Formal leadership training among orthopaedic surgeons in leadership positions

To determine what formal leadership training orthopaedic leaders had pursued to develop the leadership skills necessary to be in their current leadership roles, and what perceptions they have on including formal leadership training in medical education. An anonymous survey was distributed via email to 255 orthopaedic surgeons in leadership positions. Statistical analysis focused on differences in leadership training between different demographic groups, their formal leadership experience, and perception about the importance of formal leadership training. The survey was distributed to 247 potential recipients, of which 76 responded (response rate = 30.8%). Sixty-five of 76 (85.5%) current orthopaedic surgeons in leadership positions have received formal leadership training. The three most common types of leadership training included: institutional leadership training (n = 36; 54.5%); AOA Kellogg Leadership Series (n = 25; 37.9%); and AOA Emerging Leaders Program (n = 13; 19.7%). 77% of respondents agreed that this training helped prepare them to become a more effective leader. 79.7% of respondents agreed that formal leadership training should be incorporated, with the majority (50.8%), indicating that they believed it should be included during medical school, orthopaedic residency, and fellowship. The majority of orthopaedic surgeons in leadership positions have received formal leadership training and believe that this helped them become a more effective leader. Providing formal leadership opportunities for a more diverse set of surgeons could catalyze an increase in minority representation. Informal leadership training, such as mentoring throughout medical school and residency, could also be beneficial, especially for minorities.


Introduction
Effective leadership skills are an important attribute of all surgeons. Surgeons must communicate plans and lead their surgical team on a daily basis. Many also facilitate meetings and educate trainees. Surgeons must also demonstrate compassion, respect, integrity, and diligence. These qualities are important for the success of the surgical team, and for the safety of the patient [1]. In addition to formal leadership training opportunities, having a successful mentor, on-thejob learning, and obtaining advanced/dual degrees can help develop leadership skills. [2] The Transformational Leadership theory, which is the most widely accepted theory of leadership, states that people can choose to become leaders and learn leadership skills [2]. Many behaviors that have been identified in good leaders are modifiable behaviors, such as consideration of team members, charisma, and initiation of team structure [3]. These learnable behaviors have a greater impact on effective leadership than intrinsic traits such as intelligence or demographics.
Jaffe et al. interviewed academic surgical faculty members and found that surgeons' motivations for seeking leadership training include: recognizing key gaps in their formal preparation for leadership roles, exhibiting an appetite for personal self-improvement, and seeking leadership guidance for career advancement [4]. Participants' desired takeaways from formal leadership programs included improving leadership and communication, team building, business acumen/ finance, and greater understanding of the healthcare context. Thus, this study demonstrated that there are concrete motivations for surgeons to participate in formal leadership training, and specific goals they hope to achieve [4].
There is currently no nationally mandated or standardized formal leadership training integrated into medical school or residency training. Although the importance of leadership skills in surgeons has been demonstrated, opportunities to participate in leadership skills building programs are limited. For example, there are a limited number of national organization committee positions for residents. A study by Dy et al. investigated whether orthopaedic subspecialty organizations offered residents the opportunity to participate in committees. The authors found that in 2011, 11 of 20 (55%) specialty societies surveyed allowed resident membership, and there were only 14 total resident committee positions [5]. Similarly, positions are limited for many other leadership training opportunities, including traveling fellowships and American Orthopaedic Association (AOA) programs [6].
The purpose of this study was to determine what formal leadership training orthopaedic leaders had pursued to develop the leadership skills necessary to be in their current leadership roles, and what perceptions they have on including formal leadership training in medical education. We hypothesized that orthopaedic surgeons in leadership positions have had previous formal leadership training, and that they believe it is important to implement this throughout medical education. Secondary aims include determining if demographic trends exist within different leadership positions. We hypothesized that the majority of leadership positions would be occupied by white male orthopaedic surgeons.

Survey population
After obtaining approval from our Institutional Review Board (2019-1699), an anonymous 17-question online survey created using Survey Monkey (San Mateo, CA) was distributed via email to 255 orthopaedic surgeons in leadership positions including Orthopaedic Surgery Department Chairs, Orthopaedic Surgery Residency Program Directors, surgeons in the presidential line of national organizations [e.g., American Academy of Orthopaedic Surgeons (AAOS) specialty societies], Medical School Deans, and Directors of Musculoskeletal Institutes. These positions were chosen to be included by two orthopaedic surgeons who also serve in leadership positions (MKM and JBS). The Likert scale constructs in the survey were evaluated with ten pilot participants prior to distribution, and were found to have a high level of internal consistency, which was unidirectional, as determined by a Cronbach's α of 0.889. A follow-up email was sent 2 and 4 weeks after the initial communication to encourage more participation. The survey was posted for a total of 6 weeks. Statistical analysis focused on differences in leadership training between different demographic groups of surgeons, their formal leadership experience, and perception about the importance of formal leadership training.

