Layton F. Rikkers, MD

"Thank you all for agreeing to what I think is an excellent plan." Thus concluded the meeting led by one of the division heads in our department of surgery. The key agenda item was developing consensus on a highly controversial academic incentive plan that would transfer revenue from the busy clinicians who produced it to the faculty who were more engaged in the academic and educational missions of the division.

Several faculty members later related to me that the division head had dominated the conversation, belittled suggestions from his younger and less powerful colleagues, and "convinced" them to accept his plan with minimal alterations. They were irritated and frustrated. The division head reported to me that the meeting had gone extremely well and that he was able to gain consensus on a controversial and difficult issue. He was very pleased with himself.

I think we have all experienced this scenario – a person who is highly competent and possibly even pleasant in a social setting enters a meeting and, within minutes, irritates and comes into conflict with nearly everyone present, but sadly does not realize he has done so. What is lacking here?

The ancient Greeks called it "nothi auton" or "know thyself," and the modern parlance for it is self-awareness: the essential core of emotional intelligence and one of the most valuable attributes you can possess as a human being. In essence, it represents opening a door to your mind and discovering your own reality.

If self-awareness is so valuable, what exactly is it, why do you need it, and how do you get it if you don’t have it? Self-awareness consists of a number of components. First, it is an objective recognition of your strengths and weaknesses, values and beliefs, motives, and emotions. It also consists of an ability to continuously compare your current behavior to your core values and objectively assess whether that behavior reflects those values. Self-awareness also helps you to understand other people and how they perceive you. It helps you to recognize when you are stressed, and is a prerequisite for effective communication and interpersonal relations.

Why do you need self-awareness? Having self-awareness is required for you to be able to accept who you really are, to change those aspects of your personality that need to change, and to build on your strengths and clearly define your weaknesses. It is an important ingredient for effectively communicating with the world around you. In fact, it is difficult to imagine a happy human existence without a reasonable dose of this essential elixir.

Also, knowing oneself is the component of emotional intelligence that effective leaders possess in abundance. When I have encountered a failure of leadership in my surgical world, 90% of the time it has been due to a relative lack of self-awareness. (By the way, the division head described at the beginning of this editorial is now working elsewhere and the incentive plan for which he thought he had gained consensus is on the trash heap of unrealized objectives.)

How do you get self-awareness? In my experience, it is extremely difficult to instill self-awareness in people who are starting on empty. For individuals in leadership positions, the complete lack of this attribute may be a fatal flaw. For most of us, it is a natural part of maturation and can be improved by spending time in self-reflection, a practice few surgeons utilize because of their busy lives. Self-reflection should include spending quiet time, asking yourself difficult questions, and giving honest answers. Did I live to my core values during the meeting I just led? What could I have done better to lower the temperature in the room and avoid the conflicts that ensued? This requires commitment and courage. Also helpful is to have a sounding board of friends, colleagues, and/or mentors who are willing to critique you and provide honest feedback regarding your conduct during meetings, in the operating room, and even when having informal conversations.

So if you haven’t had the opportunity or acquired the tools to introduce yourself to yourself, it is never too late. It is not an easy process, but I believe you will be pleased with the result – a happier and more productive life.

Dr. Rikkers is Editor in Chief of Surgery News.

"Thank you all for agreeing to what I think is an excellent plan." Thus concluded the meeting led by one of the division heads in our department of surgery. The key agenda item was developing consensus on a highly controversial academic incentive plan that would transfer revenue from the busy clinicians who produced it to the faculty who were more engaged in the academic and educational missions of the division.

Several faculty members later related to me that the division head had dominated the conversation, belittled suggestions from his younger and less powerful colleagues, and "convinced" them to accept his plan with minimal alterations. They were irritated and frustrated. The division head reported to me that the meeting had gone extremely well and that he was able to gain consensus on a controversial and difficult issue. He was very pleased with himself.

I think we have all experienced this scenario – a person who is highly competent and possibly even pleasant in a social setting enters a meeting and, within minutes, irritates and comes into conflict with nearly everyone present, but sadly does not realize he has done so. What is lacking here?

The ancient Greeks called it "nothi auton" or "know thyself," and the modern parlance for it is self-awareness: the essential core of emotional intelligence and one of the most valuable attributes you can possess as a human being. In essence, it represents opening a door to your mind and discovering your own reality.

