Becoming a Leader During Training and Beyond 
Dimingo Gomez, Richard Davis, Holly P. Jones 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
There is no such thing as a great surgeon, or 
even a good surgeon, who is devoid of leadership 
skills. Nevertheless, most surgical training programs 
do not overtly supply “leadership training.” For 
example, the first chapter of Schwartz’s Principles of 
Surgery is “Fundamental Principles of Leadership 
Training in Surgery.” During our residency’s two-
year cycle through the textbook, this chapter was  
never scheduled for study, even though almost every 
other topic in the book (“Wound Healing,” 
“Pancreas,” “Trauma,” etc.) was discussed several 
times.  
At the end of a surgeon’s training, the 
surgeon is automatically placed in the role of a 
leader, whether or not they have acquired any 
leadership skills along the way. The surgeon’s 
success, and the fate of their patients, will depend on 
their ability to lead others. Surgical practice can not 
be separated from leadership. 
There are many different definitions of 
leadership. All of the following are appropriate: 
● The capability, natural or acquired, to guide, or 
influence a group towards the realization of a 
goal 
● The ability to persuade and help others develop 
future visions and to motivate subordinates to 
desire to achieve visions.  
● The possession of the human factor that binds a 
group together and motivates it towards 
achieving goals 
 
Being placed in a position of leadership does 
not imply that you are a “leader.” Being a leader 
should be more than the desire to be seen “above” 
others. Rather, leadership is an obligation or a 
challenge one feels to fulfill the related desires of the 
people in one’s circle of associates and beyond. It 
follows from this observation that the best leaders are 
often not those who first seek out the role. Often 
leaders with the greatest influence take up the mantle 
of leadership not out of personal ambition, but 
because they believe in the values of the organization 
and want to see them carried on.  
Surgery as a field requires more than just one 
surgeon’s skills: the clinic, the ward, and the 
operating room itself all have complex team 
dynamics at play. A surgeon contracts with the 
patient to successfully shepherd (lead) them through 
the process of surgical care safely: This contract can 
be made in seconds in the Casualty Department, or 
over painstaking months of clinic visits. But once 
this contract is made, the surgeon is placed in a 
position of leadership.  
The surgeon leader’s position can be an 
awkward one: the patient’s care will depend on the 
actions of myriad scrub techs, anesthetists, nurses, 
physiotherapists, and other professionals including 
other physicians. The surgeon is not the “boss” of 
any of these people; there is no military-like 
“command structure” that allows the surgeon to give 
orders and expect them to be obeyed. The leadership 
skills that are called for here are more subtle, and 
more difficult to master. 
Commonly cited fundamentals of good 
leadership include the following: 
● Self-awareness 
● Self-control 
● Understanding others 
● Managing others 
 
Aspiring leaders would be wise to cultivate 
these qualities in the order they are presented above; 
there is no self control without self awareness, and 
there is no real understanding of others without 
understanding and mastering yourself. Finally, 
managing others can only be done well when the 
other three qualities are achieved.   
 
Self-Awareness 
The ability to know and monitor your own 
emotions and reactions is a fundamental skill of 
leadership. It means you know your values, your 
personality, your habits, and how they all affect you. 
Cultivate the ability to look deep into yourself, to 
understand your strengths, your weaknesses, your 
triggers and motivators, as well as how all these 
affect or dictate your actions and  reactions to others 
around you. 
Self-awareness is a character trait that has the 
power to influence the outcome. It makes you a better 
decision 
maker, 
and 
therefore 
boosts 
your 
Becoming a Leader During Training and Beyond 
Dimingo Gomez, Richard Davis, Holly P. Jones 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
confidence as a leader. A self-aware leader carries 
particular characteristics: empathy, confidence, 
humanity, and adaptability. People who cultivate 
these abilities are usually able to communicate 
effectively, a trait we will explore more below.  
With self-awareness comes humility. Being 
self-aware, especially about your strengths and 
shortcomings, gives the ability to remain humble and 
willing to learn. Admitting when you are mistaken 
and showing genuine desire to learn is an act of great 
courage and humility, and thus defines a great leader 
Humility may at first seem similar to 
timidity. But more correctly, humility is the exact 
opposite of timidity. As a general rule, every team 
member wants a confident leader, but almost 
everyone also appreciates a humble one. It has been 
said that humility is a virtue, but timidity is a disease. 
Anyone who has to work with you, as subordinate or 
superior, will be disappointed if they see the lack of 
courage and confidence from you as a leader. Thus, 
timidity will defeat your attempts at leadership. On 
the other hand, if you are humble enough to interact 
and listen, if you are humble enough to admit when 
corrected even by your “subordinates,” you are more 
likely to be supported and your wishes heeded. 
This principle is most evident in those 
situations, described above, where you must lead 
people who are not your direct subordinates. The best 
example is your relationship with the anesthesia 
staff. If you are timid, you will be pushed around. If 
you are overbearing, you will be ignored and 
resisted, either actively or passively. Neither 
situation is best for the patient, or for your own job 
satisfaction. But if you can be simultaneously 
humble and sure of yourself, you will be most likely 
to have a collegial and supportive relationship, to 
your own benefit and the patient’s. 
There are various ways to improve your self-
awareness – be open-minded, think through your 
actions of the day, write down your desired plan and 
track your progress, have a circle of trusted friends 
and give them the independence to criticize you. 
Adaptability is the bridge between self-
awareness and self-control. You must be able to 
change your behavior as the situation changes. The 
expectations on surgeons and surgical trainees is 
enormous, and the outcome of a leader’s plans are 
not always as desired. What makes a surgical leader 
stand out is the ability to see every opportunity as one 
to learn from. 
 
