an excerpt from sbmj feb'08 on SURGERY

I’m a surgeon—respect me!
We all know the stereotypical surgeon. Laura Cherrington wonders which personality traits are really necessary and whether there’s room for change
“You can’t sit there, that’s Mr X’s seat,” the scrub nurse calls out to me in the staff room as I’m poised over a chair, identical to the 10 other vacant chairs in the room. I move to another seat. “No,” the nurse stops me again, “That’s where he puts his feet.” I look up at her about to laugh, but just look dumb struck instead when I realise that she’s serious.
What makes people think that surgeons deserve such reverence? He struts into the staff room with an air of superiority and sits on “his” chair, ignoring the hard working team with whom he is about to operate. I doubt he even knows our names.

The stereotypical surgeon
I am a fifth year medical student aspiring to be a surgeon. Last summer I worked as a theatre support worker to get an insight into the world of surgery. Many surgeons I met were kind and sociable, but others came across as arrogant and aloof. If I become a surgeon, will I be one with a reputation among the theatre staff for being a typical surgeon? We all know the surgeon stereotype: decisive, well organised, practical, hard working, but also cantankerous, dominant, arrogant, hostile, impersonal, egocentric, and a poor communicator.
As role models, I prefer surgeons who are friendly and good communicators. One surgeon sticks in my mind. He always described with fascination what he was doing during the operation to all of the team members. He included theatre support workers, whether we were medical students or not. We would be waved over to the table with a smile, “Take a look at this.” He showed no arrogance or hostility and made everyone want to pitch in.
So is it fair to label surgeons with the stereotype? As with all stereotypes, they don’t apply to everyone but often to a considerable number of the group. They frequently stem from some reflection of reality—as the saying goes, “There’s no smoke without fire.”
Thomas wrote a paper entitled “The surgical personality: fact or fiction,” which attempts to provide evidence for the existence of this stereotype.w1 He reported studies in 1997 which showed that surgeons are often described using negative connotations such as “arrogant, dominant, cold, impersonal, impatient, less friendly, aggressive and authoritarian.” He cited Greenburg, who found that surgeons considered being self sufficient, well disciplined, highly motivated, and consistent more important than traits that allow good interaction with others.w2 Thomas also did a small study of 50 non-surgeons, and found that 90% thought that surgeons shared a similar personality and 66% of the terms used to describe surgeons were negative.w1
Thomas’s paper was written nearly 10 years ago. However, from my own recent but limited experience I have to agree that a number of surgeons do fit this set of characteristics. The surgeons I speak of were clearly hard workers, well organised, and decisive, but they were often poor at communicating with other healthcare professionals. Widespread cultural depictions of surgeons also reinforce the negative stereotype. Television programmes (such as ER, Casualty, and Holby City), films, and literature often depict surgeons as arrogant and aloof. The studies that I have mentioned show that the negative attributes stem from limited interpersonal skills. With communication skills having an ever increasing emphasis within medical teaching, does the surgical personality still exist, and is it a necessity to be a good surgeon?

How did the stereotype come about?

The stereotype is thought to arise for two reasons. Greenburg proposed that it is prominent among surgeons as a result of a selection bias for the so called surgical personality when doctors are recruited for surgical jobs. That is, surgeons normally choose one of their own, someone just like them for the job, so perpetuating the surgical personality.w2
Thomas suggested that the personality may be further encouraged by training methods that promoted certain personality traits.w1 This supports the view that the stereotypical surgeon is more evident in older surgeons, the so called “old school” doctors.
However, this personality may be necessary. The more positive traits associated with the surgical profession, such as being decisive, hard working, well disciplined, and motivated, are essential traits for becoming a successful surgeon and should be retained. This could easily coincide with good communication skills and more sociable traits. Indeed it seems that many of the surgeons I have met have achieved this and do not come across as arrogant, hostile, or egocentric. Is it perhaps more likely that the few who continue to display poor communication skills are tainting the whole profession and perpetuating the stereotype that should be outdated?
Many people feel that poor communication skills lead to a breakdown of teamwork since the rest of the team are no longer motivated to work with the surgeon. As Thomas wrote, “It appears unlikely that one can expect others to support and develop allegiance to a representative of a group of individuals who are characteristically considered to be aloof, arrogant and authoritarian”.w1 This is likely to be counterproductive in ensuring patient safety and the efficiency of operative procedures.
A study by Sexton and colleagues entailed interviewing theatre staff (surgical and anaesthetic consultants, nurses, and residents) from 12 hospitals in five different countries.w3 They found that the most common recommendation for improving patient safety in the operating theatre was to improve communication.
This leads me to believe that the negative aspects of the surgical personality should be strongly discouraged. They could be replaced with good communication with other healthcare professionals, as well as with patients. Improvement could be at three key phases: during surgical training, when selecting surgical colleagues, and in mature practising surgeons. Surgeons are taught technical skills and how to make good judgments. Communication skills are important adjuncts to this training as no surgeon ever works alone in the operating theatre. Charles Vincent, who trained as a clinical psychologist, has done a lot of research into teamwork and patient safety. He has published widely and provides courses for surgeons, highlighting the importance of teamwork to them.

Leading the team
Some people argue that acquiring more sociable traits will diminish the surgeon’s standing as a leader. It goes without saying that surgeons need to take on a lead role. However, Thomas said, “Leadership should be characterized by the ability to engage in productive dialogue and to influence rather than coerce or intimidate those with whom it is necessary to work”.w1 The ability to motivate others and to discuss issues are seen as key to effective leadership.
Some surgeons have a military approach; they command and dominate like an army major. This approach is perhaps necessary in emergency situations that demand immediate action. Parallels can be drawn here with the military, fire service, and airline pilots, where life can depend on the professional. Yet these professions are possibly not as strongly associated with the negative traits seen in the surgical personality. Perhaps this is because of the style of their training, as they are trained in a heavily team orientated manner. More emphasis is put on working together. They also have briefings—meetings before executing the task—where potential issues are discussed and individuals are made aware of their role. This helps the team to understand why, in certain circumstances, the leader has to be so ruthless during the task and may help to keep them motivated to work in the face of this.
These techniques could be introduced to surgical training to diminish the misinterpretation of a surgeon’s abruptness. However, emergency operations are relatively rare. In most surgical cases, leadership could be far more effective if it takes on a more collaborative stylew4—that is, if the surgeon motivates the team, who ultimately share the same goal, as opposed to the surgeon giving a reel of orders.

What about female surgeons?

The surgical stereotype is male, but the number of female doctors is increasing. In the period 1983 to 2003 the percentage of female consultants doubled from 12% to 24%. Surgery remains a male dominated specialty, however, with only 7% of surgical consultants being women, despite being a popular career intention for female medical students.w5 The Opportunities in Surgery Committee of the Royal College of Surgeons is attempting to unravel why this is so. Fernandes writes on their behalf: “We need to understand why some women are attracted to, and go on to succeed in a career in surgery whilst others do not. Are the successful female surgeons similar to their male counterparts, is there a ‘surgical personality’?”w6
Cassell studied female surgeons in the United States and found that they encounter more hostility and conflict from other healthcare professionals because of socially constructed expectations of gender.w7 That is, the surgical personality is less tolerated in women. One woman surgeon commented, “A man who has tantrums is temperamental or high strung; a woman who has them is a bitch.” Cassell believes women surgeons negotiate their feminine gender expectations. Fernandes writes, “To elicit greater co-operation from male subordinates and especially female nurses, many women surgeons are more egalitarian, less authoritarian, and less hierarchical in their behaviour.”w6

Can surgeons change?

It is hard to alter behaviour. However, through training in communication skills more sociable traits could become associated with the surgical personality. I believe this would improve the efficiency of teamwork and enhance patient safety. I do not believe it is necessary to have a commanding, military approach to surgery except in emergency situations. Efforts must be made to discourage the negative aspects of the surgical stereotype that have become so ingrained in popular culture. By altering the expectations of surgical behaviour the career may also become more acceptable for female surgeons.
I aspire to be a surgeon myself, and I hope that I can learn to be a great team player, to engage and influence rather than to coerce and intimidate. Surgeons should be happy to collaborate with the whole team and perhaps even share their staff room chair.
Competing interests: None
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