In the land of the blind…


Leadership is one of those areas of medical training that is increasing in prevalence, and the number of schemes to ensure that medical leaders are available within the workforce is ever expanding.

Some in our profession feel that the ‘leaders’ who are ‘trained’ seem to have few leadership qualities, and even less legitimacy to lead their colleagues than those who possess ‘natural’ flare for leadership. (COI: I have been a leadership fellow in the past)

There is one very well defined team, though, in which very clear leadership is absolutely required, and in which even the most junior member of the team can display leadership, clarity of thought, and situational awareness – the cardiac arrest.

With the adoption of international algorithms, regular training days, a huge manual, rigorous testing of candidates, and mandatory updates – advanced life support has to be one of the most directive environments in which we find ourselves at work.  So leadership is required within the cardiac arrest team, to ensure that the team is working to time, maintaining compressions, and giving drugs when required – and most importantly, to review progress, determine measures of success of failure, and sadly – most often – to ‘call it’ when an attempt has failed.  Leadership skills then, would appear to be a necessary attribute of anyone on the cardiac arrest team.

A couple of recent papers published online in the PMJ raise separate but linked questions about leadership in this most stressful of situations.

A paper on leadership at cardiac arrests helpfully documents data that is a bit of a wake up call for those who ‘lead’ them.

Dr Robinson and colleagues studied the perceptions of leadership and team working among members of a cardiac arrest team.  They surveyed a range of members of the crash team at a n NHS Trust in London that covered two acute hospital sites.  Admirably the survey included wider members of the crash team too – healthcare assistants and nurses, as well as those who carry the crash bleep (pager).

The message I took from the data was that the leaders (SpRs / senior residents usually lead cardiac arrests in UK hospitals) thought that leadership at the cardiac arrest was good in 90% of cases, whereas the ‘followers’ (nurses) only thought that there was good leadership 28% of the time.  And perhaps best of all, 100% of the SpRs strongly agreed that they were confident in leading cardiac arrest response.

In this cohort, around 40% of all groups of respondents said they had experienced a debrief at any arrest they had attended.

The second paper, which looks to provide an answer to the questions posed by the first paper, through the use of a debriefing tool, considering the cardiac arrest response to be a missed learning opportunity  The authors again surveyed their cardiac arrest responders – and found that only about 30% had ever experienced a debrief following a cardiac arrest at their centre.  However, there was a great appetite for the opportunity to debrief in a structured way – using a tool which singles out leadership in particular as a domain of interest (93%).

I think that these two papers demonstrate that, although leadership remains one of those areas which induces feelings of revulsion amongst those who have experienced terrible role models, it is one of those skills which, instead of being inherent amongst the medical profession, requires practice.

What is worse is that those who occupy leadership positions by virtue of their grade of training appear to be mistaken as to their effectiveness, and demonstrate misplaced confidence in their abilities.

Whilst I have been fortunate enough to have had the opportunity to participate in a leadership programme, I don’t think I would anoint myself as the next great thing in the medical profession. However, the training I went through did teach me a lot about the capacity people have for self-deception, and the importance of truthful feedback from colleagues (see this blog from a while back)

I have doubts about the enthusiasm of crash to use a debriefing tool in the immediate aftermath of a cardiac arrest response, but these two studies have gone some way to reassuring me that there has been a shift in the culture of the medical profession to even be studying such subjects.  Long may it continue.




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