Self-Control 
This is the ability to resist impulses, maintain 
focus, and strive to see projects to completion. The 
willpower to persistently dedicate your attention to a 
task or project to a satisfactory end is self discipline. 
This important trait has several facets: 
 
Reliability  
Doing what you say you will, being 
dependable, is key to high performance leadership. 
As a leader it’s upon you to set a positive tone for 
desirable and acceptable behaviors- your example, 
positive or negative, will set the tone for everyone 
else. You owe it to yourself and the team to be 
trustworthy and reliable. Your co-workers or people 
you lead should be able to count on you to take 
initiative, meet deadlines, handle important details, 
and follow through with decisions you led in making, 
to communicate and to work well with them.  
It is also worth mentioning, at this point, that 
if you are reliable and those around you are not, they 
may be following someone else’s leadership in this 
area. This is part of the culture of a workplace, a 
subject we explore in the chapter Culture Change. It 
is enough to mention here that changing a culture is 
one of the supreme tests of a leader.  
 
Control of Emotions  
Leaders and non-leaders both have emotions. 
As humans we should all strive to be in control of our 
emotions. 
Unfortunately, 
for 
leaders, 
that 
responsibility is even greater than for other people. 
A truly great leader can certainly acknowledge that 
the situation is desperate, and recognize that 
members of the team feel this desperation. But you 
must do your best to not give into desperation 
yourself, at least not out loud. It is certainly OK to 
acknowledge some difficulty in choosing the right 
path. You may even publicly acknowledge mistakes 
in the past, at the right time. But when a decision 
must be made, make sure you are in firm control of 
Becoming a Leader During Training and Beyond 
Dimingo Gomez, Richard Davis, Holly P. Jones 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
your emotions. Seek input and advice if you can, then 
make the decision boldly and firmly. A positive 
attitude in a leader encourages a positive attitude in 
everyone else. 
 
Disciplined Experience 
 
This trait is one that you can’t “fake” when 
you need it. Like an athlete, your performance at any 
moment will depend on your previous experience 
and training. Quite simply, a good leader understands 
the domain they are leading others in, because they 
have done the work and have the experience. What 
this means, of course, is that a surgeon becomes a 
better leader as they accumulate more experience. So 
make the most of the experience you have: prepare 
for it, learn from it, and reflect on it afterwards. The 
relevant saying here (attributed to various authors) is 
“Good judgment comes from experience. Experience 
comes from bad judgment.” An experienced surgeon 
has the judgment to lead others into territory where 
they themselves have been in before.  
 
Understanding Others  
This trait is a product and a natural result of 
understanding yourself. There is no leader with the 
good fortune of leading only people with the same 
characteristics and behaviors. Thus it is important for 
the leader to try to understand all of the team, their 
strengths and weaknesses, and especially the ways in 
which these strengths and weaknesses are different 
from the leader’s own strengths and weaknesses. 
 
Paying Attention 
 
In order to understand others, you must first 
believe that it is necessary to do so. Please let us 
remind you that it is. You will not be an effective 
leader if you do not make the time and the effort to 
understand the motivations, hopes, fears, and even 
the little “quirks” that make up the people you lead. 
Yes, you must know whether someone is 
trustworthy, or whether they have the skills they 
claim that they do. But even more, when you 
understand someone’s strengths, you can use these 
strengths to the advantage of the team and your 
mission. A team member whose strengths are known, 
valued, and used will enjoy being part of the team, 
and the whole team will be better because of it.  
 
