You’re scheduled for surgery next week. You’ve likely looked up your surgeon’s credentials, years of experience and perhaps even patient reviews. You want reassurance that your surgeon has steady hands, deep expertise and a thorough command of the procedure. Technical skills feels like the thing that matters most.
But there’s another question most patients never think to ask: How well does your surgeon lead a team?
It might sound like an odd thing to consider, but in the operating room, surgery is rarely a solo act. Surgeons work alongside anesthesiologists, nurses and medical residents who must co-ordinate closely, often under intense pressure, to deliver care.
When something unexpected happens and the team needs to pivot quickly, how a surgeon leads matters in ways most patients rarely see or even think about.
In a study conducted by our research team, including Shani Pupco, Amy Akers and Darren Beiko, we examined leadership behaviours across 150 surgeries at a teaching hospital in Ontario.
Despite decades of evidence showing the benefits of inspiring, people-focused leadership, those qualities alone were not enough in complex, high-stakes operations where conditions can change rapidly.
Table of Contents
Two different leadership styles
Leadership researchers have long distinguished between two main approaches to leading teams: transformational and directive leadership.
Transformational leadership is people-focused, meaning it emphasizes inspiration, building trust, encouraging open communication and helping people feel valued and motivated.
Directive leadership is task-focused. It involves giving clear instructions, co-ordinating actions, enforcing procedures and ensuring everyone knows their role in real time.
Although sometimes associated with control or micromanagement when used to excess, in high-risk settings it can provide essential clarity and co-ordination.
(National Cancer Institute/Unsplash)
Transformational leadership has been widely studied and positively linked with better team performance, stronger morale and improved outcomes across many workplace settings. As a result, it is often examined on its own as a driver of effective leadership.
But our research suggests the picture is more complicated in environments where the stakes are high.
Complexity changes everything
Not all surgeries are alike.
Some procedures are relatively routine and predictable. An appendectomy, for example, typically follows established protocols with predictable demands and roles. In these situations, everyone on the team knows what to do and when to do it.
But surgeries don’t always go according to plan.
A routine surgery can suddenly become complicated if a patient becomes unstable, while more complex procedures may involve unexpected challenges from the start.
In these moments, the usual script may no longer be enough to guide the team. This is when leadership becomes far more important.
Situational leadership
To make sense of this, we drew on a concept from psychology called situational strength — how much a situation provides information about appropriate or desirable behaviour.
Routine surgeries are considered “strong situations.” Protocols, prior training, roles and expectations are so clear that the situation itself largely guides behaviour with little-to-no leadership required.
More complex or unpredictable surgeries can create “weak situations.” Protocols may not fully cover what’s unfolding. Roles become ambiguous and prior training no longer suffices. The team needs real-time guidance on what to prioritize, who should act and how to co-ordinate under pressure.
(César Badilla Miranda/Unsplash)
In these moments, leadership becomes critical precisely because the situation no longer provides all the answers.
Our research found that during these high-complexity moments, the benefits of transformational leadership only emerged when it was combined with directive leadership.
When surgeons paired people-focused leadership with task-focused leadership, their teams reported feeling significantly safer about speaking up, raising concerns and flagging problems as they arose, otherwise known as psychological safety.
More reported errors can signal better care
One of the more counter-intuitive findings involved surgical errors. Teams that reported higher psychological safety actually had more observed errors during surgery, not fewer.
At first glance, that sounds like worse performance. In reality, it may signal the opposite.
When team members feel psychologically safe, they are more willing to voice concerns, flag near-misses and speak up when something looks wrong. These are precisely the behaviours that prevent minor deviations from becoming serious complications.
And our data support this interpretation: teams with higher psychological safety had fewer severe complications after patients were discharged. More errors caught earlier and corrected in the operating room meant better outcomes beyond it.
What this means for training — and beyond
Recognition of leadership as a core surgical competency is growing. A recent systematic review of surgical leadership curricula spanning nearly four decades shows that training programs have evolved considerably.
But a closer look reveals that many programs focus on developing a single leadership style or approach rather than helping surgeons learn how to flexibly combine different leadership behaviours as situations change.
Our findings suggest this flexibility matters.
This has implications well beyond the operating room. Financial trading floors, emergency response teams, military units and any environment where conditions shift rapidly and errors carry serious consequences all share the same basic challenge for leaders.
The leaders who perform best in these environments don’t master one leadership style. Rather, they learn to combine and adapt approaches when it matters most.
