Latest / Behind The Knife: The Surgery Podcast / Clinical Challenges in Surgical Education: Power & Leadership
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- BTK#8 CoSEF_Power Leadership_Final === [00:00:00] Hello everyone and welcome to another Exciting Behind the Knife episode brought to you by the collaboration of Surgical Education Fellows, also known as ef. We hope you enjoyed our last episode on gossip, and we're excited to bring you another episode today. I'm Maya Hunt EFS behind the Knife Lead for this year, and I'm a general surgery resident at Indiana University where I'm currently finishing my professional development time as a surgical education Research fellow, while also obtaining my Master's of Health Professions Education through the University of Illinois Chicago. And I'm Mackenzie Rowe, another CSIF member and co-host for this episode. I'm a general surgery resident, but currently a surgical education and leadership fellow at a Nova Fairfax medical campus in Northern Virginia. And you might be wondering what the heck is csif? Well, we're a multi-institutional organization of surgical education research fellows working together to foster peer mentorship, networking, and scholarly collaboration. We meet every week to discuss ongoing research efforts by individuals or by smaller groups within the team. If you are a surgical [00:01:00] education fellow or a surgery resident interested in education and you want to join csif, you can find our email in the show notes. So today we're diving into something we don't often talk about in residency power. Why are we talking about this today, Maya? Well, power dynamics in the surgical environment have been something I've noticed since medical school rotations, where I saw subtle and not so subtle ways that power dynamics were at play amongst attendings, residents, and students. During my fourth year while listening to an episode of Brene Brown's podcast unlocking us about leadership and power that was unrelated to medicine, it really made me realize how power is used, should be part of the discussion around leadership. And yet I wasn't seeing it within the sphere of surgical education. It was a present absence, if you will. It's definitely not something we talk about enough. I think it's because it feels pretty intangible sometimes. Absolutely. It's inherently an ambiguous and slippery concept. It's not easy to determine what it is, who has it or how to get it, and it can be hard to know when someone actually wield it. Power dynamics are part of any [00:02:00] organization, but it's a hugely important aspect of leadership. And to quote Brene Brown, we cannot understand leadership if we don't talk about power. Before we introduce our guest panelists for this episode, let's quickly define power dictionary.com has 20 definitions of power, and I promise we won't subject you to those, but I think Dr. Martin Luther King Jr. In 1968 may have said it best, that power is the ability to achieve purpose and affect change. As trainees, we often experience ways in which power is used positively, calling a fellowship on our behalf for a senior, or talking up a junior to their faculty and others in which power is used. Harmfully, it can look small like shaming a resident for a mistake to broader forms of mistreatment or retaliation. And many residents feel as if we have no power at all and are entirely subject to those around us. As one of our guests has often said, power is not power if you don't know you have it. And so in today's episode, exploring power in leadership and surgical learning environments, we are joined by two board certified surgeons with very different perspectives. One shaping [00:03:00] power from inside the system and the other challenging it from the outside. Dr. Paula Ferrada is the Chair of Surgery at Inova Fairfax, an international leader in trauma critical care, a storyteller and an advocate for equity and surgical culture. Thank you so much for being here today. Thank you so much for having me. Also joining us is Dr. Francis May Harden, former ENT surgeon and co-founder of the Hippocratic Collective, who is known for her candid voice on residency culture, burnout, and reclaiming agency. Thank you so much for being with us for this conversation. Thank you, Maya. Happy to be here. So power, the ability to achieve purpose and effect change. That's still not quite tangible enough for me. I think some examples would be really helpful to get a better idea. Francis, may you have a theory about orange suits that might be helpful to illustrate? Could you talk about this a little bit? Sure. Absolutely. So the Orange Suit theory is basically about a big academic style conference that I went to, and I looked at my whole array of gray and black suits and I [00:04:00] thought, okay, which one's it gonna be this time? Like. Skirt versus pant, but they're all these like drab hues. And my husband really pushed me to go for this loud creamsicle orange suit. He was like, you know, I think that this is the move. It resonated with you. You bought it. And I said, it's way too loud. And what will people think of me? And he said, well, this way the people who. You want to connect with, they'll be able to find you more readily, essentially because, and, and I said, okay, well what if there's someone like really important or influential who now because they see me in this Creamsicle suit, they won't take me seriously and then they won't talk to me and. The hard lesson that I have learned that he