March 27, 2020
“Leadership is not a position or a title, it is action and example” – Unknown
Today was my first day as the attending in one of our ICUs dedicated to the care of critically ill patients who are COVID-19 positive or at risk. As I mentally prepared myself last night, I was struck that what worried me most was not contracting the virus, not the complexities of ICU care for patients with a novel and unstudied disease, and not even the immeasurable suffering I was about to witness. No, to be honest I was most worried about my ability to lead in a disordered and uncertain environment.
As an acute care surgeon, I am accustomed to making split-second decisions. I LOVE caring for sick patients, “crashing” and bringing them back. I don’t mind not knowing what I’ll find when we “get in”. But in trauma there are algorithms – there is a road map – everyone in the trauma and OR has a defined role. Even in the most unpredictable circumstances, there is order. And at the end of the day I usually feel like I’ve done an honest day’s work, and I have done my best not to hurt anyone in the process.
But this feels so different. I am in a “pop up” COVID unit with a “pop up” team, treating a disease that has existed in humans for less than 4 months. This requires skills beyond vent management. The protocols are dynamic, the uniform is different – even the simplest procedure takes forever. The normal hums and rhythms of the ICU are absent. Where are the families? Because nurses can’t go in and out of rooms, we are making makeshift signs to hold up through glass doors to request drugs and other basic items for clinical care. In the background there is unwelcome noise: We constantly worry that we have put our families at risk by just coming to work, and we don’t believe we have what we need to be safe.
To prepare for my unit I reviewed COVID-19 protocols, NEJM articles about retroviral therapy, and brushed up on reading about leadership. My friend Tom Varghese, Jr. MD, MS, FACS, Executive Director and Chief Value Officer Huntsman Cancer Institute at the University of Utah, gives a fantastic talk about Developing and Finding Your Leadership Style. He reviews the evolution of leadership styles and leadership tactics that are useful for surgeons. As I approach my new role there are a few styles, I think will be useful for me and other clinicians as we battle this virus.
This first, is Participative Leadership which is useful during stressful times. Participative leaders invite input from all team members and share decision making with them. This style fosters collaboration and commitment to a singular goal. This is important as I seek to engage a diverse set of team members to work together, break down silos and foster communication. The second is servant leadership, also useful in the early stages of working with a diverse team. Servant leaders share power, put the needs of others’ first, and encourage team members to perform as highly as possible. As I try to win the trust of the residents, nurses and other staff members on whom I depend to care for our patients, I must let them know that my job is to help them do their job. When push comes to shove, I will be in charge, but authoritarianism doesn’t foster the trust critical for high team performance in uncertain and high-stakes conditions. To avoid unnecessary exposure, we must protect each other, and my team needs to know that I will not put them at unnecessary risk. Finally, he describes authentic leadership which is useful to motivate others. Authentic leaders are genuine, do not hide mistakes or weaknesses, and put the organizational mission above their own self-interest. Although authentic leadership is a strategy for building long term relationships, it’s also critical in this setting where I may only work with a team for a week at a time. As there are so many unknowns, it does little good to pretend I have all the answers. We need creative solutions that can only come from frank discussions about gaps in knowledge and clinical uncertainty. It is critical that I share my authentic self not just with my clinical team but also with patients and their families who need to know that we walk this journey together.
Each of us on the “front lines” will lead in one way or another during this crisis. Such leadership will introspection and self-awareness. Think about which leadership styles suit you. I encourage each of us to develop a leadership toolbox that we can draw on so we can support our colleagues and ourselves in the long weeks ahead.
Zara Cooper, MD, MSc, is the Kessler Director of the Center for Surgery and Public Health, associate professor of surgery at Harvard Medical School, and trauma surgeon at Brigham and Women’s Hospital (BWH) in Boston.