgery. I joined the AAS at a critical juncture in the life of this marvelous academic surgical society. It was at the AAS that I learned some of the most valuable lessons in collaborative leadership, and where I first realized that the whole is a lot more powerful than the sum of the parts. Over the last two decades, I have been blessed to work with truly amazing and passionate individuals. Together, we have embraced diversity like very few other societies have, and became an all-inclusive society with representation from people from all races, genders, and all walks of academic life. It is this diversity that helped transform the AAS into the vibrant and energetic dynamo that is today. It was the influx of fresh ideas and points of view that allowed the development of so many program-building new initiative such as the fall courses, the international academic career development courses, and other global health initiatives, and many more.

We are all the result of our collective upbringing, life experiences and mentorship. Together, these form a powerful cultural shaper that comes to define the frames that we use to see ourselves, and each other. When I reflect on how my experiences have helped develop my leadership style and qualities, I think the most important lessons that I learned are the willingness of embracing diversity and the force multiplying value of developing richly textured teams. Ultimately, it is all about building Programs, and allowing these programs to become the matrix where academic surgeons are nurtured and developed. In the process, I have gone from mentee to mentor of many of our students, residents, and faculty; I consider this awesome responsibility my most important job.

How Culture Impacts Leadership Styles in Surgery

We completed our training a couple of decades ago and during this time we have adapted to the “Anglo” style of leadership, in part as a necessity but mostly as the recognition that it is the best possible way to motivate others to follow and achieve a common goal. But as we look at each other and reflect on our careers, some common leadership traits emerge among us, the FMGs:

  • FMGs tend to set high standards and be very hard on themselves. In terms of leadership style, this translates into the desire to lead by example and serve as a role model, by being honest and ethical, hard-working, and showing excellence in patient care both in operating room and on the ward.

  • FMGs leaders tend to be less tolerant of those who expect things to be given to them without working hard to earn them.

  • FMGs leaders have a desire to help others who share the same vision and goals.

  • FMGs are often more embracing of differences than American born leaders. Having been exposed to prejudice themselves, FMG leaders they try to avoid it in their own work environment. Thus, a leadership style that is characterized by compassion, generosity, and sensitivity to other people’s needs is common.

  • FMGs leaders tend to have clear goals and expectations

  • FMGs tend to lead by team building. They foster an environment designed to create consensus, rather than autocracy.

  • Finally, based on their own life experience, FMGs are able to make decisions and take ultimate responsibility for them. They exhibit a leadership style characterized by decision making and resilience.

Conclusions

Culture affects leadership. The ideal end-result is achieved by those individuals who have been able to identify and blend the best characteristics of the two cultures, the one of their country of origin and that of the country where now they work and live. The responsibility of those who have gone down this path is to assist the FMGs who will come after them, making sure that they understand that while it is essential to focus on the destination, it is also important to enjoy the wonderful journey in the world of American surgery.