Survey content and statistical analysis
Five questions were related to the respondent's demographics, including their region of practice, sex, age, ethnicity, specialty area, and current leadership position. The remaining questions evaluated time spent in their leadership positions, whether they had received formal leadership training and if so what type, what the impact of this training was on their career, and their perceptions of whether leadership training prepared them for their current leadership role (Appendix 1). There were three multiple response questions, including "which leadership position(s) do you currently hold?," "what leadership training have you received?," and "what leadership training is needed going into the field of orthopaedics going forward?". Three questions required respondents to write-in a response, including "longest time served in a leadership position," "which leadership position have you served the most time in," and "which leadership training opportunity was most impactful in your career." All other questions required the respondents to choose only one answer. Questions were formulated and edited by medical student CH, as well as orthopaedic surgeons and leaders in their fields MKM and JBS.
The survey data were downloaded from Survey Monkey into SPSS Statistics 26 (IMB, Armonk, New York) for analysis by our statistician NK. All survey responses were categorized with anonymous identifiers. Ordinal logistic regression was used to ascertain the effects of demographic variables on outcomes. Categorical thresholds for questions involving Likert scales were analyzed by examining the distributions of raw data between different demographic groups of surgeons. Univariate analysis of categorical variables and multiple response sets was performed using the χ 2 test, scale variables with an independent t test, and dichotomous variables using Fisher's exact test, and ordinal variables using the Mann-Whitney U test. A p value < 0.05 was considered statistically significant.
An ordinal regression was used to ascertain the effects of demographic variables, including sex, age, and ethnicity, on the ordinal outcome variables. Orthopaedic surgeons between the age of 35 and 40 years had a 3.44 higher odds of finding leadership training helpful (95% CI [− 0.150, 5.47]), and surgeons between the ages of 51-55 had a 1.13 higher odds of finding leadership training helpful (95% CI [− 0.874, 2.95]). Ethnicity and sex had no statistically significant effect on ordinal outcome variables. No demographic variables were significant for the question of whether formal leadership training prepared surgeons to be more effective leaders in the field of orthopaedics, or whether medical school and residency adequately prepared orthopaedic surgeons for leadership roles.

Current leadership experience
Individuals in our sample held an average of 1.6 leadership positions at one time (SD = 0.81), with half our sample (36 of 75, 48.0%) holding more than one leadership position at one time. The majority of respondents that were male Orthopaedic Surgery Department Chairs were between the age of 56 and 65 years (64.3%, n = 20, P = 0.004). Respondents that identified as white also made up the majority of all leadership positions, including 73.1% (n = 19) of Presidential Line of AAOS Specialty Societies, 84.4% of Orthopaedic Surgery Department Chairs (n = 38) (P < 0.005). There was a strong positive correlation between age of the respondent and amount of time served in a leadership position, r s = 0.457, P < 0.0005, with Orthopaedic Residency Program Directors serving the longest amount of time (M = 13.33 years, SD = 3.77 years). There was no significant difference between female and male respondents in duration of time served in a single leadership position (P = 0.529).
There was a statistically significant difference between leadership positions that men and women held.  Table 3).

Formal leadership training experience
Individuals in our sample had an average of 2.4 leadership training experiences (SD = 1.75) per person. The majority of our sample (63 of 74, 85.1%) received formal leadership training, including 100% of female respondents (n = 10) and 82.8% (53 of 64) of male respondents. 89.4% (n = 59) of respondents reported receiving leadership training when they were a practicing physician, with the remainder of the sample receiving leadership training in residency (n = 9, 13.6%), taking time off to pursue training (n = 9, 13.6%), prior to medical school (n = 7, 10.6%), and during medical school (n = 6, 9.1%).
Over half of our respondents (54.5%, 36 of 66) reported that they received leadership training through an institutional leadership training program. Several participants reported receiving leadership training through the American Orthopaedic Association (AOA) including the AOA Kellogg Leadership Series (37.9%, 25 of 66) and AOA Emerging Leaders Program (19.7%, 13 of 66), as well as the AAOS Leadership Fellows Program (LFP) (18.2% 12 of 66). The remainder received training from a variety of sources including military training (n = 9, 13.6%), university courses or business school classes (n = 9, 13.6%), Master of Business Administration (MBA) (n = 3, 4.5%), and on the job experiences (n = 3, 4.5%) ( Table 4).
The majority of our sample (64 of 68, 94.11%) reported that leadership training opportunities were helpful to their current job duties and responsibilities, with 24 participants (35.3%), indicating that these training experiences were "extremely helpful." Helpful experiences for survey respondents are detailed in Table 5. More senior surgeons, specifically those between the ages of 61-65 years old, were more likely to cite personal study (n = 3, 42.9%) and on-thejob experience (n = 4, 57.1%) as beneficial to their careers.

