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Editorial

Millennial Leaders: Ready or Not, Here They Come

Rohrich, Rod J. M.D.; Rodriguez, Abigail M. M.D.

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Plastic and Reconstructive Surgery: May 2020 - Volume 145 - Issue 5 - p 1331-1337
doi: 10.1097/PRS.0000000000006753
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Millennials rising to leadership positions in plastic surgery is an inevitability. In general, millennials have a negative reputation for being uncommitted and self-centered. The validity of this reputation is called into question in this article. The concepts of leadership and followership are reviewed, and the current landscape of leadership in plastic surgery is analyzed. Millennial traits that are anticipated to impact their rise to leadership in plastic surgery are detailed. Plastic surgeons from the millennials generation are our future leaders. They merit mentoring and training to augment their strengths and improve on their weaknesses, thereby appropriately preparing them for leadership positions.

BACKGROUND

To many, hearing the term “millennial” precipitates a despondent groan. The stereotypical millennial is a narcissistic, entitled, lazy individual born out of the “Me Me Me Generation.”1 Millennials were born between 1981 and 1996 (Table 1) and are predicted to overtake boomers in population this year.2,3 Millennials constitute an increasing percentage of the overall workforce, and plastic surgery is no exception. For several years, millennials have been graduating from residency/fellowship training and transitioning to practice. Millennials are positioned to enter plastic surgery leadership positions imminently. This article aims to provide a foundational background of leadership and to analyze the changing landscape of leadership specifically in plastic surgery. In addition, this article will highlight the unique characteristics of millennials that are anticipated to suitably equip them to succeed as leaders, and those that are likely to impede them.

Table 1. - Generational Timeline*
Generation Born Age in 2019
Silent 1928–1945 74–91
Boomers 1946–1964 55–73
Generation X 1965–1980 39–54
Millennials (Generation Y) 1981–1996 23–38
Generation Z 1997–2012 7–22
*Source: Dimock M. Defining generations: Where Millennials end and Generation Z begins. Pew Research Center. January 17, 2019. Available at: https://www.pewresearch.org/fact-tank/2019/01/17/where-millennials-end-and-generation-z-begins/. Accessed July 20, 2019.

WHAT IS A LEADER?

A vast array of definitions of a “leader” exist. At the core, a leader is simply “someone who has followers.”4 More specifically, leaders are “persons who, by word and/or personal example, markedly influence the behaviors, thoughts, and or/feelings of a significant number of their fellow human beings… [or] followers.”5 The majority of leadership definitions assume that “intentional influence is exerted over other people to guide, structure, and facilitate activities and relationship in a group or organization.”6 Common leadership descriptions assume that “intentional influence” is exerted by the leader, and classic texts classify leaders by one of five approaches6:

  1. Trait approach: The trait approach emphasizes the personality, values, skills, and motives of a leader. This is underpinned by the assumption that leadership is innate for some.6
  2. Behavior approach: The behavior approach focuses on a leader’s actions and decisions. Leadership effectiveness is partly determined by a leader’s behaviors, such as coping with challenges, seizing opportunities, and resolving conflicts.6
  3. Power-influence approach: This approach evaluates leaders on a power spectrum from autocratic to participative leadership styles.6 Power alone does not ensure that significant change will occur, whereas terror often does (e.g., Mao Zedong).5
  4. Situational approach: The situational approach identifies contextual factors that shape the leadership process, such as follower characteristics, organizational type, and the challenge being faced.6 Certain leader attributes will be beneficial in certain situations but not others.7
  5. Integrative approach: This approach involves more than one leadership variable (e.g., traits, behavior, influence processes, and outcomes).

Numerous other frameworks for leadership exist. However, these five approaches present critical considerations for analyzing both leaders and followers.

ARE ALL LEADERS “GOOD” LEADERS?

Not all leaders are “good,” moral, ethical, or effective. Indeed, the question is not whether leaders will use power, but rather, “Will it be used wisely and well?”8 It is common to view the concept of a leader through a lens of positivity.5 Frequently cited “leadership traits,” such as fairness and integrity, presuppose that a leader will exhibit such qualities.4,8 However, there have been many deplorable leaders that have been objectively effective at pursuing their goals, such as Hitler.5 Good leaders are a desirable subset of leaders that typically present an inclusive message, directing followers to accomplish positive changes. The morality and ethicality of a leader’s decision can vary across cultures and can be challenging to interpret. For instance, some followers may benefit and others harmed by a single decision made by their leader.6

Within a focused institution such as plastic surgery, morality and ethicality is more clearly defined. The American Society of Plastic Surgeons Code of Ethics covers a range of topics, from improper financial dealings to misleading and dishonest photographs.9 At a minimum, good plastic surgery leaders are expected to adhere to the Code of Ethics.