articulated that day is just that that person probably doesn't wanna talk to you anyway. Or even if you wore your drabs suit and they were willing to talk to you that day at the conference, there probably is a lack of [00:05:00] long-term alignment where like you're just saving yourself time. Show up in the creams. Cut out some of the messy middle, it'll get you to your people faster. I do think that it requires a person to look inward and decide and then commit to whether they're going to try to make everybody happy or if they're going to try to be authentic. I have found that that is a divergence point for many of us. I really love this. It's making me feel better about the bright purple satin jumpsuit from the eighties that I just got. So glad to hear that the bold colors are still in. But it sounds like this theory relies a lot on utilizing your personal power, which is the influence that comes when people like you or want to be like you, and you're finding your people by having this confidence to be yourself, to wear the orange suit, and that way you can find these other people. Dr. Ferrato, do you feel similarly? How are you? How are you engaging with us? I love the story by the way. Thank you for telling it. I, [00:06:00] something similar for me, for those that that know me and have seen me physically. I am different. I am an immigrant. I'm from Colombia, and when I was different, when I was in Colombia than other women around me 'cause different mindset, different goals in life and, and that's why I'm not there, right? But here I'm also different from most people. My skin is darker. I try to do many things to fit in. That was before the enlightenment of Brene Brown too, but also a lot of life experience. There's this amazing book that I'm finishing that talks about the balance between being warm and being perceived as assertive and how people that actually have a lot of influence and a lot of power are people that are able to balance both. Warmth and assertiveness that you are warm enough that people trust you. Because it's all about trust and relationships, that we have real relationship with authenticity and the power of authenticity is the [00:07:00] power of people trusting you and knowing that you don't sound like a, you know, used car salesman. And the power of also while being authentic, being very effective, being very efficient, and you can be warm and efficient and have both. So it's, it's managing balance so you can have both. For me, I went through a part of my career where I just wanted to fit in. I didn't wanna disappear right in the crowd necessarily, but I did not want it to be different. I wanted to be taken very seriously. I knew what I wanted from my career and I had it in my brain and I was. Trying to find ways of how to achieve it, but my personality for those that you know, me bubbly humor has always been my mechanism of defense, which sometimes can come across as overly warm. So I decided that. In order for me to be taken seriously, I was gonna cut my hair and wear studs. And then it ended up being that I hated my hair and I didn't like how it looked with studs. And I still was [00:08:00] equally silly because your personality doesn't change. So I figured that I was most effective in continue to grow my influence and showing my effectiveness and not letting go of my warm while still being authentic. And I think that ways to become more powerful while being authentic is master your craft. Because people trust, expertise, and influence comes from trust. Build alliances, not followers. When people say, oh, I'm a fan, you're not a fan, you're a friend. Some of those are not friends, they're foes, but that's okay. I learned the power of frenemies and enemies as well, and staying grounded because as your influence grow, that could serve your ego and nothing good comes when your ego goes first. Leave the ego outside of the hospital. That erodes trust, and I think most magnetic leaders can child empower into service, not status. We're talking about power and influence. What ultimately is leadership. If service is beneath you, then leadership is not for you. I [00:09:00] like a lot of what you're saying there and something that stood out to me is you're talking about alliances and network. And that's a source of power in itself, right? Utilizing those like-minded people who like the way that you are. We're also talking about authenticity, vulnerability, so using that alliance, your authenticity, and then creating larger networks of people over which you then have influence. And then that's a way to have power as well. Dr. Frady, you're pointing to an aspect in which you felt like you couldn't show up and be yourself and needed to try to be somebody else, and then eventually decided it was much harder and you're just gonna be yourself. So did you feel something similar, Francis May? Did you have like a similar inflection point or struggle with the same thing? Yeah, again, I think I am one of those people, not unlike, you know, most surgeons where I need to learn the lesson a few times before it really like sinks in. And so, yes, I do feel like over the years I now really know the difference between how it feels when I show up and. It's a place where I feel seen and [00:10:00] people find my message. They don't have to always agree, but maybe like can receive it respectfully versus where it is just like we are missing each other. We live on two different planets and I really do try to now just be more like even protective of