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

Re. Excising the “surgeon ego”? Is this a fair representation of the UK Surgical Workforce? A response from Association of Surgeons in Training (UK)

Dear Editor,

The Association of Surgeons in Training (ASiT) read with interest the article which correctly highlights some interesting traits and important issues regarding ‘ego’ in the work place. However, we feel as an organisation involved in training the next generation of surgeons, that this article unfairly represents the majority of today’s UK surgeons and fundamentally this phenomenon is not exclusive towards surgeons or those working within the medical profession.

ASiT is an independent professional organisation that represents and promotes excellence in surgical training. We welcome discussion of hurdles that need to be overcome to ensure all-comers feel able to flourish within our training programs and wider surgical teams. However, the continued high profile journalism of extreme cases, to demonstrate the damaging effects of ‘surgical ego’ in the workplace, are sensationalised and unrepresentative of the majority. To dispel some of the assumptions described, we feel it would be useful to discuss some of the strategies utilised within the UK system which seek to drive improvement, maintain standards and change culture within our training schemes and beyond.

The surgical workforce in the UK is changing at a rapid pace with an increasing proportion of female medical students progressing into surgical training (1). UK based training programs have evolved to be much fairer, more accepting and encouraging towards nurturing surgical careers. However, we acknowledge that boundaries remain and that we must continue to work hard to break these down. Indeed, a study conducted by ASGBI in 2018 (2), reported a ‘lack of formal mentorship, inflexibility towards part-time careers, gender stereotypes and poor work-life balance’ to be the primary perceived barriers inhibiting women progressing in surgery. The survey revealed a largely male-dominant sociocultural working environment embedded within surgical specialities, but there was no evidence to suggest that surgeon ego deters women from pursuing surgical careers as elucidated in this paper.

Whilst historically, traditional surgical personality traits may have existed, these have almost universally dissipated in the UK. Surgical teams can be a positive and enjoyable places to work and nurture both medical students and trainees alike. Social media campaigns such as ‘#hammeritout’ and the RCSEd ‘#letsremoveit’ campaign (3) have raised the profile of workplace bullying and it is now rightly met with zero tolerance. The colleges acknowledge that collaboration is required to have a long term influence on training and workplace environments. Whilst not perfect, ASiT believes the UK healthcare workplace is much more positive than this article suggests.

The UK system is embracing an open and honest culture within the theatre environment with a flattened hierarchy which prioritises patient safety. The use of pre-operative team briefs and ‘time outs’ encourage individuals to speak out and this process has been integrated into national safety standards (4). Additionally, non-operative technical skills for surgeons (NOTSS) are now taught throughout the surgical curriculum to encourage early development and understanding of the social and cognitive skills that underpin technical knowledge and expertise in the operating room. Furthermore, whilst the article notes that teamwork and leadership are not traditionally taught within American medical schools, both these elements are embedded within all UK undergraduate and post-graduate curricula.

Focussing purely on individual personality type and its effects on ‘progressing the culture of surgery’ is too simplistic and fails to acknowledge a complex interplay of factors involved. Workplace culture is multifactorial including elements of communication, teamwork, work environment and pressures within it, leadership, ownership and training and development (5).

The article states that medical students often perceive surgeons to be ‘overly self-confident to the point of arrogance and believe they need to fit this stereotype ’. This statement is based on a small qualitative UK study with a specific focus on ‘students’ perceptions of surgeon stereotypes’ prior to surgical exposure in the workplace (6). Stereotypes are often longstanding and may require many years of change to dispel. Interestingly, the article suggests one solution is to ‘increase exposure and share real life narratives’ implying that perhaps perception is not the same as reality. Likewise, the American based study by Cochran et al. 2014 (7) referenced demonstrates some evidence of inappropriate surgical behaviour although this was at single institution and therefore difficult to use to assess its broad applicability. However, global differences should be acknowledged. One study in India found duration of training and individuals’ lack of academic interest to be the primary demotivating factors against a surgical career rather than ego (8). Likewise, in Africa aspects such as gender, marital status, and first degree relatives were more highly considered (9). Clearly the decision to follow a surgical career is complex and the factors at play are multifaceted.

It is interesting, that when examining personality traits within healthcare professionals (HCP), Bucknall et al. (2015) (10) stated that ‘surgeons were found to have significantly higher levels of narcissism than non-surgical colleagues’. However, this article concluded that overall HCP’s expressed a significantly lower level of these traits than the general population. Furthermore, a study of personality traits in 5000 doctors found no difference in agreeableness and conscientiousness between physicians and surgeons (11). Whilst surgical personality traits may exist, there is no strong evidence that this has a negative impact on progression. Highlighting a few isolated individuals only serves to perpetuate the negative perception that exists.

The article does however raise some interesting training opportunities that ASiT would support. The use of simulation and managing high fidelity scenarios to develop teamwork would certainly be positively received. NOTSS is increasingly being incorporated into curricula and widespread uptake from the existing consultant workforce should be encouraged. Finally, several trusts are utilising a pre-interview assessment day at consultant interviews to focus and assess candidates positive and negative personality and ASIT would support this being widely adopted.

Whilst ASiT acknowledges that the system is far from perfect, we believe that surgery provides a fantastic career opportunity and huge progress has been made in embracing wholesale cultural change. Articles such as this simply serve to reinforce stereotypes for which there is little evidence and as such provide limited value to the current literature.

References

1. Moberly T (2018) A fifth of surgeons in England are female. BMJ 363:k4530
2. Bellini M, Graham Y, Hayes C, Zakeri R, Parks R, Papalois V. (2019) A woman’s place is in theatre: women’s perceptions and experiences of working in surgery from the Association of Surgeons of Great Britain and Ireland women in surgery working group. BMJ Open;9:e024349
3. https://www.rcsed.ac.uk/media/416807/progress-report-july-2018.pdf
4. https://www.england.nhs.uk/wp-content/uploads/2015/09/natssips-safety-st...
5. https://www.cipd.co.uk/knowledge/culture/working-environment/organisatio...
6. Hill E, Bowman K, Stalmeijer R, Solomon Y, Dornan T (2014) Can I cut it? Medical students perceptions of surgeon and surgical careers. American Journal of Surgery, 208 (5) 860-867
7. Cochran A, Elder WB. (2014) A model of disruptive surgeon behavior in the perioperative environment. J Am Coll Surg 219 390-8.
8. Anand R, Sankaran P (2019) Factors influencing the career preferences of medical students and interns: a cross sectional, questionnaire-based survey from India. J educ Eval Health Prof 16.12
9. Lawal T, Afolabi A (2013) Factors influencing the choice of surgery as a career by pre-registration interns. African Health Science 13 (3) 814-819
10. Bucknall V, Burwaiss S, Macdonald D, Charles K, Clement R (2015) Mirror mirror on the ward, who’s the most narcissistic of them all? Pathologic personality traits in health care. CMAJ 187 (18) 1359-1363
11. Stienen MN, Scholtes F, Samuel R, Weil A, Weyerbrock A, Surbeck W (2018) Different but similar: personality traits of surgeons and internists—results of a cross-sectional observational study. BMJ Open 8 (7):e021310. doi:10.1136/bmjopen-2017-021310

Competing interests: No competing interests

24 June 2019
Adam B P Peckham-Cooper
StR General Surgery (ST8)
Elizabeth Kane, Josh Burke, Deidre Nally, Gemma Humm
Association of Surgeons in Training
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