Effective leaders are often self-confident without being arrogant, and have high energy levels and stress tolerance.4,6 Adaptability and a willingness to accept and embrace change are critical for leaders to be effective.10 The “that’s how we’ve always done it” mentality is incongruous with a resilient, adaptable leader.11 Leaders with high expectations for themselves have correspondingly high expectations for followers.12 Other common features of an effective leader include high emotional maturity, personal integrity, socialized power motivation, and achievement orientation.4,6,13 Effective leaders value interpersonal relationships but do not necessarily prioritize them; they are willing to make unpopular decisions if necessary and are not preoccupied with being liked by followers.

An effective leader in plastic surgery is challenged to excel in numerous spheres simultaneously, without compromising one for another.4 Superlatively effective leaders in plastic surgery must also demonstrate humility and “professional will,” the “unwavering resolve to do what must be done.”4,14

OTHER POSITIONS OF POWER

A leader may simultaneously hold separate positions of power, either informal or formal. For instance, leaders may also act as managers or mentors. Although managers can certainly motivate employees, they do not necessarily have the ability to inspire and create lasting change as leaders do. Leaders succeed through storytelling that connects them with followers and can change ideas and behaviors for the long-term.5,15 “A story does what facts and statistics never can: it inspires and motivates.”16

Mentors are individuals with greater experience that engage in a voluntary relationship with those with less experience. This relationship is founded on mutual respect and involves the exchange of advice, knowledge, and support that may benefit both parties.17 Within plastic surgery, mentorship has been identified as critical both during and after training.18 Mentorship facilitates professional development, academic productivity, grant funding, research, and career advancement.19 A 2012 study of academic plastic surgeons indicated that lack of mentorship was a key predictor of attrition.20 Leaders are advised to equip followers with the tools to succeed, and this may involve acting as a mentor to followers.4,21

WHAT IS A FOLLOWER?

Leaders do not exist without followers. Followers are imperative to translating a leader’s story into a reality. Effective followers compose the teams that accomplish the goals agreed on by the group with the leader. Effective followers are responsible and self-energizing, and demonstrate independent, critical thinking.22,23 Much overlap exists between the desirable traits of a leader and a follower.

Some organizations invest upward of 80 percent of development resources for the benefit of leaders and only 20 percent for the benefit of followers.24 Leader-centric organizations may fall short of achieving their full potential by overlooking followership development. For instance, in plastic surgery, increased attention to developing junior faculty and residents may improve retention, academic achievements, and suitability to progress to leadership roles later.

WHERE ARE WE NOW?

Two recent studies evaluated the current landscape of academic leadership in plastic surgery, including program directors, division chiefs, and department chairs.25,26 The majority of program directors have completed a fellowship and are often internally promoted.25 Seventy percent of program directors indicated that they were not interested in promotion to division chief or department chair.25 Program directors emphasized their teaching ability and interest in working with residents in this survey.25

Division chiefs and department chairs were less likely to have completed a fellowship compared with program directors.25 Most were internally promoted and viewed their academic accomplishments, productivity, business acumen, and institutional knowledge as valuable skills for their position.25,26 Forty-one percent of chiefs/chairpersons graduated from one of nine residencies, with Harvard being the most common.26 Eighty-three percent of division chiefs and department chairs in plastic surgery are Caucasian, with only 13 percent Asian, 3 percent Latino, and 1 percent African American.25

Plastic surgery leadership is overwhelmingly male.25,26 Women constitute approximately 5 percent of division chiefs and department chairs and 11 percent of program directors.25,26 Female representation in academic leadership positions is similarly dismal in general surgery, with only 5.7 percent of chairpersons and 18.4 percent of program directors being female.27,28 In plastic surgery, women are less likely to receive promotions and are more likely to leave academic medicine.29

The academic leadership of plastic surgery is demonstrably homogenous. Furnas et al. and Silva et al. expertly outline key steps required to improve gender diversity among formal leadership positions and among informal leaders within plastic surgery.29,30

MILLENNIALS: ADVANTAGES FOR LEADERSHIP

Certain trends among millennials can be predicted as advantageous to leadership development. Key characteristics include the following.