my time and energy. I don't need to go to the latter. I'm not out here trying to like colonize new worlds. I would say that a lot of how I try to contribute to society, to the field of medicine and surgery. Is to support and provide resources for, and like safe spaces for people who need them not to be out here trying to convert people. The people who think that there's absolutely nothing wrong in surgery, culturally and in medical education, I cannot change their mind, and that's totally fine. That's just not the best use of my energy. The last thing I wanted to mention really quickly, I loved what Dr. Ferdo was saying about alliances, and it reminded me of this quote I have here on my desk. When you talk about even alliances and not followers, that we want to build this famous quote, if you want to build a ship, don't [00:11:00] drum up the men to gather wood, divide the work and give orders. Instead, teach them to yearn for the vast and open sea. I feel like what I'm hearing from both of you is kind of a different way to wield power, right? There's not just one way to have power, and power in itself is not good nor bad. And so a way to conceptualize this is to think about power over versus power with Maya. Can you tell us a little bit more about that? Absolutely. So I really like how Brene Brown breaks it down. I think it's a bit of an easier framework to understand and we've. We'll link it in the show notes of this episode. So one way to view power is in a power over relationship. Power over is the belief that power is a finite resource and therefore it must be hoarded and protected. And so the way that you protect your own power is by utilizing fear, blame, and shaming of others to protect your own. And in this view, being right is more important than getting it right. Yeah. I think this sounds pretty familiar to a lot of us listening. Yeah, especially in [00:12:00] surgery, it can be less than ideal though for an educational environment because asking questions in a power over dynamic can be seen as a challenge or a threat to one's power, even if it's just a question for clarification. So I wanted to ask Francis, may, you spoke openly about power dynamics in your residency training. I was hoping you would be able to give us an example of when power overthinking was used by a leader during your training and how it may have affected you. I certainly experienced just a pattern and you know, daily string of the power over this type of like exertion that you're describing. I think that one of my core issues with that, that I have felt. For years. You know it when you see it and when you feel it is that in the hierarchy of surgery, people time passes and they move up and they advance, and now they might be in a position of power over someone. And what I find pretty unique to the hospital and medicine and surgery that. Isn't mirrored across all industries [00:13:00] is that they don't always have skills that you would expect of somebody in those higher positions. It's just a hierarchy where like time passes and you just move up. Or maybe you're a great surgeon. I won't even discount that. Right. Like your, your hands are great. I can tell you the, the Venn diagram of people whose hands are great. People who have incredible leadership or communication skills. It's not a circle. So up until I was a ENT resident, I would say that all the teachers I had, they didn't teach us by exerting power over us. They had power over us because they were teachers and we were students. But you didn't feel that as the learner. You didn't feel threatened, and they actually earned respect. They earned it the old fashioned way by like showing up and being kind. Being good teachers, and I can't ever overemphasize how much that paradigm was just flipped on its head. In my residency experience, it was like, I'll do nothing to earn your respect and I will wield power over you and you'll feel it. So I just think that that to me really was like the [00:14:00] core of the issue as I saw it at that particular institution. Even if that was an extreme example, I know that elements of that are happening nationally. Absolutely. I believe, and I'm not unique in this 'cause there's a lot of literature that shows this. Then when you have this dynamic of powering over people without allowing even a question, that is a recipe for that is not only bad for culture, it is not only bad for retention and recruitment. It's not only bad for morale, but it's terrible for patient safety because that's how people die when people are not allowed to question the status quo. That's how science dies when you're not allowed to question, why are we doing things? How can we do it? I mean, I mean, respectfully, right? We end with data, but you should be able to hold these conversations and as I said before, approach life science, medicine, relationships. With more curiosity and less judgment. If we listen again since we're quo, Rene Brown, listen the or read the address of the heart. And there's a [00:15:00] part of that that says that accountability is inversely proportional to blame and shame. And how do we used to, we don't do this at our institution that were here, but I have seen it multiple times in my past. How do we used to handle morbidity and mortality? Right. Finger pointing, attacking immediately. Oh, you should seen people. I have heard people talking about partners, about people that they should respect, implying that the person shouldn't be a surgeon and is an assassin because he or she