Leadership in Anaesthetic Departments: A Surgeon’s View 209Leadership in Anaesthetic Departments: A Surgeon’s ViewMOHAMED KHADRA; B MED, GRAD DIP COMP, M ED, PHD, FAICD, FRACSHead, Department of Urology, Chair, Medical Staff Council, Nepean Hospital; Professor of Surgery, University ofSydney, NSW 2006Mohamed Khadra is Professor of Surgery at the University of Sydney, a urologist <strong>and</strong> a published author. His booksinclude, ‘Making the Cut’ (2007), ‘The Patient’ (2009) (R<strong>and</strong>om House) <strong>and</strong> most recently, ‘Terminal Decline’, whichwas released in October 2010 (R<strong>and</strong>om House). He has co-authored a play with David Williamson entitled ‘At WhatCost?’ which premiered in Sydney in <strong>2011</strong>. He has postgraduate degrees in surgery, computing <strong>and</strong> education <strong>and</strong>has held senior leadership positions in universities <strong>and</strong> in hospitals in Australia <strong>and</strong> internationally.INTRODUCTIONFrom A Psalm of LifeLives of great men all remind usWe can make our lives sublime,And, departing, leave behind usFootprints on the s<strong>and</strong> of time;Footprints, that perhaps another,Sailing o’er life’s solemn main,A forlorn <strong>and</strong> shipwrecked brother,Seeing, shall take heart again.Let us then be up <strong>and</strong> doing,With a heart for any fate;Still achieving, still pursuing,Learn to labor <strong>and</strong> to wait.(Henry Wadsworth Longfellow, 1807-1882)‘Why is a surgeon invited to comment on leadership in <strong>Anaesthesia</strong>?’ This question has been asked by manyperplexed anaesthetists with whom I have the pleasure to work <strong>and</strong> befriend. ‘Who better?’ is my reply. I have, inmy career, had the privilege of seeing anaesthetic departments in a number of different contexts, admittedly, notas a member. During my training at the Royal Prince Alfred Hospital in the 1980s <strong>and</strong> 1990s I witnessed a departmentthat at once contained Professors Douglas Joseph, Michael Bookalil <strong>and</strong> Bruce Clifton. How one place couldcontain all three giants is a question I only afterwards asked. A better question would be ‘How could any one placesustain all three people?’ Yet, there was a distinct sense of leadership <strong>and</strong> direction in the department <strong>and</strong> wesurgeons were in no doubt of that. In the ensuing years, my career <strong>and</strong> life path has taken me to a diverse numberof settings: rural <strong>and</strong> remote hospitals in Australia <strong>and</strong> internationally, senior leadership in university, corporateorganisations <strong>and</strong> a number of tertiary referral hospitals. Throughout my career, anaesthesia <strong>and</strong> anaesthetic politicshas been a companion at work <strong>and</strong> at home. When the leadership of a department of anaesthesia is functional <strong>and</strong>worthy, there is a sense of contentment, direction <strong>and</strong> belonging. The reverse seems to engender discontent,malevolence <strong>and</strong> Machiavellian politics. The same, of course, can be said of any organisation <strong>and</strong> even departmentsof surgery.LEADERSHIP IN ANAESTHESIAIn the years I have often contemplated what makes good leadership. There are multiple publications in the popularpress which purport to turn us into good leaders. Yet, despite the popularity of these best sellers, good leadersseem to be rare in the hospitals <strong>and</strong> settings in which I have worked.One problem is the gender inequality among leaders in anaesthesia. In the United States, one study showedthat 92% of heads of departments are male <strong>and</strong> 68% decided early they wanted to be the head early in their career. 1I suspect that these findings could be replicated in our country. Despite the preponderance of females within thesenior leadership of the Australia <strong>and</strong> <strong>New</strong> Zeal<strong>and</strong> College of Anaesthetists (President, Vice President, CEO,multiple councilors, Chair of Final Examinations Sub-Committee to name but a few), gender equality in leadershiphas not been achieved in the majority of departments of anaesthesia. This experience is reflected throughout otherorganisations in Australia. Women make up almost 46% of the workforce but only 2.5% of chairs of companies,3% of chief executive officers <strong>and</strong> 8% of executive managers. 2Another issue to be faced is the lack of formal qualifications possessed by many who are thrust into seniorleadership roles. Mets suggested that only 9% of chairs of anaesthesia in the US had any leadership qualifications. 1While a Masters of Business Administration (MBA) or a similar qualification may be useful, my suspicion is thatthere is a difference between the mechanics of administration <strong>and</strong> leadership. While an MBA may help one becomea better administrator I do not believe that it transforms people into leaders. It does however, give the person someof the basic tools that allow them to manage a department’s budget <strong>and</strong> human resources <strong>and</strong> importantly, thebasic language skills necessary to interface with administration <strong>and</strong> the bureaucracy.