Empathy 
In psychology, empathy is defined as 
“understanding another person’s experience by 
imaging oneself in that other person’s situation.” 
Emotional intelligence is a strong foundation for this 
characteristic, and when a leader has it, they build 
stronger relationships with the team. Surgical 
leadership, especially when leading trainees from 
different backgrounds, requires identifying with 
them and their points of view. Be very slow to judge 
them or their ideas, but recognize their emotions. 
 
Kindness  
Many leaders would advise keeping some 
“distance” between yourself and those you lead. 
Others think this is nonsense. But however you feel 
about this advice, remember to be kind to those you 
are leading. Consider the following story from a 
young surgeon:  
“I went to the Operating Theater around 
4AM one morning to sort out an urgent case. There, 
I met the single scrub team just finishing a case, 
about to take their first break all night. I told them 
about the patient. but also told them that given the 
circumstances, we would do this operation first on 
the morning list rather than immediately. They saw 
that as an act of kindness and never forgot it. Even 
others who only heard about it were thankful, and 
have offered their services anytime I enter the 
operating theater, even if not for a case.”  
 
 
This surgeon brought together several of the 
traits we have discussed so far. He had control of his 
emotions- although he was concerned for his patient, 
he did not let this feeling overwhelm him at the 
expense of other considerations. He had the 
disciplined experience to know that the patient could 
safely be managed with a 3-4 hour delay. He was 
paying attention to the state of the Operating Theater 
staff. This allowed him to act with empathy and 
kindness, safely managing all of the resources under 
his care and making some valuable allies along the 
way.  
Becoming a Leader During Training and Beyond 
Dimingo Gomez, Richard Davis, Holly P. Jones 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
As surgeons, and surgical residents, we spend 
more time in the operating room than we do 
anywhere else in the hospital. There, we are leaders 
of the team we work with. Nevertheless, we must 
remember that we do not “own” these people. They 
do not directly report to us. The way we handle the 
operating theater team of anesthetists (predominantly 
nurse anesthetists in our settings) and scrub 
technicians will affect their response to our needs 
thereafter. Be kind to them, but not weak. Kindness, 
when appropriately applied by a leader, is a strength 
rather than  a weakness. 
 
Communication  
Communicating well with others is a function 
of understanding them. All great leaders have 
excellent communication skills, because of two 
factors: they understand themselves, and they 
understand how people around them express their 
views. These two factors are the key to 
communication: 
understanding 
yourself 
and 
understanding others.  
Your ability as a leader to get people to work 
together and to support your game plan depends on 
how much and how well you communicate. 
Intelligent 
communication 
is 
a 
gateway 
to 
influencing others, through your words and backed 
by your actions and emotional intelligence. The 
magnitude of information you share with your team 
should be shared with everyone. Do not assume that 
some members of the team are not important enough 
to get certain information.  
 
Boldness/Confidence  
As a surgical leader, you owe it to yourself 
and the team to be bold, without being a bully. 
Confidence is the art of recognizing and accepting 
your strengths as well as your shortcomings. Your 
subordinates look up to you when the first “arrow” is 
shot. This may vary depending on what group of 
surgeons you are leading. When I was handing over 
the chief resident role to the successive chiefs, I said 
to them, “you should be willing to accept blame to 
protect the others, even if what happened was not 
your fault.” The act of taking the first “arrow” for 
someone lightens the grief of the evaluator. You may 
then turn to the junior or same level colleague and 
remind them that they will not get the same luck next 
time. As a leader, you earn the respect of that 
colleague. The consultant surgeon, who may even be 
aware that it was not at all your fault, will know that 
you are on top of the situation and you will make sure 
it happens no more. 
 
Managing Others  
This may be the final “level” of leadership we 
have been building up to, but as you can see we’ve 
already been leading others with the previous three 
levels. Now we bring together all of the skills into 
one potent package. We use emotional intelligence, 
which is really the combined skills of knowing and 
understanding yourself, and knowing others. We use 
patience, both with ourselves and with others. We 
give heed to the different personalities of the people 
under our leadership. We develop  the ability to adapt 
our leadership style to these differences in 
personalities amongst the group. This capability is 
the highest level of leadership: using our 
understanding of ourselves and of others, to change 
our behavior (self-control,) in ways best suited to this 
particular group of individuals, in order to lead them 
effectively. 
 