made a mistake and. I wanna say to those people that still believe that that's the right way of communicating, and that they make the excuse of that behavior because they care about patients, that that's the opposite. You are hurting patients, but not allowing questioning, and by not allowing better communication within partners. Moreover, everybody's listening. The nurses are listening, the administrators are listening, the medical students are listening, and some people are learning by example. I want to encourage people that are listening to [00:16:00] this when you are seeing those examples, to learn who not to be in the future, because that's not where we should move. We need to move to a safer culture, to a more inclusive culture. To a place where people are not doing things because they're being yelled at or told to do. But because you are doing it, because you understand the why behind it and where we keep people in our patients in the center of all the decisions rather than our ego in the center of all our decisions, in our conversation. Absolutely. I think power over is a very common way that we see power wielded, but it's not the only way, a different way of looking at power is through a power to, or a power with lenss, where power is seen as an infinite resource that actually expands when shared with others. It allows learners to explore with curiosity, removing fear, associated with questions, A lot of what you guys are talking about because they're not a threat anymore at that point. Power to or power with emphasizes that getting it right is more important than being right. And so both of you have mentioned that during your training experience, it sounded like you had a [00:17:00] lot of power over dynamics that you dealt with. But Dr. Ada, as one of your residents right now, I can attest that you lead more with a power with dynamic. So is that just inherently natural to you or is that something that you've had to intentionally strive for? So I think. We're talking about power, but always sums out to leadership. I think that some of this stuff, it comes naturally to you and probably because your mom raised you correctly and you listen to those like share things, not you don't yell and scream, right? Those things that we should have learned from H one to five, that some people somehow bypass those. But it's not only that, I think that you have an opportunity in life when you go through hardship. I accept that and, and I live that proudly. When I was saying I learned about from my frenemies and from my, my enemies, I don't right now, retrospectively, I don't condone by behavior, but I can tell you I'm infinitely grateful that I run into those individuals that exerted power over [00:18:00] me and power over others, and that they did, and they say these things that they didn't say because I learned so much, I learned so much from those interactions that I don't think it can be taught in a book. And more importantly, like I said before, it teaches you who not to be. It leaves a really harsh impression of what happens when you are, how bad leadership destroys morale and destroys teams, and how we sometimes make sure that we don't continue the mission of surgery, of maintaining people in the workforce. So I took a decision, a very intentional and personal decision that when I went through that I was not gonna become part of it. I was gonna become part of the solution. So very intentionally not to fall on those straps and very intentionally lifting others up as you go and do that with, I'm saying intention too many times, but intention, time, purpose is super important when we do these things and we help others around us. [00:19:00] Francis May. What about you? Is this a natural dynamic for you or something that you've had to work on? I would say that I make a conscious effort to try and not be intimidating. I can come off as like pretty stoic. And so I actually think that I probably, when I lead a team, I try to overcorrect for that. I would give the example, let's say I'm a chief resident and a PGY one or two asks a question. One easy way that I think that a person can ease that learner along is language like, oh, I totally. Remember that giving me some like confusion as well. I remember when that was giving me trouble, right? 'cause they're asking a clarifying question or they're having difficulty with some like 3D spatial anatomy. I just think that, again, not buying into the expert's illusion. Not acting like I came out of the womb. With that knowledge and understanding is a way to just consciously, like, genuinely, consciously make an effort to say, we're the same. I was just you three years ago. And I think that the more that people can [00:20:00] do that in surgery, the more human like the whole team might feel. That being said, this is a little bit of a hot take. I am comfortable going on the record saying that every really. Brilliant person that I've ever met. They didn't pull this power over stuff. I've never seen it in my life. Every person whose intelligence I admired, they just truly like, they made other people feel at ease. They never came down on people for asking questions. And so it's very interesting. I actually personally feel that it's, it's a sign of mediocre intelligence. When you have to resort to falling back on, I have power over you, you're gonna know it. That's okay. That sounds good. That just makes me think that you don't have it. I love what you just said because I completely agree. I'm not sure if it's a