If self-awareness is so valuable, what exactly is it, why do you need it, and how do you get it if you don’t have it? Self-awareness consists of a number of components. First, it is an objective recognition of your strengths and weaknesses, values and beliefs, motives, and emotions. It also consists of an ability to continuously compare your current behavior to your core values and objectively assess whether that behavior reflects those values. Self-awareness also helps you to understand other people and how they perceive you. It helps you to recognize when you are stressed, and is a prerequisite for effective communication and interpersonal relations.

Why do you need self-awareness? Having self-awareness is required for you to be able to accept who you really are, to change those aspects of your personality that need to change, and to build on your strengths and clearly define your weaknesses. It is an important ingredient for effectively communicating with the world around you. In fact, it is difficult to imagine a happy human existence without a reasonable dose of this essential elixir.

Also, knowing oneself is the component of emotional intelligence that effective leaders possess in abundance. When I have encountered a failure of leadership in my surgical world, 90% of the time it has been due to a relative lack of self-awareness. (By the way, the division head described at the beginning of this editorial is now working elsewhere and the incentive plan for which he thought he had gained consensus is on the trash heap of unrealized objectives.)

How do you get self-awareness? In my experience, it is extremely difficult to instill self-awareness in people who are starting on empty. For individuals in leadership positions, the complete lack of this attribute may be a fatal flaw. For most of us, it is a natural part of maturation and can be improved by spending time in self-reflection, a practice few surgeons utilize because of their busy lives. Self-reflection should include spending quiet time, asking yourself difficult questions, and giving honest answers. Did I live to my core values during the meeting I just led? What could I have done better to lower the temperature in the room and avoid the conflicts that ensued? This requires commitment and courage. Also helpful is to have a sounding board of friends, colleagues, and/or mentors who are willing to critique you and provide honest feedback regarding your conduct during meetings, in the operating room, and even when having informal conversations.

So if you haven’t had the opportunity or acquired the tools to introduce yourself to yourself, it is never too late. It is not an easy process, but I believe you will be pleased with the result – a happier and more productive life.

Dr. Rikkers is Editor in Chief of Surgery News.

"Thank you all for agreeing to what I think is an excellent plan." Thus concluded the meeting led by one of the division heads in our department of surgery. The key agenda item was developing consensus on a highly controversial academic incentive plan that would transfer revenue from the busy clinicians who produced it to the faculty who were more engaged in the academic and educational missions of the division.

Several faculty members later related to me that the division head had dominated the conversation, belittled suggestions from his younger and less powerful colleagues, and "convinced" them to accept his plan with minimal alterations. They were irritated and frustrated. The division head reported to me that the meeting had gone extremely well and that he was able to gain consensus on a controversial and difficult issue. He was very pleased with himself.

I think we have all experienced this scenario – a person who is highly competent and possibly even pleasant in a social setting enters a meeting and, within minutes, irritates and comes into conflict with nearly everyone present, but sadly does not realize he has done so. What is lacking here?

The ancient Greeks called it "nothi auton" or "know thyself," and the modern parlance for it is self-awareness: the essential core of emotional intelligence and one of the most valuable attributes you can possess as a human being. In essence, it represents opening a door to your mind and discovering your own reality.

If self-awareness is so valuable, what exactly is it, why do you need it, and how do you get it if you don’t have it? Self-awareness consists of a number of components. First, it is an objective recognition of your strengths and weaknesses, values and beliefs, motives, and emotions. It also consists of an ability to continuously compare your current behavior to your core values and objectively assess whether that behavior reflects those values. Self-awareness also helps you to understand other people and how they perceive you. It helps you to recognize when you are stressed, and is a prerequisite for effective communication and interpersonal relations.

Why do you need self-awareness? Having self-awareness is required for you to be able to accept who you really are, to change those aspects of your personality that need to change, and to build on your strengths and clearly define your weaknesses. It is an important ingredient for effectively communicating with the world around you. In fact, it is difficult to imagine a happy human existence without a reasonable dose of this essential elixir.

Also, knowing oneself is the component of emotional intelligence that effective leaders possess in abundance. When I have encountered a failure of leadership in my surgical world, 90% of the time it has been due to a relative lack of self-awareness. (By the way, the division head described at the beginning of this editorial is now working elsewhere and the incentive plan for which he thought he had gained consensus is on the trash heap of unrealized objectives.)

How do you get self-awareness? In my experience, it is extremely difficult to instill self-awareness in people who are starting on empty. For individuals in leadership positions, the complete lack of this attribute may be a fatal flaw. For most of us, it is a natural part of maturation and can be improved by spending time in self-reflection, a practice few surgeons utilize because of their busy lives. Self-reflection should include spending quiet time, asking yourself difficult questions, and giving honest answers. Did I live to my core values during the meeting I just led? What could I have done better to lower the temperature in the room and avoid the conflicts that ensued? This requires commitment and courage. Also helpful is to have a sounding board of friends, colleagues, and/or mentors who are willing to critique you and provide honest feedback regarding your conduct during meetings, in the operating room, and even when having informal conversations.

So if you haven’t had the opportunity or acquired the tools to introduce yourself to yourself, it is never too late. It is not an easy process, but I believe you will be pleased with the result – a happier and more productive life.

Dr. Rikkers is Editor in Chief of Surgery News.

"Get this thing out of my operating room! The colon stapling device exploded into pieces when I hurled it against the operating room wall."

Most would assume that this must be a quote from an earlier era, when surgical icons ruled their surgical kingdoms and such behavior, especially by them, was tolerated. However, this quote was not unearthed from the surgical archives of an academic institution – instead, it comes from a recent best-selling autobiographical account by a surgeon who graduated from one of our esteemed residencies not too long ago. It reinforces the caricature of the intolerant surgeon, which is how many in America perceive us. Unfortunately, that caricature holds true in too many of our operating rooms.

During my years as a surgery department chair, I spent an inordinate amount of time dealing with operating room miscreants. I suspect that most surgery chairs or division chiefs, whether in academic or private institutions, have had a similar experience.

My disruptive surgeons represented a small minority of our surgical staff, but most were frequent repeat offenders. Some had minimal to no self-awareness and were not cognizant of their abusive behavior. Others felt bad about their inappropriate conduct but were incapable of correcting it. Bad behavior almost seemed to be embedded in their DNA.

After rather intensive and frequent counseling sessions, behavior would sometimes improve, but it was rarely sustained. These were always difficult conversations, because at times the offending party was a close friend, a prominent surgeon with well-placed and strongly supportive constituents, or a very busy surgeon in a highly profitable field who contributed significantly to the bottom line of departmental and hospital finances. What to do?

In late 2000 we formed a Professional Conduct Committee (a subcommittee of our Operating Room Committee) to address these recurring issues in surgery departments within our institution. Guidelines were written and submitted for approval to the Medical Board, the governing body of our medical staff. The committee members were to be appointed by the Operating Room Committee and would consist of three highly respected senior surgeons, two prominent senior anesthesiologists, and the nurse manager of the operating room. The formation of the committee and the accompanying guidelines were enthusiastically approved by the Medical Board.

Disruptive behavior was explicitly defined as verbal and/or physically threatening behavior, harassment in any form, demonstration of anger by destroying property or throwing instruments, and threats of retaliation as a result of learning that disruptive acts were reported.

To prevent retaliation, we developed a "Disruptive Behavior Report" form that allowed anonymous recounting of the incident. The first step of the process is submission of this form to the committee by the aggrieved individual and, after due diligence to protect the rights of the accused surgeon, the committee decides whether the complaint is justified. If justified, one or more members of the committee meet with the surgeon and remedial action such as anger management or counseling may be recommended to the surgeon and his or her department chair.

If disruptive behavior recurs or if the initial incident is particularly egregious, the next step is to require the accused surgeon to meet with the entire committee, along with his or her department chair, and to state a zero tolerance policy for further occurrences. If a repeat episode of disruptive behavior still occurs, the final stage is to send a written report from the committee to the president of the medical staff, the physician-in-chief, and the hospital CEO with a request for disciplinary action by the Medical Board. The disciplinary action can consist of a reprimand, probation, or reduction, suspension, or revocation of clinical privileges. In extreme cases, suspension or revocation of medical staff membership can be recommended.

In the 12 years since the formation of the Professional Conduct Committee and initiation of this policy, only a few surgeons have progressed through all three stages. None have had their clinical privileges permanently revoked, and none have lost their medical staff membership. Clearly, the fear of these consequences and of public discussion of their disruptive behavior before the Medical Board has been an effective deterrent. Although always kept in the information loop, surgical department chairs – with their inherent biases regarding their own faculty members – have been relieved of making the difficult disciplinary decisions that they generally avoided making in the past. They have all been complimentary about this new approach.

The working environment in our operating rooms has markedly improved. The congeniality quotient has increased, the fear of harassment or embarrassment has been reduced, and there is less turnover of OR personnel. If you do not have such a process in place in your institution, you might want to consider it. I think you will be impressed.n

Layton F. "Bing" Rikkers, M.D. is an emeritus professor at the University of Wisconsin and Editor in Chief of Surgery News, an Elsevier Publication.

"Get this thing out of my operating room! The colon stapling device exploded into pieces when I hurled it against the operating room wall."

Most would assume that this must be a quote from an earlier era, when surgical icons ruled their surgical kingdoms and such behavior, especially by them, was tolerated. However, this quote was not unearthed from the surgical archives of an academic institution – instead, it comes from a recent best-selling autobiographical account by a surgeon who graduated from one of our esteemed residencies not too long ago. It reinforces the caricature of the intolerant surgeon, which is how many in America perceive us. Unfortunately, that caricature holds true in too many of our operating rooms.

During my years as a surgery department chair, I spent an inordinate amount of time dealing with operating room miscreants. I suspect that most surgery chairs or division chiefs, whether in academic or private institutions, have had a similar experience.

My disruptive surgeons represented a small minority of our surgical staff, but most were frequent repeat offenders. Some had minimal to no self-awareness and were not cognizant of their abusive behavior. Others felt bad about their inappropriate conduct but were incapable of correcting it. Bad behavior almost seemed to be embedded in their DNA.

After rather intensive and frequent counseling sessions, behavior would sometimes improve, but it was rarely sustained. These were always difficult conversations, because at times the offending party was a close friend, a prominent surgeon with well-placed and strongly supportive constituents, or a very busy surgeon in a highly profitable field who contributed significantly to the bottom line of departmental and hospital finances. What to do?

In late 2000 we formed a Professional Conduct Committee (a subcommittee of our Operating Room Committee) to address these recurring issues in surgery departments within our institution. Guidelines were written and submitted for approval to the Medical Board, the governing body of our medical staff. The committee members were to be appointed by the Operating Room Committee and would consist of three highly respected senior surgeons, two prominent senior anesthesiologists, and the nurse manager of the operating room. The formation of the committee and the accompanying guidelines were enthusiastically approved by the Medical Board.

Disruptive behavior was explicitly defined as verbal and/or physically threatening behavior, harassment in any form, demonstration of anger by destroying property or throwing instruments, and threats of retaliation as a result of learning that disruptive acts were reported.

To prevent retaliation, we developed a "Disruptive Behavior Report" form that allowed anonymous recounting of the incident. The first step of the process is submission of this form to the committee by the aggrieved individual and, after due diligence to protect the rights of the accused surgeon, the committee decides whether the complaint is justified. If justified, one or more members of the committee meet with the surgeon and remedial action such as anger management or counseling may be recommended to the surgeon and his or her department chair.

If disruptive behavior recurs or if the initial incident is particularly egregious, the next step is to require the accused surgeon to meet with the entire committee, along with his or her department chair, and to state a zero tolerance policy for further occurrences. If a repeat episode of disruptive behavior still occurs, the final stage is to send a written report from the committee to the president of the medical staff, the physician-in-chief, and the hospital CEO with a request for disciplinary action by the Medical Board. The disciplinary action can consist of a reprimand, probation, or reduction, suspension, or revocation of clinical privileges. In extreme cases, suspension or revocation of medical staff membership can be recommended.

In the 12 years since the formation of the Professional Conduct Committee and initiation of this policy, only a few surgeons have progressed through all three stages. None have had their clinical privileges permanently revoked, and none have lost their medical staff membership. Clearly, the fear of these consequences and of public discussion of their disruptive behavior before the Medical Board has been an effective deterrent. Although always kept in the information loop, surgical department chairs – with their inherent biases regarding their own faculty members – have been relieved of making the difficult disciplinary decisions that they generally avoided making in the past. They have all been complimentary about this new approach.