Valuing Everyone 
Share responsibilities! As a surgeon or a 
surgeon in training, you are encouraging others to 
follow in your footsteps. Getting everyone involved 
gives everyone a sense of ownership and feeling of 
responsibility towards achieving the common goal. 
People also generally support their leaders better 
when they feel valued and important. Thus, instead 
of continually telling them what to do, allow them to 
suggest to you what to do sometimes. As we said 
above, a team member who is allowed to work within 
their strengths will feel valued. A team member who 
is “stretched” just a little beyond their strengths will 
gain new strengths and become more valuable.  
The issue of sharing responsibilities raises 
the issue of micro- vs. macro-managing. There is a 
balance to be found here, between not giving a 
subordinate enough responsibility, and giving them 
too much. We discuss this issue more below.  
Becoming a Leader During Training and Beyond 
Dimingo Gomez, Richard Davis, Holly P. Jones 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Influence, Coaching and Motivating Others  
As a leader, strive to be influential in the lives 
of your colleagues. Your highest achievements 
should include helping others achieve their goals. 
This act will come naturally during residency 
training, where there is an established “ladder” that 
everyone ascends. Senior residents are expected to 
teach and mentor junior residents. But this 
expectation should not end when training is over. Set 
positive examples, play the role of a “big brother” or 
“big sister” and help others achieve their goals. 
Leave a legacy which they will use to grow the 
program, and they will remember you. In your 
leadership role, create leaders.  
The unfortunate alternative, seen too often, is 
“Founder’s Syndrome,” where a leader makes 
themselves indispensable. Without realizing it, this 
leader structures the organization so that it cannot 
exist without him. Other young leaders, seeing no 
room to grow, realize they must go elsewhere. In 
fact, the greater the potential a young leader has, the 
more likely they will go elsewhere. And so the 
organization persists, made up of ambition-less 
underlings, until it collapses when the Founder 
finally retires (or dies.)  
 
Have Vision and Create New Standards  
There is always something that needs to be changed 
or improved. Regardless of how well organized a 
team or program is when you take over, the wisdom 
is in “what” needs to be changed and, perhaps more 
importantly, “when” the change should be made.  
In my first few years as resident trainee, the 
attitude of residents was the same, we always thought 
the consultants needed to change: they needed to be 
more friendly, they needed to trust us more with 
operative cases, they needed to allow us to make 
more decisions. By the time I was a senior resident, 
it became clear to me that it was on us to prove we 
were ready. We needed to earn the trust of the 
trainers, show more responsibility, and to prove that 
we could run the academic and operative side of the 
training program. In our eagerness to be given 
autonomy, we had greatly overestimated our own 
skills.  
It is common advice to young physicians that 
they should not seek positions of leadership in their 
organization (Chief of Surgery, Program Director) 
until they have been in independent practice for at 
least five years. Many organizations have formal 
rules stating the same. As we said above, the best 
leaders are not motivated by a desire for power, but 
by a belief in the values of the organization and a 
desire to see them carried on.  
 
Some Other Points 
 
The special situations described below can be 
thought of as exercises in one or more of the four 
domains listed above. As you consider these 
“Managing Others” scenarios, and as you consider 
scenarios of your own, consider whether they fall 
under 
“Self-Knowledge,” 
“Self-Control,” 
“Understanding Others,” or some combination.  
 
Micromanaging vs. Over-Delegating 
 
There is a delicate balance to be found here: 
as a leader you ultimately have responsibility for 
every decision made by those you supervise. But you 
cannot possibly be involved in every one of those 
decisions. If you try, you create an environment 
where no one dares to do anything without your 
approval, a form of “Founder’s Syndrome.”  
 
The key here is to have trusted “lieutenants” 
under you… and to really trust them. Recognize that 
they are experts of their areas. Tell them clearly what 
you expect from them. Give them the tools they need 
to deliver these things. Then, leave them to do their 
jobs. You should aim for an environment where the 
following phrase is not heard very often: “I don’t 
know, I have to ask Dr. ___ (you).”  
 
