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ACKNOWLEDGMENTS
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To Jason Malley, Peter Boyle, Catherine Saggese, and all at McGraw
Hill, we are thankful for the continued belief in and support for
this book.
We wish to thank Katie Elsbury for her dedication to the
organization and editing of this book.
F. Charles Brunicardi, MD, FACS
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PART I
Basic Considerations
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CHAPTER 1
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Leadership
1. The fundamental principles of leadership are:
A. Vision and willingness
B. Command and control
C. Time management and mentoring
D. Coaching, pacesetting, and democratic
2. A senior resident and attending are performing a laparoscopic cholecystectomy. The resident initially performs
the majority of the case following instruction from the
attending. However, the resident informs the attending
that he feels uncertain whether he has truly obtained the
critical view of safety. With the attending’s assistance,
the case was successfully completed. After the case, the
resident then asks the attending for a debrief of the case.
Which fundamental principle of leadership is being
demonstrated by the resident?
A. Conflict resolution
B. Vision
C. Effective communication
D. Willingness to lead
Answer: A
Vision and willingness are the two fundamental principles of
leadership. Command and control is a colloquial term for the
previously predominant style of leadership in surgery based
on fear and intimidation. Time management and mentorship
are key leadership skills. Coaching, pacesetting, and democratic are leadership styles. (See Schwartz 11th ed., p. 4.)
Answer: C
Leadership is a complex concept. Surgeons should strive to
adopt leadership qualities that provide the best outcomes for
their patients based on the following fundamental principles:
vision, willingness, time management, conflict resolution,
recruitment, and culture (see Table 1-1). (See Schwartz
11th ed., p. 5.)
TABLE 1-1 The fundamental principles of leadership
Description and Application in the Field
Leadership Skill
Vision The act of establishing tangible goals of care
Effective
communication
Willingness to
lead
Willingness to
learn
Conflict
resolution
of Medicine
for patients on both a daily basis as well as for
long-term purposes.
Establishing an open, respectful, and
nonjudgmental forum for communication
among different members of the health care
team and with the patient.
Taking on full responsibility for the care of
patients and remaining ethical, professional,
and committed despite the especially
challenging rigors of joining the field of
surgery.
A commitment to lifelong learning of the latest
scientific, medical, and surgical updates to
deliver optimized patient care.
The art of resolving conflicts in a peaceful and
ethical manner in team settings.
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3. Effective communication is a key component of leader-
CHAPTER 1
Leadership
ship, given that miscommunication is a leading cause
of medical errors. Which of the following statements is
FALSE regarding communication?
A. To Err Is Human, a publication by the US Institute
of Medicine, identified medical errors as the eighth
leading cause of death in the United States, causing
100,000 deaths annually.
B. Effective communication that ensures all team mem-
bers understand daily goals of care for an ICU patient
can significantly decrease their length of stay in the
IC U.
C. Communication errors are often simply due to negli-
gence and failure to transmit information.
D. Information transfer and communication errors
cause delays in patient care and can cause serious
adverse events.
E. Improved communication in the OR among cardiac
surgery patients is associated with decreased adverse
outcomes.
4. Which of the following statements is FALSE regarding
modern conflict resolution techniques?
A. Based upon objectivity and willingness to listen.
B. Should seek a solution that benefits all involved and
that is based upon core values of the organization.
C. Traditional command and control based on fear and
intimidation can lead to sanctions and lawsuits.
D. Conflict resolution is more successful when both
sides can admit they share some fault.
Answer: C
Communication errors are often caused by miscommunication due to hierarchical differences, concerns with upward
influence, conflicting roles and role ambiguity, and interpersonal conflict. (See Schwartz 11th ed., p. 8.)