sign of lack of intelligence, but definitely it's a sign of insecurity. In surgical training, we're taught not to be vulnerable to the point, not to be vulnerable with our feelings, with our needs, from sleeping, to [00:21:00] eating, to emotional needs. And to create a gap between you and the patient, and we know now by data that actually that doesn't work. Your patients will trust you more if they know you're human. I believe for decades, surgeons have wore the batch of lack of sleep, lack of eating, being unhealthy and dying at age 96, still operating in front of a patient. As a badge of honor, and I think that one of the challenges is to question that well with curiosity, understanding why was that even there in, in the first place? Because ownership of patients does not have to translate on you live in a completely unbalanced life and allowing ourselves to be more vulnerable. And I completely agree with you. The people that I seen that have. The hardest time showing vulnerability are the people that have something to hide. Either they're uncomfortable because they're not great technicians, or they're not great clinicians, or they're uncomfortable in their leadership, or they're uncomfortable with your growth.[00:22:00] You are going to fast for them, and that's scary, and that's when you see the barks and roars. The majority of the people that are really powerful. They bring people up with them. They listen with curiosity, and they're lifelong learners. I believe something interesting came up in a leadership class that I was in recently that reminds me of what you were saying. A clerkship director in my group asked, well, what do I do about these attendings who yell or scream or get angry to try and help residents or students learn? Because their arguments are always, well, they're learning, aren't they? So as the director, you know, he said, what do I say back to that? And so our class discussed and ultimately it's, yes. I mean, maybe they learned that point that you were trying to make, not to do that very specific thing. But now in the future. They don't feel like they can come to you with questions. They don't feel like you're a safe person to talk to. So you're really losing all of this future learning opportunity by creating that [00:23:00] environment and with those responses. And so, yes, maybe it helps in that moment, but long term, like you guys are saying, it just, it really isn't checkout. Mackenzie, I completely agree with you, and in what you're describing, you're not just learning the information, but encoding the memory of that moment, which includes the fear and shame associated. So retrieving that information in the future, retrieves those heightened emotions paired with it. That's not ideal when you're trying to learn the information, not learn an emotional response. So we've talked about a few examples of power and how to conceptualize it, but who has power? As residents, students, and even early faculty, we often feel powerless. It's rare that we control our own schedules. Someone above us is always telling us what to do. So is it only our department chairs that have power? Our attendings? I feel like we can see examples of power in literally every role on the team. I actually had surgery myself recently, and I had a fourth year medical student on my team. She did a ton of things to make me feel more comfortable, both before and after my surgery. She was able to put a [00:24:00] song I requested on and held my hand as the anesthesia set in. She checked on me several times and made sure I had everything I needed. We sat and we chatted about her upcoming interviews. She completely changed my experience in the hospital and that's. Power. She affected change by improving my perioperative experience. I've worked with a lot of medical students as a resident also, and they've completely improved the way our team functioned by being prepared by being there, learning. And so clearly students have a lot of power to affect patient care and team dynamics. Francis May I wanna get your take on this. Looking back, what power did you have as a student or resident, whether you realized it or not? I do think that medical students have some power. I think that they tend to have more power than residents do. You know, when I was in training, people always used to say, rolls downhill and residents are at the bottom of the hill. And just anecdotally. I do think that there are more reporting systems and infrastructures in place. Often I see at least slightly better outcomes for [00:25:00] medical students compared to the more truly defenseless, which I regard to be resident physicians. The main thing that I think that medical students and residents. Don't think enough about is the power in numbers. Like especially in my experience, I was in an ENT residency, there were 11 residents total. So getting a quorum wouldn't take that much effort. Interestingly, of course, I think that the system did a really good job of protecting itself and thereby dividing us and pitting us against each other. That was kind of part of it every day, right? But it's like if you can see past the way that often they pit us against each other, they start doing that. Not uncommonly at the medical student level, then you can organize. Obviously we live at a time when unionization is increasingly difficult, especially this year. But even if you take a step backwards from there into organization, I view that like some of the missed power by this next generation of physicians