210 <strong>Australasian</strong> <strong>Anaesthesia</strong> <strong>2011</strong>Leadership in Anaesthetic Departments: A Surgeon’s View 211CHANGES IN HEALTHCAREThe growth of the centralised bureaucracy in health, in my view, is a major cause of a disenfranchised medicalprofession <strong>and</strong> has been a large deterrent to doctors engaging <strong>and</strong> volunteering for service roles in their hospitals.It is worthwhile considering the changes in governance of our public hospitals <strong>and</strong> the health system in Australia.Prior to 1972 <strong>and</strong> the advent of the Whitlam government, public teaching hospitals in Australia were the predominantplace for surgical intervention <strong>and</strong> hospitalised medical treatment. Over the ensuing years this preeminent positionhas shifted. In a report in 2008, the Federal Department notes that of the 2.1million surgical procedures performedin Australia only 908,000 were in public hospitals. 3 The public hospitals, where the largest departments of anaesthesiaare found, have been eroded over the last two decades in more important ways than can be measured numerically.An important <strong>and</strong> fundamental shift away from traditional allegiance to public hospitals by specialists occurred asa result of the doctor’s strike of 1985, at the introduction of Medicare during the Hawke government. This era alsocoincided with the rise of centralised bureaucracy.The rise of centralised bureaucracy has created a divide between clinical departments <strong>and</strong> hospital administration;the latter now looks centrally to the state bureaucracy, rather than being accountable to local clinician power. Thereport into the state of hospitals in NSW by Peter Garling SC perhaps summarised the basic issue most succinctly:“During the course of this inquiry, I have identified one impediment to good, safe care which infects the wholepublic hospital system. I liken it to the Great Schism of 1054. It is the breakdown of good working relationsbetween clinicians <strong>and</strong> management which is very detrimental to patients. It is alienating the most skilled in themedical workforce from service in the public system. If it continues, NSW will risk losing one of the crown jewelsof the public hospital system: the engagement of the best <strong>and</strong> brightest from the professionals who are able toprovide world-class care.” 4The Workplace Research Centre at the University of Sydney in its submission to the Garling Report in 2008found that only 17% of doctors <strong>and</strong> 33% of nurses in public hospitals trusted their managers. The national workplaceaverage is 70%. 5In his submission to the Garling Report, Professor Michael Cousins, previous President of the <strong>Australian</strong> <strong>and</strong><strong>New</strong> Zeal<strong>and</strong> College of Anaesthetists said 6 :“After 50 years of observing this hospital, I’m sad to say that over the last 10 to 12 years there has been aprogressive <strong>and</strong>, I would have to say, increasing erosion of morale, commitment <strong>and</strong> loyalty to the institution….I, like many others, are on a knife edge, of feeling that we’ve just about tolerated as much as we can <strong>and</strong> we areconsidering leaving…I would feel an enormous sense of loss – not loss for myself, but a sense of loss for whatmight happen to the service that I have tried so very hard to build...one of the key issues is a lack of delegationof decision-making…We still bear the responsibility for the clinical services, quality <strong>and</strong> the safety...The problemfrom my point of view (is) it’s been very difficult to get a decision.”Partly, the issues outlined by Cousins <strong>and</strong> others relate to the nature of bureaucracy. According to Germansociologist, Max Weber, 7 writing in the late 1800s, bureaucracy has fundamental characteristics:• centrally controlled <strong>and</strong> hierarchical,• it is policy driven, ie one size fits all,• it is budget driven, even budget obsessed,• rules are implemented by neutral officers, it is highly impersonal,• risk averse.To these characteristics, Cyril Northcote Parkinson, a British naval historian, added that bureaucracy was selfreplicative. 8 In fact he created a much quoted law of bureaucracy that ‘All work exp<strong>and</strong>s to fill the resources <strong>and</strong>time available for its completion’. A corollary of this law is that bureaucracy is self perpetuating.If one compares these characteristics to the practice of medicine, one sees an almost opposite set of characteristics.These fundamental characteristics of bureaucracy make it unsuitable as a paradigm for the management <strong>and</strong>running of health. Consider that medicine runs in an almost opposite milieu:• control is devolved to the point of care. Ultimate control is at the end of an injection of Propofol,• each case is completely different,• spending is emotional,• it is highly personal,• it is risky.The National Health <strong>and</strong> Hospitals Reform Commission has tried to address this chasm through the creation ofsmaller health governance district boards. This may bring about nothing more than further local accountability withdelegation <strong>and</strong> decision making being kept central. Time will tell.BAD LEADERSHIPRegardless, there is a need to interface with the bureaucracy, <strong>and</strong> the medical profession can no longer sustain aGh<strong>and</strong>i-like non-participation policy. We need to take up the challenge. To steer all clinical departments, includinganaesthetic departments, through these changing <strong>and</strong> stormy times we need good leaders <strong>and</strong> leadership. Whatdoes