Leadership of a Department of Surgery 
Sharmila Dissanaike 
 
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:  
Being a Department Chair is one of the most 
fulfilling, and also one of the most challenging jobs 
in healthcare. The responsibilities of a Chair will 
vary significantly between countries and institutions. 
There will be variance between academic and private 
practice even within the same country or insustion.  
In some centers, the job will focus exclusively on 
managing other surgeons, advocating for their needs, 
and academic productivity. In others, financial 
stewardship and management of operative services 
will be a priority. Quality assurance, and maintaining 
high standards of patient care and professionalism, is 
a component in almost all cases. Education, training 
the next generation of surgeons and physicians, is a 
key component in academic departments. 
This chapter provides a very brief overview 
of the different aspects of the mission a leader of a 
department should expect to handle. For much more 
useful, in-depth information, the reader is referred to 
the recently published Surgical Chairs Playbook, 
produced by the Society of Surgical Chairs and the 
American College of Surgeons. Additional resources 
can be found in the bibliography.  
 
Education 
Times have changed since the old era of “see 
one, do one, teach one.” Modern trainees are required 
to absorb a volume of new information that is 
increasing at an exponential rate, while developing 
operative skills in open, laparoscopic, robotic, and 
endoscopic surgery – a huge ask, especially in a 
limited time frame. In addition, high level 
communication skills and professionalism are 
expected of the modern surgeon, and these must also 
be deliberately inculcated. Therefore, training 
surgeons is very much an intentional, carefully 
structured and monitored process requiring frequent 
assessments. A modern surgical education is a far cry 
from the traditional apprenticeship model that was 
the mainstay of surgical training for much of the 
history of our profession. 
Building a strong educational program is 
crucial to attracting “the best and the brightest” 
physicians to train as surgeons. In formal accredited 
programs, a Program Director is usually appointed to 
oversee this aspect of the mission. While some 
Chairs choose to take on this role themselves, it can 
be a gargantuan task, especially with regulatory 
requirements for frequent updates to paperwork, 
leading 
to 
significant 
administrative 
burden. 
Therefore, it is best delegated to another individual 
with an interest and talent for educating surgeons in 
cognitive, technical, and professional skills.  
 
Finances: 
The mission of a surgery department should 
be patient care, education, and research, rather than 
generating profit for its own sake. Based on the 
healthcare payment structure of the country and 
institution, surgical departments may either be a 
cost-center or a profit-center. While the overall 
financial background against which we practice is 
not under the control of any Chair, it is important to 
understand and manage finances adequately in order 
to maximize revenue, and minimize cost, so as to 
serve as a responsible steward of the Department’s 
resources. It is not usually necessary to obtain formal 
qualifications such as a Master’s in Business 
Administration (MBA) in order to perform this task. 
However, a basic understanding of the principles of 
accrual 
accounting, 
balanced 
or 
zero-based 
budgeting, 
understanding 
profit 
and 
loss 
spreadsheets and balance sheets, will be immensely 
helpful. Understanding the fundamental principles of 
managing a business will serve the Chair well. 
Assistance from a financial professional in 
calculating costs of new programs, such as how to 
include appropriate fringe benefits, taxes etc., and 
identifying hidden overhead costs both fixed and 
variable, will be an advantage in proposing new 
services and negotiating to recruit additional 
surgeons to grow the Department. 
 
Quality Assurance 
Maintaining quality standards is essential for 
the integrity of the Department. As technology 
becomes ever more complex, ensuring surgeons are 
appropriately trained and credentialed for the 
procedures they perform, and ensuring there is a 
formal, structured process to incorporate new ideas 
and technology within the Department, is crucial. 
Leadership of a Department of Surgery 
Sharmila Dissanaike 
 
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  
 
Ensuring compliance with standards of infection 
control, and adoption of systematic protocols for pre- 
and post-operative care, are also core requirements 
of a Surgery Chair. One of the often less popular 
tasks for a Chair is introducing evidence-based 
protocols.  Asking surgeons to adopt these uniform 
new standards, rather than continue to do things “the 
way I have always done them” can be challenging. 
While nobody is advocating for cookbook medicine, 
there are many instances where systematic 
protocolization helps ensure high quality care, while 
reducing opportunity for error. The pre-operative 
time-out, and use of checklists, are well-known 
examples that are now routine practice in many 
centers, after fairly strong initial backlash when they 
were first introduced.  
Developing 
a 
robust 
performance 
improvement/quality assurance program will be an 
essential component for any Department leader. 
Integrating different divisions and specialties to 
ensure adequate input from non-core surgeons so as 
to ensure unbiased perspective often needs to be 
orchestrated. 
Discussions 
around 
quality 
improvement, along with the infrastructure to 
monitor and track rates of common problems such as 
surgical infections, wound complications, bleeding 
etc., are some of the basic building blocks of 
performance 
improvement. 
It 
is 
strongly 
recommended that the Chair undertake a course or 
two in performance improvement to learn the basic 
language and ethos of this important specialty, that is 
usually not covered in traditional surgical training. 
 
