Doing Surgery on the Culture of Surgery

Recently I spent a delightful day teaching a group of 40 surgeons.  We were focused on leadership and cultural change.  During one of the breaks, one of the new surgeons told me he had the opportunity to take a position with a number of medical systems, but he chose this one because of the culture.  He said  none of the other systems had an interest in culture or leadership.  Since he places a high value on teamwork, he selected his present job.

After the break, I asked two men to come to the front of the room.  The older man had been the department chair eight years ago.  The younger man has become chair more recently.  I repeated the claim of the new surgeon, and I asked the two of them to recount the last eight years of cultural work in the department.

The older man gave a rendition of what the department used to be like.  He told of driving everyone hard.  In seeking greater achievement, he concluded that there should be a training program on leadership.  To him, this meant learning the skills from a business school.  It meant obtaining tools from disciplines like operations research, information technology, finance, and so on.  He asked the younger man to take charge of developing the curriculum.

The younger man talked about being referred to me.  He shared that in our first meeting I listened as he spoke of the desired inputs or management topics, the technical tools that were needed.  I asked him about outcomes: what result did he want to create?  He wasn’t sure.  I suggested he go home, ponder the query, and return.

When he returned, he wanted to discuss the narcissistic behavior that was sometimes a part of the culture.  He indicated that the department, like all departments of surgery, was governed by a culture of self-interest.  As a result, many patients, staff members, and young surgeons suffered.  He wondered if it were realistic to imagine a positive culture.

I suggested it was possible to co-create social excellence.  It was possible to do surgery on the culture of surgery.  He wanted to believe, and he was willing to include some emphasis on leadership and culture, but the existing expectation set called for a curriculum centered on “hard” skills.

At this point in recounting the history, the senior person interrupted.  He said, “That is what we knew we needed, the hard skills of management.  It turned out we were wrong.  The hard skills were helpful, but they were not what we really needed.  What we needed to learn was how to create a positive culture.”

He pointed at the younger man and said: “He internalized everything that was taught.  When he replaced me as chair, he operated from the fundamental state of leadership.  He implemented all the positive concepts we have learned.  He enlisted everyone in creating a culture of excellence.  The impacts were observable.  In fact, in my new position, I have to deal with all the departments.  It is a real wake-up call.  Not one of the other departments has a culture like our culture in surgery.  They tend toward normal, transactional, self-interested cultures.  They need what we have, but they cannot imagine creating it.”

The younger man responded, “He is right about internalizing the framework.  As chair, I have to make harder decisions than I have ever had to make before.  Yet I make every decision by first reflecting on the fundamental state of leadership and on the kind of culture we want.  The focus is on creating a positive culture.  With each decision, I ask myself the four questions: What result do I want to create?  Am I internally directed?  Am I other focused?  Am I externally open?

“The answers often lead me to do unusual things.  We, for example, just recruited for a new position.  We had several impressive people to choose from.  One had spectacular credentials on his resume.  Another had a record that was slightly little less stellar, yet he clearly had more emotional intelligence.  He had values that aligned with the culture we are trying to nurture.  We hired the second person.  It was a great decision that we would not have made formerly.  If you operate from a framework of positive leadership, and stay constant, the decisions are not normal.  They are outside the box.  Yet they are align with one another.  You begin to see synergies and the culture becomes increasingly positive.”



  • Does your current culture produce social excellence?
  • Why was there such a strong expectation for hard skills?
  • Why do synergistic patterns emerge in the nurturing of a positive culture?
  • How could we use this passage to create a more positive organization?



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