“IQ and technical skills are important, but emotional intelligence is the sine qua non of leadership.”
Daniel Goleman
The attractiveness of medical careers remains evident worldwide with ever increasing applicant pools. The world’s population is aging, medical interventions continue to expand, and purchasing power worldwide continues to drive the demand for physician services. Because there are far fewer positions than applicants for medical education, selection pressure is significant. Test scores, class ranking, advanced degrees, numbers of publications, rotations in the field of interest, and active scientific engagement have all been used as proxy measures of aptitude.1 However, it appears that our resident interview process may not be as useful as perceived and may not predict subsequent performance as either a trainee or as an attending physician.2–4 In addition, 20% of physicians will have a psychological health issue during their career, reports of burnout among anesthesiologists are becoming more frequent,5–8 and the lack of effective tools for managing stress and burnout in the medical profession is increasingly recognized as a problem.9 Thus, it is timely to ask how we might improve resident selection in the specialty, and how we might support fully trained anesthesiologists throughout their careers.
A decade ago, a milestone study in management sciences showed that “Emotional Intelligence” (EI)—defined by the psychological dimensions of self-awareness, self-regulation, motivation, empathy, and social skills—affects the performance of leaders. EI has been described as helping to “provide the fundamental groundwork” to ensure that operating room leadership promotes high-quality and safe patient care.10 Reliability of EI measurements in the medical professions has been questioned11; nonetheless, it is apparent that certain aspects of EI have predictive value in the performance of anesthesiology residents,12 and some anesthesiology training programs have begun incorporating the aspects of personality in their resident selection processes.4 Although it remains unclear whether EI is a learnable function, an inherent trait, or a combination of the two,11 it is possible that the negative consequences of a lack of EI may be mitigated through education, mentorship, and collegial support.
Several aspects of EI correspond to competencies that medical training seeks to deliver.13 Empathy, organizational awareness, the ability to influence, provide role modeling, and motivate others—all components or consequences of EI—are among the necessary attributes of successful team leaders.14 As leaders in perioperative medicine, anesthesiologists must also possess reliable strategies for self-management to cope with daily work; this is especially important in large hospitals with multiple surgical departments where situational adaptation and coordination between an operating room’s stakeholders can pose challenges15 for aligning patient safety, surgeon access to scheduled operating time, and operating room efficiency.16
“Adaptive coordination,” a component of EI defined as “the situational management of coordination requirements,”17 is known to be a key characteristic of high performing teams,18 especially in more complex settings such as among a multicultural and multidisciplinary workforce.19 An organizational culture that supports adaptive coordination directed toward group orientation and reduced hierarchy is associated with an increased safety climate.20 Given that possession of EI is an important characteristic of perioperative team leadership relevant to providing high-quality and safe patient care in anesthesiology and acute care medicine, it might be prudent to assess the relevant personality characteristics of resident applicants in addition to the traditional proxy measurements of aptitude noted above. Reliability, honesty, ability to function under stress, punctuality, and discipline have been described as desirable personality traits (ie, a person’s fixed patterns of behaviors revealed in different situations, influenced by the person’s EI, thus affecting their adaptive coordination) in anesthesia residents.21 In a small, single-center cohort, Merlo et al found that personality traits “may be associated with success” in anesthesiology residency programs.22 In this regard, it should not be surprising that, although the personality type of anesthesiology residents was not associated with their performance on standardized examinations, personality type was associated with faculty evaluations of their performance.23
It is evident that a profound scientific grounding is necessary for a physician to be able to formulate a cogent management plan for an ill patient, and the successful clinician must be able to pass a certification examination. However, because computer systems become more and more adept, the scientific/technical components may be readily available and less dependent on the technical knowledge of the physician; the greater contribution of the caregiver will likely be leadership and human interaction. An ill or injured patient (and his or her relatives) not only wants understanding of the medical issue from a physician, but the patient also wants compassion, empathy, and caring. With the ever increasing complexity of clinical cases and increasing medical and technical knowledge,24 there is a tendency to overlook this critical human and humane relationship. In the field of anesthesiology, there are frequently situations where compassion and caring require coercive and/or pacesetting leadership rather than kindness and empathy, for example, during life-threatening A-, B-, C-, or D-problems according to ACLS or ATLS protocols. In such moments, emotionally intelligent anesthesiologists will be well aware of the pressure, yet will self-regulate, approach the situation with clarity, motivate their teams, and support a climate of respect even in highly stressful circumstances.25,26
In her milestone article, Diane Coutu27 described the properties of personalities with such down-to-earth behavior that not only embraced the “coolness” to accept harsh realities and the ability to realize “what matters for survival,” but additionally to create meaning from them as “resilience.” Since then, EI and adaptive coordination, resilience, and themes of reflective practice toward self-awareness, development of core values, and moral leadership have been described as fundamental goals in an active and constructive process of professional identity formation in medicine.28 Zwack et al asked “if every fifth physician is affected by burnout, what about the other four?” They found that focusing on positive aspects of work, “personal reflexivity,” and accepting both personal and professional boundaries were resilience strategies employed by experienced physicians.29 In medicine, the recognition that resilience is a key to optimal performance has emerged only recently.30,31
Given the evidence from both business and medical science, the selection of team members is probably the critical task for leadership in anesthesiology32 and for patient safety.33 But the question remains: do psychological measurements gleaned from the interview process allow us to select individuals who know what really matters? If not, can we learn to select for personality types who can be taught what matters?
CONCLUSIONS
The available evidence suggests that EI is a desirable attribute for physicians in anesthesiology and acute care medicine. Anticipating the evolution of our specialty, it is plausible that emotionally intelligent anesthesiologists are more likely to be successful in the future health care environment. Accordingly, we advocate including an evaluation of EI in our resident selection process, as well as ongoing EI training throughout an anesthesiologist’s career. EI is not soft kindness or unprofessional commiseration. It is the sine qua non of leadership.
DISCLOSURES
Name: Markus M. Luedi, MD, MBA.
Contribution: This author helped write the manuscript.
Name: Dietrich Doll, MD, PhD.
Contribution: This author helped write the manuscript.
Name: Steven D. Boggs, MD.
Contribution: This author helped write the manuscript.
Name: Frank Stueber, MD.
Contribution: This author helped write the manuscript.
This manuscript was handled by: Thomas R. Vetter, MD, MPH.
Acting EIC on Final Acceptance: Thomas R. Vetter, MD, MPH.
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