Answer: D
Modern conflict resolution techniques are based upon objectivity, willingness to listen, and pursuit of principle-based
solutions. For example, an effective style of conflict resolution
is the utilization of the “abundance mentality” model, which
attempts to achieve a solution that benefits all involved and is
based upon core values of the organization, as opposed to the
utilization of the traditional fault-finding model, which identifies sides as right or wrong. Application of the abundance
mentality in surgery elevates the conflict above the affected
parties and focuses on the higher unifying goal of improved
patient care. Morbidity and mortality (M&M) conferences
are managed in this style and have the purpose of practice
improvement and improving overall quality of care within
the system, as opposed to placing guilt or blame on the surgeon or surgical trainees for the complication being reviewed.
The traditional style of the command-and-control technique
based on fear and intimidation is no longer welcome in
any health care system and can lead to sanctions, lawsuits,
and removal of hospital privileges or position of leadership.
(See Schwartz 11th ed., p. 9.)
5. Daniel Goleman of the Harvard Business Review
described six key leadership styles. Which of the following statements is FALSE regarding leadership styles?
A. The coercive style of leadership is antiquated and is
no longer effective in surgery.
B. Democratic leadership is useful for building team
consensus and minimizing conflict but may frustrate
team members if there is no clear, unifying vision.
C. The pacesetter leads by example and sets high stan-
dards for his team but typically takes over the tasks
of something falling behind instead of building
them up.
D. The authoritative leader is often the most effective
and focuses on directing the team toward a common
vision allowing team members room for innovation
and experimentation, and supporting their efforts.
Answer: A
The coercive leader demands immediate compliance. This
style reflects the command-and-control style that has historically dominated surgery. Excessive coercive leadership erodes
team members’ sense of responsibility, motivation, sense of
participation in a shared vision, and ultimately, performance.
The phrase “Do what I tell you!” brings to mind the coercive
leader. However, it is effective in times of crisis to deliver clear,
concise instruction. This style should be used sparingly and
is best suited for emergencies. (See Schwartz 11th ed., p. 12.)
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6. Which type of program couples grade/high-school students with physicians to provide experiential learning
and development of mentoring, presentation skills, and
networking?
A. Community outreach
B. “Pipeline”
C. Physician teacher
D. Bottleneck
7. Which of the following statements about how leaders in
surgery effectively address disparities in social determinants of health and recruitment of women and underrepresented minority residents and faculty are TRUE?
A. Diversity training obstructs leadership and strategic
human resource management due to excess use of
resources.
B. Diversity programs improve recruitment of women
and underrepresented minority residents and faculty.
C. Diversity helps address disparities in social determi-
nants of health.
D. B and C.
Answer: B
Studies indicate that the bottleneck in diversity occurs at the
level of the medical school application pool, which in turn is
caused by educational deficiencies at the primary, secondary,
and collegiate levels. As an attempted solution, the University
of Michigan developed a “pipeline” program that pairs gradeschool and high-school students with physicians for experiential learning and the development of mentoring, presentation
skills, and networking. It is important for departments of surgery to develop a diversity program for recruitment of residents and faculty. Multi-institutional blinded studies indicate
that the implementation of formal leadership and diversity
training improves diversity leadership and strategic human
resource management. (See Schwartz 11th ed., p. 12.)
Answer: D
The past quarter century has seen a steady increase in diversity within the field of surgery. Women, as of 2015, represent 38% of surgical trainees and 10% of academic professors
currently, but have doubled their representation in the past
20 years. Some fields, such as head and neck surgery and
plastic surgery, have studied their own subspecialty groups
with similar findings. African Americans comprise both 6%
of medical school graduates, 6% of surgical trainees, and
2% to 4% of professors of surgery nationwide. Hispanics
represent 5% of graduating medical students, 9% of general
surgery trainees, and 4% to 5% of persons at all levels of
academic surgery. Physician diversity is crucial and may
help to address disparities in social determinants of health.
(See Schwartz 11th ed., p. 12.)
CHAPTER 1
Leadership
8. The development and demonstration of effective leadership skills are essential during surgical training. Which
of the following is considered the gold standard for the
training and assessment of clinical and nontechnical
skills with high reliability and validity?
A. Command-and-control leadership
B. Simulation training
C. Coworker observation reporting system
D. Objective structured clinical examination (OSCE)
9. