William N. Levine, MD, FAAOS | Cara A. Cipriano, MD, MSc, FAAOS
June 4, 2025
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SFTTR asked two surgeons to each describe an essential aspect of leadership in the OR. Here’s what they said…
Bill Levine, MD, Columbia University: Communicating
We’ve found that our most influential leaders are also exceptional communicators. In the operating room (OR), communication is not just helpful—it is critical to the seamless execution of surgical plans.
This process begins with the preoperative indications conference, where attending surgeons, fellows, residents, medical students, and advanced practice providers (APPs) gather—often via Zoom—to review the surgical cases scheduled for the week. These discussions clarify the indications and contraindications for surgery, which are vital for trainee education. It’s not uncommon for attending surgeons to be challenged by their peers or trainees to justify a proposed surgical approach. These conversations are essential for aligning the team and ensuring everyone understands the reasoning behind each case.
Detailed communication during these sessions includes the patient’s positioning, anesthesia considerations, procedural risks, required instrumentation, the presence of vendor representatives, and the planned surgical technique. Addressing these elements in advance ensures the team starts from a shared understanding.
Intraoperatively, the attending surgeon assumes the role of the quarterback. But as in football, no quarterback can succeed without a strong team: a skilled offensive line, agile receivers, and a dedicated coaching staff. In the OR, this team includes fellows, residents, scrub and circulating nurses, anesthesiologists, and even the OR cleaning staff. Each plays a vital role in the outcome.
The day begins with a morning briefing, where the entire case list is reviewed in a thorough and unhurried manner. With the frequent hand-offs, breaks, and staff transitions that occur throughout the day, this proactive approach helps minimize miscommunication and potential complications. We firmly believe the attending surgeon—our quarterback—must assume responsibility for the day’s operations. Clear, transparent communication about each person’s role should occur well before the team assembles at the surgical site. When expectations are defined early, team members are more engaged, and morale stays high.
Finally, postoperative communication completes the circle. Key questions must be addressed:
- What imaging is needed to confirm that the procedure was successful?
- Where will the imaging be performed—OR or PACU?
- What assistive device is required (e.g., sling, knee immobilizer), and when will it be applied?
- What is the patient’s weight-bearing status?
- When does physical therapy begin, and has it already been ordered?
- What is the pain management plan, and has it been clearly communicated to the patient and their family? We typically have provided the post-op pain medication preoperatively so that the patient and/or their family do not have to scramble to retrieve it on the day of surgery.
- When is the first postoperative follow-up visit?
Communication is the common thread that connects every phase of the surgical journey. The most successful surgeons are those who communicate clearly and consistently:
- With patients preoperatively to manage expectations
- With the team to plan the procedure
- During the operation to execute it safely and efficiently
- And afterward to ensure optimal recovery
Bottom line: To be a great surgeon, become a master communicator.
Cara Cipriano, MD, University of Pennsylvania: Setting the tone
One of the most important things you do as a leader every day, whether you realize it or not, is set the tone in your working environment. As a surgeon, you play a major role in dictating the activity, priorities, and focus of the team in your OR; in addition, you influence the mood of the people around you. All of these elements determine the level of engagement and effectiveness of your team.
You can start this process in advance of your cases, whether at the beginning of the week, the new resident rotation, or each morning. For example:
- “We have a lot to get through tomorrow, so we’ll need to be efficient while taking great care of patients.”
- “Our second case is high risk and will require everyone’s focus.”
- I’m looking forward to seeing how much of the approach you remember from last time.”
- Or simply, “It’s going to be a great day.”
To be an effective leader, try exemplifying the characteristics you’d like to encourage in others. When your behavior shows that you value qualities like professionalism, collegiality, and dedication to patient safety, others are more likely to take them seriously as well. Additionally, cognitive neuroscience research suggests that your mood itself will directly impact the people around you. This doesn’t necessarily mean you need to be chipper all of the time; you can be authentic, only be aware that if you are upset, frustrated, or otherwise not at your best, your team will pick up on it. In these situations, it may be best to acknowledge and explain so that your team understands; otherwise, they may worry or assume it is related to them. For example, “I noticed that I’m feeling cranky today and wanted to let you know it’s not because of you; I just had a frustrating experience in clinic.” This not only provides clarity and puts people at ease, but, if done in a professional manner, can also create connection and trust by showing that you are human, too.
As Dr. Levine articulated, communication within a team is key, and your goal should be to create an environment where it is accepted and valued. You can help do this by soliciting other opinions; for example, “The repair looks good from here; how does it look from your side of the table?” Even more important, you must demonstrate this by listening carefully when other do speak and not dismiss anything that is said, even if you don’t agree. You don’t need to take every idea, but you should at least validate it. For example, “Thanks so much for bringing that up. I see what you’re saying about the position of the implant, but in this case we do want it to sit more anterior because of the patient’s anatomy, as you can see here. Great point.” Don’t ever make someone feel small for asking a question or offering an idea.
Many surgeons erroneously believe that, in order to be decisive, they cannot consider input from other. In fact, the best leaders and decision-makers solicit multiple perspectives as part of their process. Listening to others makes you more, not less, confident that you are making good decisions.
The tone you set is also critically important for patient safety. One of my colleagues likes to tell her team, “Mistakes are welcome here, but you need to make new ones.” Punishing mistakes can be dangerous because you would rather have people to acknowledge, not hide, when they have occurred. For example, if something is contaminated during surgery, you would rather have someone speak up so the risk can be mitigated. Becoming angry when errors happen doesn’t prevent them from happening; it only prevents them from being reported. Likewise, if you work with trainees, you want them to be able to develop skills rather than be paralyzed by fear. Pushing people to make “new mistakes” provides a safe environment to grow while holding them accountable for learning and improving.
Bottom line: You have the power to set the tone in your OR, which influences the experience as well as the behaviors of your team.
DISCLOSURES: Dr. Levine is on the Columbia faculty. Dr. Levine serves as a paid consultant and surgeon designer for Zimmer Biomet. International Board of Shoulder and Elbow Surgery – Treasurer : Type: Board of Directors or committee member: Self Dr. Cipriano KCI: Paid consultant, Link Orthopaedics: Paid consultant, Musculoskeletal Tumor Society: Board or committee member.
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