make good leadership? I think the obverse is probably easier to answer. Bad leadership is clear to any whohave struggled under its burden. Each of the bad leaders I have observed in my career thus far tends to exhibit afatal flaw, a deadly sin that causes them to be less effective. These sins fit into the seven cardinal sins first outlinedin 590 AD by Pope Gregory the First. He was the first monk to become a pope <strong>and</strong> is credited with indirectlyconverting the pagan English, the Anglo Saxons, to Catholicism. He categorised sins into the venial (everydayforgivable sins) <strong>and</strong> the cardinal sins (those that relegate the sinner to eternal hell).Some bad leaders exhibit the sin of pride which is about a feeling or desire that they are more attractive <strong>and</strong>important than others. These are the leaders whose first order of business after being appointed is to design <strong>and</strong>print good quality business cards, have the signage in the department changed <strong>and</strong> order a new computer <strong>and</strong>, ifthe budget allows, new office furniture. Often, coupled with the sin of pride, is a lack of insight into their ownperformance <strong>and</strong> more importantly, a lack of insight into the bemusement in which they are held by their department.Other leaders I have met exhibit the sin of envy where they believe that another person has something theyperceive themselves as lacking, <strong>and</strong> wish the other person to be deprived of it. These are the leaders who areconstantly whispering in corridors <strong>and</strong> hatching Machiavellian games to destroy others in order to self promote.They are amusing in the short term <strong>and</strong> tiresome in the medium to long term. These leaders are so busy with thepolitics that they fail to achieve tangible advances <strong>and</strong> benefits in their departments.Wrath is also a cardinal sin. These leaders display impatience with any of the processes that actually can advancetheir departments. They advocate withdrawal of services as a first line strategy when dealing with the hospitaladministration <strong>and</strong> believe business plans are a waste of time. They see cooperation with hospital administrationas weakness <strong>and</strong> believe that the media is a viable <strong>and</strong> sustainable forum for their venomous views about theirperceived lack of resources. Meanwhile, their departments <strong>and</strong> their areas suffer. The bureaucracy is not averse tousing their own strategies to negate the media attention these leaders generate.Then there are the leaders with avarice as a cardinal sin. Avarice also includes greedy behaviour, disloyalty, <strong>and</strong>deliberate betrayal, especially for personal gain. This is the leader who takes the best lists for themselves <strong>and</strong> usestheir position for their own personal gain. In other words, they are disloyal to their colleagues in order to benefitthemselves. Sometimes this type of leader will enter pacts with the administration on how to control members oftheir department. This behaviour engenders distrust among the department which quickly becomes ineffective.A related sin is that of gluttony. This is about over-indulgence to the point of waste. I have seen this often indepartments that have a leader with a strong subspecialty interest. All other departmental pursuits <strong>and</strong> prioritiespale into insignificance when the subspecialty of the departmental leader requires more resources. There are theresearch nurses, the offices <strong>and</strong> the laboratories - meanwhile the rest of the department struggles for a meetingplace or lounge.The next cardinal sin is lust which is exhibited by the leader who uses their current post to achieve the next.They take on the leadership of the department as a means of achieving a job in administration, state bureaucracyor even the pharmaceutical industry. Their every action aims to add to their burgeoning curriculum vitae. They arein it for themselves.Finally, there is sloth. This is the most common of all the cardinal sins. The appointment is made by lookingaround the department to spot the anaesthetist who has not yet had a turn at being head of department. Thisreluctance to be appointed is used as an excuse to avoid hospital meetings at which their departmental budget isbeing decided. The world is run by those who turn up <strong>and</strong> these slothful leaders do not turn up, much to thedisadvantage of their department.GOOD LEADERSHIPSo let us turn now to trying to answer the more difficult question of what makes a good leader. There is muchwritten about the characteristics of good leaders but all seem to agree on three characteristics. Garry Wills, writingin the Atlantic Weekly in 1994 outlined these as integrity, the ability to listen <strong>and</strong> finally the ability to create a sharedgoal or vision. 9 Hogan found that leadership is a survival tool for an organisation, is vital for its success <strong>and</strong>fundamentally is about convincing individuals to give up their selfish goals in order to pursue a common <strong>and</strong> sharedgoal. 10When we consider the characteristics of good leadership it becomes clear that anaesthetists are naturallyselected leaders. They minimise distractions among the staff, registrars, patients <strong>and</strong> theatre administration toachieve the shared goal of completing the day’s work with efficiency <strong>and</strong> safety. More importantly they are calledupon to coordinate, counsel, arrange, cajole <strong>and</strong> organise surgeons! No greater test of leadership exists.
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