Leading in the Operating Room

By Erin A. Gillaspie, MD, MPH | May 24, 2022

Surgery is an elegant, choreographed dance among anesthesiologists balancing physiology and scrub techs and surgeons seamlessly passing instruments while delicately manipulating tissue to achieve the goals of the surgery. 

The operating room (OR) is a dynamic space requiring meticulous attention to detail, high technical skill, cognitive skill, and importantly, a unity and honesty among team members to facilitate care of patients. 

Building and maintaining a team is complex, in particular as we are facing a time of record turnover rates within hospital systems. 

Below are some considerations to help achieve greater success in leading an OR team. 

Personal Leadership Style and Emotional Intelligence

One of the most important aspects of surgical leadership is understanding our own strengths and weaknesses and seeking opportunities to enhance or ameliorate these. 

Emotional intelligence was a concept first published by two researchers—Peter Salovey, PhD, and John Mayer, PhD—in an article titled “Emotional Intelligence” published in 1990 in the Journal of Imagination, Cognition and Personality. The concept was popularized by Dan Goleman in 1995, and he broke the concept into key principles: self-awareness, self-management, social awareness, and relationship management.

The emotions of a leader often set the tone for the entire team and can create either a positive or negative atmosphere. Self-awareness allows a surgeon leader to recognize their own emotions and interpret the impact on others and the performance of the team. This is a skill that requires practice such that intended emotions are always consistent with the interpreted emotions. 

Self-regulation and having the ability to express emotions appropriately are among the most critical aspects of managing stressful situations or cases that demand cohesiveness, focus, and can be significantly hindered by distress of the team. This self-regulation coupled with social awareness can inspire calm, cohesiveness, and drive a team toward a common goal or vision.

Team Preparedness

Building a strong rapport with the team is an essential part of leadership in the operating room. Effective and clear communication is at the root of preparedness and can enhance efficiency, function, and reduce surgical errors. 

Introduce yourself to new team members
When entering a room or during the time out, it is important to make sure all team members know one another and have clear roles in taking care of the patient. 

Pre-operative planning or briefing
The use of checklists and briefing has been shown in studies to promote improved culture and efficiency of patient care. Case difficulty and patient complexity varies greatly. Set expectations for the day and discuss specific patient considerations or challenges so the team can be prepared. Discuss special needs or instruments ahead of surgery so that the staff feels prepared and does not have to leave the room for hard-to-find items during the case. Likewise, careful planning with anesthesiology colleagues to facilitate seamless transitions from the intraoperative to postoperative time periods can enhance overall recovery. 

Encourage questions and re-affirming information
As surgeons, we often jokingly say to our scrub techs “give me what I need, not what I ask for.”  Showing respect for the team by allowing them to ask questions enhances their understanding of the case and what is needed to help take care of the patient, and fosters better collaboration among team members. 

Environment Considerations

The primary emphasis in the operating room is the care of a patient. The ultimate operating room should be one in which there is a state of a focused, relaxed efficiency that ultimately leads to the optimal completion or a case. The operating room is a busy setting and controlling that environment effectively is important to patient outcomes. 

Maintain focus 
Distractions in the OR are unfortunately commonplace. This includes loud background noises, staff entering and exiting the room as instruments or supplies are being delivered, staff being relieved for breaks, music, and personal devices. 

The full magnitude of the impact has been incompletely studied, however, distractions can no doubt lead to miscommunications, reduced efficiency, decreased vigilance, and error. Minimizing distractions and maintaining the focus of all team members are essential to good patient outcomes. 

Thoughtful leadership and communication can help to realign focus and plans for care. Describe to or alert team members about an upcoming more difficult portion of a case. Inform anesthesia colleagues (who often cannot directly visualize the operative field) of potential changes that could impact hemodynamics. Turn off music and ask for conversations to be paused to allow for clarity of communication. If necessary, request for staff changes to be delayed, allowing for consistency while navigating a difficult portion of a case. 

Leadership during Crisis
One of the greatest challenges, particularly in early career, is leading during a crisis in the OR. Primarily a plan must be communicated, ideally in a precise and focused manner without escalating emotions or creating a panicked environment. Tasks should be appropriately delegated while leveraging skills sets of the team members.

Assure that adequate help is available, including calling for additional anesthesiology assistance and help from partners. While some fear that asking for assistance may be seen as a sign of weakness, in fact, it reflects strength of character and confidence. 

Evaluations by the Joint Commission have demonstrated that communication failure is a common, underlying factor in operative sentinel events. 

Inspire the Team to Have a Unified Commitment

An unexpected joy of my career has been the long-term follow-up of my oncology patients—the opportunity to celebrate cancer-free anniversaries, delight in photos of family vacations and grandbabies, and fathers living to walk daughters down the aisle. Our team members—while playing a critical role in the outcomes of our patients—do not often share in the opportunities to know patients outside of the OR. 

I enjoy taking the time in the OR to introduce the team to the patient who we will be caring for, sharing not only our operative goals but the patient’s personal goals. Perhaps more importantly I give postoperative updates. I let the team know how our patients have recovered and any feedback or positive comments they make during follow-up. A patient’s great outcome is our collective success, and recognition of the team effort is important. 

Standards of Excellence

Setting high expectations for team performance is appropriate in the operating room. As a team leader, it is critical for surgeons to exemplify this through actions and words and to coach and support team members to achieve those standards. 

An effective leader will have an effective team. Leadership skills are not a common part of any educational curriculum to become a doctor and each of us must be committed to not only develop these skills, but to revisit, revise, and improve them over time.