The working environment in our operating rooms has markedly improved. The congeniality quotient has increased, the fear of harassment or embarrassment has been reduced, and there is less turnover of OR personnel. If you do not have such a process in place in your institution, you might want to consider it. I think you will be impressed.n

Layton F. "Bing" Rikkers, M.D. is an emeritus professor at the University of Wisconsin and Editor in Chief of Surgery News, an Elsevier Publication.

"Get this thing out of my operating room! The colon stapling device exploded into pieces when I hurled it against the operating room wall."

Most would assume that this must be a quote from an earlier era, when surgical icons ruled their surgical kingdoms and such behavior, especially by them, was tolerated. However, this quote was not unearthed from the surgical archives of an academic institution – instead, it comes from a recent best-selling autobiographical account by a surgeon who graduated from one of our esteemed residencies not too long ago. It reinforces the caricature of the intolerant surgeon, which is how many in America perceive us. Unfortunately, that caricature holds true in too many of our operating rooms.

During my years as a surgery department chair, I spent an inordinate amount of time dealing with operating room miscreants. I suspect that most surgery chairs or division chiefs, whether in academic or private institutions, have had a similar experience.

My disruptive surgeons represented a small minority of our surgical staff, but most were frequent repeat offenders. Some had minimal to no self-awareness and were not cognizant of their abusive behavior. Others felt bad about their inappropriate conduct but were incapable of correcting it. Bad behavior almost seemed to be embedded in their DNA.

After rather intensive and frequent counseling sessions, behavior would sometimes improve, but it was rarely sustained. These were always difficult conversations, because at times the offending party was a close friend, a prominent surgeon with well-placed and strongly supportive constituents, or a very busy surgeon in a highly profitable field who contributed significantly to the bottom line of departmental and hospital finances. What to do?

In late 2000 we formed a Professional Conduct Committee (a subcommittee of our Operating Room Committee) to address these recurring issues in surgery departments within our institution. Guidelines were written and submitted for approval to the Medical Board, the governing body of our medical staff. The committee members were to be appointed by the Operating Room Committee and would consist of three highly respected senior surgeons, two prominent senior anesthesiologists, and the nurse manager of the operating room. The formation of the committee and the accompanying guidelines were enthusiastically approved by the Medical Board.

Disruptive behavior was explicitly defined as verbal and/or physically threatening behavior, harassment in any form, demonstration of anger by destroying property or throwing instruments, and threats of retaliation as a result of learning that disruptive acts were reported.

To prevent retaliation, we developed a "Disruptive Behavior Report" form that allowed anonymous recounting of the incident. The first step of the process is submission of this form to the committee by the aggrieved individual and, after due diligence to protect the rights of the accused surgeon, the committee decides whether the complaint is justified. If justified, one or more members of the committee meet with the surgeon and remedial action such as anger management or counseling may be recommended to the surgeon and his or her department chair.

If disruptive behavior recurs or if the initial incident is particularly egregious, the next step is to require the accused surgeon to meet with the entire committee, along with his or her department chair, and to state a zero tolerance policy for further occurrences. If a repeat episode of disruptive behavior still occurs, the final stage is to send a written report from the committee to the president of the medical staff, the physician-in-chief, and the hospital CEO with a request for disciplinary action by the Medical Board. The disciplinary action can consist of a reprimand, probation, or reduction, suspension, or revocation of clinical privileges. In extreme cases, suspension or revocation of medical staff membership can be recommended.

In the 12 years since the formation of the Professional Conduct Committee and initiation of this policy, only a few surgeons have progressed through all three stages. None have had their clinical privileges permanently revoked, and none have lost their medical staff membership. Clearly, the fear of these consequences and of public discussion of their disruptive behavior before the Medical Board has been an effective deterrent. Although always kept in the information loop, surgical department chairs – with their inherent biases regarding their own faculty members – have been relieved of making the difficult disciplinary decisions that they generally avoided making in the past. They have all been complimentary about this new approach.

The working environment in our operating rooms has markedly improved. The congeniality quotient has increased, the fear of harassment or embarrassment has been reduced, and there is less turnover of OR personnel. If you do not have such a process in place in your institution, you might want to consider it. I think you will be impressed.n

Layton F. "Bing" Rikkers, M.D. is an emeritus professor at the University of Wisconsin and Editor in Chief of Surgery News, an Elsevier Publication.