The focus on leadership in the surgical community is intense. Given the high-risk context of the operative theatre, surgeons instinctively recognize the need for strong leadership and organizational structure; certainly, we have all heard the “captain of the ship” metaphor relating the role of the surgeon in complicated patient care settings. The patient safety movement and emphasis on crew management, and simulation efforts, has further sharpened our awareness and urgency in gaining control of all possible variables—a real feat, given the complexity of our workplace. The need for active leadership recurs as a requisite ingredient as we aim for the best possible patient outcomes. These leadership skills can be deployed in the OR, in our surgical divisions and clinical practices, and in large departments and hospitals. To this end, there is a growing industry focused on clinicians as leaders; and also emerging scholarly work focusing on the surgeon as a clinical leader, leadership development for surgeons,1,2 and numerous retrospective reviews of the leadership qualities of famous surgeon-leaders.
Curiously, not as much attention has been given to those who collaborate with the leaders—the followers. In fact, being a follower carries with it something of a pejorative overtone in the surgical ecosystem. The reality is that all of us are both leaders and followers; the university president leads a large and complex organization, but must respond to the board of trustees; the chief medical officer manages a hospital or clinic, but responds to the chief executive officer; and so on. Organizations invest 80% of their development resources towards the leadership; yet a mere 20% is dedicated to enhancing the skills of the followers, who constitute the majority of the workforce.3 Indeed, considerable effort is spent recruiting junior faculty and residents, individuals whose followership skills, including the central adoption of a patient care mission and willingness to maintain a strong work ethic, are critical to the success of the department. The conceit of a leader-centric posture with a lack of emphasis on the effective follower has received some attention in the industrial organizational academy; however, a PubMed search in July 2017 reveals a single review article introducing the concept of followership in surgery.4
The notion of the idealized leader is ancient and richly represented in literature and historical narratives. The successes, and failures of the great empires are typically cast with a tenor of epic and personal accomplishment—ergo, “Caesar conquered Gaul!” as if he, alone, was able to do this. As late as 1974, Hollander noted that the role of an organizational leader was to direct the activities of others; furthermore, leadership was held through the position of authority—posited as a fixed, if not static, role.5 Leaders did the thinking, and followers did as they were told with little individual agency or recognition. The obvious dependence on followers to reach success only began to appear in the literature in the 1930s.
Robert Kelley in 1988 presented the first significant academic effort to understand the value of the effective follower.6 Kelley presented followers along 2 dimensions: A passive/active dimension that explores the level of engagement and energy that an individual brings to their work, and the dependence axis, which explores the ability of a worker to think critically and independently. Using these 2 axes, a supervisor can ground their assessments of the follower's style. In general, 5 followership styles emerge: survivors, conformists, passive followers, alienated followers, and effective followers. The goal of the organization is to have effective followers and to identify and, if possible, mitigate the conditions that restrain the other types from becoming effective.
Kelley's conceptual map for followership (Fig. 1) is helpful when considering the followership types. In the lower critical thinking and dependence quadrants, we reflect on the conformist (“yes” people) and passive followers. Although dependent, the conformist is content to take orders and act on them while not directly challenging leadership. Their baseline deferential state, when combined with a leader lacking judgment or confidence, can lead to alliances that dampen creativity. Passive followers require both leadership and continuous supervision. Among the independent followers, we recognize some as alienated followers—they score high in independent thought, but are low in active engagement. These individuals think critically, but are not active participants; they are passive in their roles, but can be cynically consenting. The preferred behavior is one of a positive balance of independence, critical thinking, and self-energized activity; these are the effective followers, well-balanced and responsible, and they offer tremendous value to the organization. Somewhere in the middle of the rubric lies the final group, the pragmatic follower, also known as the survivor, who reveals occasional independence and engagement.
Several similar followership models have been proposed: Chaleff7 proposed axes reflecting support for, and also the ability to challenge, organizational leadership; this model defined the individual employee as an implementer, a partner, and individualist, or a resource. Meanwhile, Kellerman8 proposed a single axis based on levels of engagement with the following typology reflecting increasing engagement: isolates, bystanders, participants, activists, and diehards. Another model, proposed by Adair, categorizes the followers using a “4D” alliterative framework: disgruntled, disengaged, doers, and disciples.9 Although the Adair model may resonate colorfully for some departments, the Kelley model is less judgmental and may present the leadership with a more practical approach.
There is a need to redefine the role of the follower and how important contributions can be assessed and rewarded. Leadership is not independent of followership; both are critical to the success of the organization. By virtue of their position leaders develop strategy and vision, motivate the organization, and muster the resources to reach goals. Effective followers compose the teams that accomplish these aims, and they do so with the ability to balance both corporate and personal objectives without impeding either. The effective follower is an independent and critical thinker, can auto-regulate, and acts responsibly towards others on behalf of the organization. In fact, the effective follower demonstrates many of the same traits that are sought in leaders.
To maximize organizational productivity and collegiality, it makes sense to evaluate everyone on typical “leadership qualities” like independent thinking, competence, self-regulation, and the like. Taking this approach one can also incorporate observations from peers, superiors, and direct reports, thereby reflecting on the same attributes, but couched in the role of leader or follower. This strategy permits nuanced insights; for example, some employees may be creative and energized only when allowed a leadership opportunity, but are more passive when part of a medium sized team.
Consider, hypothetically, a mid-career faculty member who has had to close their small animal laboratory due to loss of funding, and has had to increase their clinical load to fulfil their obligations to the department. This individual is now in a constant low-grade state of unease, and his general negativity is affecting everyone around him. He is not engaged with the department often missing Grand Rounds, and other department meetings. The world that he ruled, where he was independent and functional, is no longer accessible, and his energies are misplaced. He is an alienated follower in the Kelley model. How do we move him from alienation to effective followership? Perhaps, this surgeon will no longer be able to run a laboratory, but may be interested in supporting the institutional review board where his research skills make him a valued member of that team; the leader's role, in this case, is to help this surgeon identify a way forward through purposeful and effective followership. The relationship between the leader and the follower is interdependent and defined by shared common purpose.10 In the clinical context, that goal is achieving optimal patient outcomes and, where relevant, advancing other institutional missions like research and education. Our challenge is to find the component of our mission that motivates this individual to re-engage and move from a passive to an active mode and where he may contribute to the institution with improved job satisfaction.
It is worth revisiting the idea that leadership and followership are roles, and not people or titles per se. The general opinion is that leadership must be taught, but followership comes easily. This outlook presupposes that the leader is the fountain of all direction in an organization and, therefore, of more value than the followers. The reality is that followers need development and training to maximize their impact. In particular, training in critical thinking, self-management, acting responsibly for the organization, and the value of alignment of personal and organizational goals is important. A training paradigm such as this could underpin the annual evaluation process reflecting the successful integration of these behaviors in settings where strong followers are needed; for example, small group activities where a leader is not formally identified. The effective follower shares the vision of the organization and is critical in its success; when a leader steps down, the effective followers keep the shop open. Organizations would be well-served recognizing this relationship explicitly and developing structures for development, assessment, and rewards that align with this notion.
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