Intended for healthcare professionals

Analysis

Excising the “surgeon ego” to accelerate progress in the culture of surgery

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4537 (Published 21 November 2018) Cite this as: BMJ 2018;363:k4537

Responding to the “Surgeon Ego”: Progress Made and Paths Forward

We appreciate the comments offered on our recent analysis article.[1] We are particularly encouraged to see discussion of the progress that has been made in shifting the surgical culture and skillset in a more positive, humanistic direction, including interventions and training programs in non-technical (but certainly essential) skills, as well as peer groups for case discussion and reflection.

We also value the constructive challenges offered by some of the responses, as they are key additions to the discourse on this issue. Though often exaggerated in public perception or media, the “surgeon ego” is a nuanced and complex issue, and we are glad to have spurred further discussion in this domain. To be sure, the extreme ego depicted in media stereotypes is quite rare in practice, but focusing attention only on these high-profile cases risks overlooking the more common, milder forms of disruptive ego-driven behavior in surgery.

This is why we are somewhat concerned to see several responses invoke the stressful nature of surgery as a reason for excusing milder forms of ego-driven or arrogant behavior among surgeons. The operating environment is certainly stressful and can be a cause of disruptive behavior (alongside personality factors and cultural conditions).[2] However, there is a risk embedded in allowing the nature of the work to excuse all behavior.

“Acting out” in disruptive ways, even as a “mask” to hold it together in the face of a difficult situation, can inadvertently make the situation worse and harm patients. For instance, a surgeon who engages in aggressive, ego-driven behavior in the operating room (even in a forgivable attempt to “blow off steam” during a difficult case) may unwittingly create a situation where a nurse is subsequently less likely to page that surgeon about a post-operative patient with an ambiguous symptom or a questionable trend in lab values, for fear of drawing the surgeon’s ire.

In short, we are less concerned about there being many Bramhalls operating around the world, but more concerned about surgeons whose (less extreme) ego-driven attitudes or behavior influence their ability to work effectively with others in the operative environment. The real threat to patients, in our mind, comes from situations where a surgeon’s colleagues (consciously or subconsciously) disengage or feel unable to speak up about an issue during or after the surgery because of the surgeon’s attitude or behavior.

Much of our success in caring for patients comes from recognizing and addressing post-operative complications, which relies on a good team environment where everyone can speak up and collaborate to work through issues that arise.[3] This recognition is at the root of why we observe other arenas where there are similar levels of stress (as surgeons are certainly not the only profession to suffer the negative emotional consequences of a bad patient outcome), but perhaps less tolerance for arrogant attitudes or disruptive behaviors.

Looking outside of medicine, for instance, there is a widespread recognition among airline pilots of the value of humility and the potentially mortal consequences of a pilot’s ego, evident in the multiple accidents traceable to an inability or unwillingness of others to speak up to a pilot-in-command to identify or correct an error (e.g., the 2011 crash of First Air flight 6560[4]). Likewise, substantial research in the organization sciences has established expressed humility as a significant positive predictor of an individual’s (e.g., a leader’s) work performance, tempering the effects of narcissism and improving the engagement, satisfaction, and retention of those whom the individual is leading.[5,6]

We certainly want to treat surgeons working in these stressful environments with understanding and kindness, but we must be wary of not addressing a real issue because it is difficult or unpleasant to do so. There are more productive ways to deal with the stress of surgery than to indulge ego-driven attitudes or behavior – alternatives that do not come with the same potential consequences for patient care and team well-being.

The logical next question then perhaps becomes: how do we support surgeons in identifying and making use of such productive outlets for stress? As highlighted in the responses to our article, surgical culture historically asked surgeons to “deal with it and move on” in the face of difficult cases, but more supportive and constructive alternatives (including peer discussion and training) are becoming increasingly available. The promising path forward seems to be one of exploring how we can excise this ego with both the precision and compassion of a skilled surgeon, rather than assuming an all-or-nothing, callous remedy to a nuanced and complex challenge.

Christopher G. Myers, PhD
Johns Hopkins University
cmyers@jhu.edu

Yemeng Lu-Myers, MD, MPH
University of Maryland

Amir A. Ghaferi, MD, MS
University of Michigan

References

[1] Myers CG, Lu-Myers Y, Ghaferi AA. Excising the ‘surgeon ego’ to accelerate progress in the culture of surgery. BMJ 2018;k4537.

[2] Cochran A, Elder WB. A model of disruptive surgeon behavior in the perioperative environment. J Am Coll Surg 2014;219:390–8.

[3] Smith ME, Wells EE, Friese CR, et al. Interpersonal and organizational dynamics are key drivers of failure to rescue. Health Aff 2018;37:1870–6.

[4] Dubinsky Z. First Air captain ignored co-pilot's warnings before Nunavut crash. CBC News. 2014. http://www.cbc.ca/news/canada/north/first-air-captain-ignored-co-pilot-s... (accessed 7 Dec 2018).

[5] Owens BP, Johnson MD, Mitchell TR. Expressed humility in organizations: Implications for performance, teams, and leadership. Organ Sci 2013;24:1517–38.

[6] Owens BP, Wallace AS, Waldman DA. Leader narcissism and follower outcomes: The counterbalancing effect of leader humility. J Appl Psych 2015;100:1203–13.

Competing interests: No competing interests

19 December 2018
Christopher G. Myers
Assistant Professor
Yemeng Lu-Myers, Amir A. Ghaferi
Johns Hopkins University
Baltimore, MD, USA