The converse of this rule is, a leader must 
recognize which decisions are hers alone. Don’t get 
so addicted to delegating that you fail to recognize 
where your input is the only appropriate one. For 
example, a surgical Department Head may allow the 
Division Chiefs under her command to decide which 
surgeons to hire. But in order for this arrangement to 
go well, the Department Head must be able to trust 
them implicitly. Only with trust then she can leave 
them to make decisions, even consequential ones, 
without the need to “micromanage.”  
Becoming a Leader During Training and Beyond 
Dimingo Gomez, Richard Davis, Holly P. Jones 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Striking this balance takes wisdom and 
experience. In other words, if you consciously try to 
find this balance, you will get better at it over time. 
In general, it can be summarized as in the Table 
below, which continues the example of a Surgical 
Department Head:  
Type of Decision 
Examples 
Delegatable 
Which operation to 
perform 
When to order new 
supplies 
Which days to have 
clinic 
Hiring of individual 
physicians 
Disciplining of 
individual physicians 
Not Delegatable 
Whether to expand 
(physical plant, adding 
a division or clinical 
service) 
Hiring of Division 
Chiefs 
Firing of any 
physician* 
*This is a serious enough matter that the Department Head 
should be involved, even as the matter is led by the Division 
Chief.  
 
Advice from Others 
 
A common misperception of leaders is that 
they are bold and decisive. They cannot “show 
weakness.” In this way of thinking, failure to 
immediately know what to do- in every possible 
situation- is a form of weakness.  
Clearly, this wrong approach puts appearance 
over function. Such a leader is more concerned with 
“looking” like a leader than with making the right 
decision. This is a failure of self-control. There are 
two key attitudes to take to avoid this trap: 
First of all, learn to recognize which 
decisions must be made urgently and which can wait. 
A good leader appreciates having time to find the 
solution to a complex problem and does not let the 
“felt urgency” of others push him to act rashly. One 
good mental exercise is to ask yourself two 
questions, and then decide which would lead to a 
worse outcome: 
1.  What would happen if I took one week (or other 
timeframe) to make this decision? 
2. What would happen if I made the wrong 
decision?  
 
Most of the time, the situation is not as urgent 
as others might make it seem: you have time to make 
the right decision.  
The other way to avoid the “trap” of needing 
to appear decisive is to publicly and humbly accept 
the advice of others. If you believe that this behavior 
is a sign of weakness, consider the number of 
successful leaders who were known to have an “inner 
circle” of advisors. This is a very common practice. 
At first it may set you apart, especially in a culture 
that expects leaders to work alone. But in the end, it 
will be your success that sets you apart- individuals 
fail, teams succeed, especially when important 
decisions need to be made. Be the leader of that team, 
but do have a team.  
 
 
Romantic Relationships with Subordinates 
 
We could summarize this section with one 
word: “Don’t!”  
As a leader, you have a responsibility to act 
morally and responsibly, to create a safe environment 
for those under your care. It may feel good to find 
yourself in a position where people are listening to 
your every word, asking for your opinion, and 
seeking your help. Don’t confuse this with romantic 
feelings. This is just what a power dynamic looks 
like. You, as a leader, are the one with power in this 
relationship. It is up to you to shut any feelings down.  
This situation applies even if there are any 
actual romantic feelings in one of your subordinates, 
that go beyond respect and admiration for an 
accomplished leader. Realize that most of the time, 
this is not the case; you are simply misreading the 
situation. That attractive younger person who seems 
to admire you personally, and seems to have 
romantic feelings for you, likely does not. Again, it 
is your job to make sure the relationship goes no 
farther than a professional one.  
Becoming a Leader During Training and Beyond 
Dimingo Gomez, Richard Davis, Holly P. Jones 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
If you do not avoid romantic relationships 
with subordinates, or if you even appear to be 
interested in such relationships, subordinates will 
quickly realize that this is the case. The inevitable 
result is a toxic environment. No one knows whether 
the leader approves of their ideas, attitude, or 
performance, or whether you are merely trying to 
“groom” them for a relationship. No one knows 
whether someone was promoted because of their 
merits and hard work, or for “other” reasons. The 
expectation of fairness, equity and trust goes out the 
window. 
People under your leadership will have to 
think about every interaction with you. Will that 
promotion, or that work trip, really be good for their 
career? Or are you just trying to get them alone?  
Others see this morally and ethically wrong 
behavior in someone they respect and trust. The 
consequences of behaving this way literally spread 
across the whole department and even the whole 
hospital.  
 
Conclusion 
 
We describe here one technique to become a 
better leader, following the progression described 
above. Know yourself, achieve self-control, and 
understand others. Mastery of these elements, and 
the lessons and skills thus acquired, is the key to 
managing others effectively.  
 
 
Dimingo Gomez MD FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
Holly P. Jones, PhD 
Northern Illinois University 
USA 
 
May 2023 