Perceptions of leadership training
The majority (58 of 63, 92.1%) of respondents agreed that formal leadership training helped prepare them to become When asked what type of leadership training was needed in the field of orthopaedics, 74.7% (n = 56) of respondents stated that networking and mentorship opportunities were important, 69.3% (n = 52) supported a formal leadership curriculum, and 69.3% (n = 52) supported organizational management (Table 6). Write in suggestions (n = 10, 13.3%) for leadership training included "public speaking", "selfmanagement and self-awareness" and "dealing with people and their problems, creating teamwork", and "participation in organized medicine, including state and national medical societies".

Discussion
The majority (85.1%) of current orthopaedic surgeons in leadership positions have received formal leadership training. Furthermore, there was an overall positive perception of formal leadership training, with 77% of respondents, agreeing that it helped prepare them to become a more effective leader. There was also a difference in male versus female representation in these leadership roles. For example, roles such as Department Chair or Program Director were highly male-dominated (97.7% and 100% male, respectively), whereas positions such as AAOS Specialty Society Presidential Line had higher female representation (80%). It is also important to note that the majority of respondents were white (81.6%). The majority of these leaders believe that leadership training should be incorporated either during residency (34%) or medical school, residency, and fellowship (50.8%). This supports our hypothesis that the majority of orthopaedic surgeons in leadership positions have received formal leadership training, and that they believe it is beneficial. Most respondents agreed that formal leadership  training should be incorporated in orthopaedic residency. The ACGME has taken steps to increase leadership training in residency, offering a leadership skills training program for chief residents of all medical specialties [7]. However, most respondents also believe that it should be integrated in medical school and fellowship, as well. Adding this training to medical school would help prepare students for residency and their future career, but would be broader and not necessarily specific to the leadership skills required of surgeons. This might be difficult to fit into an already packed curriculum. Leadership training during residency and fellowship training would be much more specific and could likely be incorporated in a longitudinal manner throughout training. The benefits of formal leadership training in medicine have been demonstrated in many other studies. A study by Saravo et al. quantified the impact of a four-week leadership training program addressing transactional and transformational leadership skills for medical residents in a range of specialties [8]. The authors found a significant difference (p < 0.001) in leadership scores (15% increase in transactional leadership skill performance and 14% increase in transformational leadership skill performance) between subjects in the group that took the leadership course versus a control group, as assessed by a Multifactor Leadership Questionnaire. In 2015, Sonnino et al. surveyed graduates of the Executive Leadership in Academic Medicine (ELAM) program to determine what types of leadership positions they had pursued. The authors found that 63.5% of their graduates achieved positions of department chair or greater, which is a higher proportion than control groups [9]. Similar to the findings in our study, these findings support the notion that formal leadership training could substantially benefit orthopaedic surgeons seeking to improve their leadership skills.
There was some variation between specific demographic factors and various aspects of leadership experience and perceptions. Notably, there was a statistically significant difference between leadership positions held by men and women. This finding is not specific to orthopaedic surgery. For example, in 2017, Wu et al. collected data from North America, Europe, and Oceania in a cross-sectional study analyzing gender disparity in leadership positions in general surgery societies. The authors found that males had significantly higher representation (p = 0.010) than females in all eight societies they selected [10]. In the field of orthopaedics, the Ruth Jackson Orthopaedic Society has helped increase the proportion of female AAOS Specialty Society Presidential Line leaders, but there are not similar groups, policies, or individuals advocating for female leadership in roles such as Deans and Orthopaedic Surgery Department Chairs that are historically and currently male-dominated. There was only one female Orthopaedic Surgery Department Chair in the 2015-2016 academic year [11]. Cherisse Berry, MD, one of only 24 female chairs of surgery departments in the United States, stated "I think it's a mentorship and sponsorship issue, in the sense that you really need people in high leadership positions that are actually sponsoring and putting forth names of women in leadership roles." [12]. The diversity of orthopaedic surgeons with respect to sex, race, and ethnicity has slowly increased over time. In 2008, 4.1% of orthopaedic surgeons were female, versus 5.8% in 2018 [13]. The percentage of white orthopaedic surgeons has decreased from 89.3% in 2008 to 84.7% in 2018, with an increasing proportion of Asian, Hispanic/ Latino, African-American, and Multiracial surgeons [13]. In 2016, Rohde et al. surveyed members of the Ruth Jackson Orthopaedic Society to determine reasons women choose orthopaedic surgery as a specialty, and the role that early exposure to orthopaedics and mentorship plays in this choice. The authors found that 69% of respondents agreed that women might not choose orthopaedic surgery due to a lack of strong mentorship in medical school or earlier [14].
There are several limitations to this study. First, this is a survey-based study and is therefore subject to all the limitations inherent in this type of study design. Second was the small sample size. Although the survey had an adequate response rate (30.8%), there were only 76 total respondents. Analysis of statistical significance between demographic factors was limited by the fact that the majority of respondents were male (84.2%) and white (81.5%).
There were also limitations within the survey itself. Some questions included open-ended responses or writein "other" options, while others had finite answer choices, which could have limited the way respondents answered. Survey respondents also may have held multiple leadership positions, making it more difficult to separate and stratify responses according to leadership position.