is in the absence of [00:26:00] organization. The point you're making about organizing ourselves is huge. I'm doing my thesis on motivations to unionize, and it frequently comes up just how bad surgeons are at organizing ourselves. Usually it's from time constraints and we're physically sequestered in the or, but this inability to organize ourselves well really impacts the ability for surgeons to have as powerful of a voice as we could. You know, both of you mentioned that we only have power over ourselves, right? We can't control what others do. And I think sometimes we forget that we directly control the environment for a lot of people around us. We make the culture of our teams. So even just trying to be positive that day, or let something brush off your shoulder, choosing to be authentic or to share a struggle that you've been having that can make a difference to the people around you. And so even those things are power since they affect the culture. I also do feel like what's funny is there is a role for someone to like be a lightning rod. And I think the really quick way that I could succinctly explain this is that over the summer a husband of a resident reached out. Lovely guy. He [00:27:00] is himself not in medicine, he's in business, so I'm sure this all looks like really foreign to him. And his wife is in ortho, right? So this is a surgical base specialty. And he shared that. At graduation, he was like, your name came up, your videos. I don't know these people. This is like very far removed from me personally, but they saw my social media and he was like, the guy said, how crazy is she? How fake is all of that? Which gave the women an opportunity to say, not fake. That actually rang pretty true. So it was really. Very life affirming, I think, because he was like, you know, positive discourse occurred maybe like everyone left that evening with a slightly better understanding of what like other residents even within that program were experiencing. And so unfortunately someone just has to be a sacrificial lamb in that scenario. We've had some great discussion today and before we wrap up, I wanna make sure we have some practical takeaways for residents to start identifying and using their own power. So, Dr. Ferdo, what power do residents have and how do you encourage someone to utilize what they have? Residents have a huge [00:28:00] amount of power, especially in the United States. If you think that something is going on with your program director and you think that person is not helping you, you can complain to A GME and that person will be removed. Don't think about yourselves as the last in the food chain. Your presence is actually giving a tons of, not only you're taking care of patients, which is the most important thing, and advancing education and advancing research and advancing innovation. It all comes from the resident. But also hospitals are benefiting from the amount of money that they get because of the residency as well. Not to mention that what you're getting paid is probably, I don't know, one 10th of where you actually are earning in terms of the actual clinical work that you're doing. So I think in the United States you have a ton of power. I think it's different in other countries, unfortunately. But as it was mentioned before, powered by numbers. You know, find allies, talk to each other. Don't let people fragment you and triangulate you while keeping your North and your purpose [00:29:00] will help you funnel that power so you can get the results that you need. Francis May for a resident who feels powerless right now. What's one tangible step they can take today to recognize their own power? I think Dr. Ferta said it best that we do all have that inherent power and value, and so I suppose my answer would be turning inward. I know it sounds lame. When I was a surgery resident, if somebody told me to turn inward, I just wanted to punch them in the face. I was like, we don't have time for that. We're doing poorly. In all seriousness, that is the thing that helped me like actually own my own life again, like take agency over my life. And I go back to the old mantra, you can't control other people. You can only control yourself. So you do have that power. There is an internal value and power that every single one of us brings to the table. It's interesting 'cause you can spend more effort and focus on your own power, your inner world, as opposed to trying to change other people's minds and, and their own inner worlds. There's many hidden [00:30:00] ways each of us has power in teaching others, advocating for patients impacting culture, and simply in self-determination of finding where you do have the power in your own life, which may be outside of medicine. As we're coming to a close here, it's important to remember that power isn't about titles or control. It's the ability to affect change in our patients' lives, our peers, and the culture in our institutions. We all have more than we realize. I wanna thank our guests, Dr. Paula Ferrada and Francis May Harden. Thank you so much for taking the time to chat with us today. Thank you guys so much for having me. It is always a privilege chatting with you, and I loved learning from Dr. Ferta as well. Thank you so much for having me this week. We want you to ask yourself, where can I use my power with intention to connect, to elevate, and to create safety for those around us. Thank you for listening to The Behind the Knife podcast, and as always, go forth and dominate the day.