Collaboration

Millennials tend to be team-oriented and collaborative. Millennials do not crave power and influence over others as much as members of Generation X.31 Rather, millennials place greater value on close affiliation with groups and achieving success.31 The team mentality is integral to the millennial mindset, and this should help them succeed in leadership positions.

Ambition and Optimism

Even in discouraging environments, ambition and optimism abound among millennials. Their generation has a daunting level of student loan debt, in addition to low income and relatively high unemployment levels.32 This does not deter millennials whatsoever. In fact, 88 percent of millennials are confident that they will earn enough income in the future to support their desired lifestyle, even though they may not presently.32 The ambition and optimism of future millennial leaders needs to be channeled into creating a realistic, positive outlook, and a well-planned vision for the future.4

Honesty and Authenticity

Millennials strongly prefer leaders and organizations that are “authentic” and committed to social responsibility.32 Millennials demonstrate and expect personalized communication and transparency, almost to an extreme, as “‘TMI’ isn’t part of the Millennial vocabulary.”32 Communication is also a constant “24-hour-a-day, seven-day-a-week dialogue,” facilitated by technology.33 The content of this communication is expected to include clear expectations and frequent, prompt feedback.

Self-Confidence

Millennials are not lacking in confidence, as evidenced by self-promotion and the selfie phenomenon of their generation. They tend to possess traits such as self-esteem, high expectations, assertiveness, and extraversion.33 These traits may be beneficial to millennial leaders, as they may be more likely to influence followers to act courageously and pursue innovative, riskier goals.6

Digital Native

Unlike all prior generations, millennials have never had to strain to adapt to new technologies.34 As a result, millennials are 2.5 times more likely to be early adopters of new technologies (“digital native”).33 These new technologies are viewed by millennials as tools that make their lives easier and bring them closer to friends and family.32

Multitasking

Millennials appear to be expert multitaskers. Studies show that, in reality, adeptness in “task switching” has developed in this group.35 Millennials have had such intense “multitasking training” to the extent that brain rewiring has occurred, enabling them to process more complex tasks in a more rapid succession.33 The ability to manage and prioritize numerous tasks, particularly with the constant influx of information from various technology sources, is a fundamental skill for current and future leaders.

Work-Life Balance

Happiness, love, and friendship are valued over money and power within the millennial generation.33 Work-life balance is not only desired but demanded. Seventy-five percent of millennials say work-life balance drives their career choice.33 Older generations may interpret the emphasis on work-life balance as a means to shirk duties. Millennials, however, strike a balance by achieving “work-life integration and harmony,” meaning that they focus on getting work done but are less concerned as to where or when the work gets done.35 They are more likely to complete work tasks at home or outside of the structured work day, fitting work into their lives, where they can to optimize efficiency and avoid personal sacrifices. This approach may help reverse the rising rates of burnout that are particularly high in surgical subspecialties.35 Leaders that maintain a work-life balance are likely to be approachable and relatable to followers.

Diversity

The millennial generation is the most racially diverse in all of American history: 19 percent are Hispanic, 14 percent are African American, and 4 percent are Asian.33,34 Within surgery, this diversity would be greatly beneficial among leaders to improve overall cultural competency and increase access in underserved communities.35 Racial diversity, along with gender diversity, can be beneficial, as varied perspectives can fuel innovation, a key component of leadership.4

MILLENNIAL: DISADVANTAGES FOR LEADERSHIP

Millennial traits that may be unfavorable, at least in certain leadership contexts, include the following.

Ideas Valued over Experience

Egalitarian, flat infrastructure is preferred by millennials over hierarchical structure at work.35 They believe that successful ideas and strong work output are more valuable than length of experience.33 Millennials expect praise, promotions, and even early advancement in their careers based on merit and achievement rather than age and position.35 This clashes with the rigid hierarchy of surgical training and career progression. In addition, overlooking advice from a follower with years of experience and wisdom may prove foolish and naive.

Short-Term Focus

On the flipside of their characteristic ambition, optimism, and emphasis on work-life balance, millennials are more likely to abandon their current job and look for a better one.36 If they do not feel fulfilled in their current position, they will search for another opportunity or organization.36 This “flight risk” may be perceived as a lack of commitment by followers.33

Unprofessional Workplace Etiquette

Millennials lack deference to the standard vertical hierarchy.35 They expect to be partners with their leaders, viewing them as coaches or mentors with whom they prefer to collaborate in a casual setting.35 Millennials do not blindly follow. They are inquisitive and quick to challenge policies and rules that have unclear benefit.37 These attitudes may be interpreted as presumptuous, disrespectful, or unprofessional.