Patient Care and Satisfaction 
Surgery, along with the rest of medicine, has 
a long history of a somewhat paternalistic attitude to 
patient care and satisfaction. Being a highly technical 
specialty, there is an even greater tendency to assume 
that the rationale for our recommendations would be 
too complex for a layperson to understand, and thus 
a degree of benevolent paternalism is warranted. In 
the modern era, patient expectations (and rightfully 
so) are for the surgeon to provide their expert 
recommendations along with a clear explanation of 
the reasons behind them, as well as a brief evaluation 
and explanation of other options. An informed 
patient is a key partner in the enterprise of shared 
decision-making, which should be the ethical 
underpinning of all surgical actions. An important 
role of the Surgery Chair is to ensure there is a clear 
expectation that surgeons will take the time to engage 
their patients as partners in any endeavor, and afford 
adequate time and patience to answer their questions. 
Whether patient satisfaction in this regard is 
monitored formally or informally, it is important that 
the Chair ensures the patient remains the center of 
our surgical practice and efforts, and that their 
viewpoint and perception is seen as crucial to inform 
performance improvement and future directions. 
 
Self Development as a Leader 
Ability to set long-term strategy and vision 
for growth, along with efficiently managing the 
myriad day to day responsibilities, will take a 
significant investment of time from the Chair, 
requiring a corresponding reduction in personal 
clinical and research responsibilities. This is a 
painful but necessary step when becoming a leader. 
Conversely, it is important that the Chair maintains 
some clinical presence and activity, in order to 
understand the challenges and opportunities faced by 
other members of their Department.  
There are few places left in the world where 
a Department will unquestioningly follow a leader’s 
orders just “because I said so.” The traditional my-
way-or-the-highway authoritarian style of leadership 
is no longer viable in the modern environment. 
Therefore, the aspiring leader would be wise to 
invest the time and energy necessary to develop a 
collaborative leadership style – an item not included 
in traditional surgical training. This allows the Chair 
to garner the skills necessary to actively listen, 
encourage participation, allow plenty of opportunity 
for input from the team, and consolidate these into a 
unified vision and strategy for the Department.  
Developing a strong network of next-tier 
leaders is also essential to ensure all aspects of this 
complex task are managed well and in a timely 
fashion, especially in larger Departments. Titles for 
these individuals may include Division Chiefs, Vice-
Chairs, Directors, and Senior Administrators, based 
on local norms. Growing and developing these 
Leadership of a Department of Surgery 
Sharmila Dissanaike 
 
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  
 
leaders, alongside investing time in one’s own career 
development, is essential for the successful Chair. 
 
Conclusion 
I hope this cursory overview of what is 
required to lead a surgical department piques the 
reader’s interest and encourages further exploration. 
There are an overwhelming number of books on 
leadership, self-development, quality assurance and 
adult education available today, as well as many 
online courses. The brief selection below are simply 
a few of the books I personally have found most 
helpful. 
 
Bibliography 
Surgical Chairs Playbook Eds. Higgins R., 
Matthews J., Rosengart T., Wong S. Society of 
Surgical Chairs of the American College of 
Surgeons2023 
https://www.facs.org/for-medical-
professionals/news-publications/books-and-
manuals/surgical-chairs-playbook/ 
 
Optimal Resources for Surgical Quality and Safety 
Hoyt D., Ko CY., American College of Surgeons 
2017 
https://www.facs.org/for-medical-
professionals/news-publications/books-and-
manuals/optimal-resources-for-surgical-quality-and-
safety/ 
 
Fundamental of Physician Leadership: Finance 
American Association for Physician Leadership. 
https://www.physicianleaders.org/education/course/
fundamentals-of-physician-leadership-
finance?v=41462416769204  
 
The 15 Commitments of Conscious Leadership 
Dethmer J., Chapman D., Warner-Klemp K. 
Conscious Leadership Group 2014 
https://conscious.is/15-commitments 
 
The Contrarian's Guide to Leadership Steven 
Sample. Warren Bennis Book, Wiley Imprint 2002 
https://about.usc.edu/steven-b-sample/contrarians-
guide-to-leadership/ 
 
Sharmila Dissanaike MD FACS FCCM 
Texas Tech University Health Sciences Center 
Lubbock, Texas, USA 
 
May 2023 
 