Lack of Adaptability

Although some sources disagree, millennials are frequently described as lacking adaptability.33,38 Millennials need to develop “learning agility” to survive in the increasingly complex environment of health care administration and plastic surgery.11 Inflexibility is incompatible with continual development as a leader.

Lack of Initiative

Millennials are risk-averse and have a general fear of failure. This fear may derive from the “equitable reward system” that millennials experienced during their upbringing, where everyone was given a trophy for simply participating in a sport or event.39 Millennials are used to having the security of a group to shoulder the pain of failure.36 Fear of failure may cripple a leader and prevent them from acting decisively and diligently to achieve a goal. Millennials need to have the confidence and initiative to take the first step and the humility to learn from personal failings.

Less Interest in Member-Based Organizations

Compared to prior generations, millennials may have less interest in member-based organizations. In years past, networking was a central draw for members to join organizations and attend conferences. Millennials view traditional networking as inefficient. Instead, they self-organize through social media platforms and therefore are networking constantly.33 However, through these platforms, millennials may not prioritize meaningful connections and may actually be distracted by the barrage of contacts.36 The quality of information and mentorship available through member-based organizations may be unjustifiably eclipsed by the quantity of networking contacts available through other means preferred by millennials.

Poor Communication Skills

The in-person communication skills seem to have suffered at the expense of technologically mediated communication among millennials. The compulsive desire to multitask is perceived as a lack of engagement by older generations.33 Lack of eye contact when constantly attending to cell phone alerts can be perceived as disinterest. Both verbal and nonverbal communication need to improve among millennials for them to achieve success as leaders.

Discomfort with Criticism

Millennials give and receive criticism poorly.33 Effective leaders need to welcome complaints, recommendations, and feedback from followers. “If leaders do not listen to those under their leadership, not only will the percentage of wrong decisions be high, but they miss out on the opinions and expertise of those who may well know more about a situation than they do, compromising their ability to make the best decision.”4

THE TRANSITION TO MILLENNIAL LEADERSHIP

How can millennials be guided to draw on their strengths and improve on their shortcomings as they ascend into leadership roles? The responsibility lies not only with the millennial generation but also with those generations preceding them. Leadership needs to be taught; “it must be intentional, planned, modeled, and practiced.”40

There is always change from one generation to the next with regard to values and traits. Generational features of millennials have gained a negative reputation, but the stereotype paints an incomplete picture. As with all other generations, nearly each undesirable trait can be countered with a desirable one. Even these “undesirable” traits may be beneficial in certain leadership contexts.

To engage millennials and effectively teach them leadership skills, they should be included in discussions in a collaborative way. Millennials need to understand their place in the “big picture,” within their department, organization, and community. Millennials need to believe in the mission before buying in. Self-confidence should not be confused with empowerment.31 Encouragement and validation of millennials’ strengths is desired and needed for them to develop those skills further. Direct and forward communication is best when communicating with millennials. No news is no longer considered good news. Rather, to millennials, “silence is interpreted as negative.”35 Frequent feedback and specific goal-setting is preferred to gauge progress and achievement.31 Millennials value accessibility and approachability in their mentors.

Beyond informal leadership modeling, formal leadership training may be beneficial to millennials. Approximately one-third of medical schools already have formal leadership development curricula in place.40 Ideally, leadership training programs should teach basic leadership principles, reinforce good leadership behaviors, and correct bad leadership behaviors.41 Given time constraints in residency, gradual leadership training through goal-setting and modeling would be a realistic approach.

As millennials ascend into leadership roles within plastic surgery, the leadership landscape will undoubtedly be influenced by their style. Participative leadership, transformative leadership, and authentic leadership styles may gain increased prevalence as a result.6

CONCLUSIONS

Millennials possess many traits that can be refined to enhance their leadership potential. They also possess traits that are unfavorable for leaders in the current climate. The predecessors of millennials are encouraged to teach leadership skills and to show them how to improve in their areas of weakness. Millennials will rise into prominent plastic surgery leadership positions and will likely create more team-oriented, diverse groups with an emphasis on work-life balance. Millennial leadership is an inevitability and should be embraced, developed, and improved on to the extent possible while the opportunity remains.

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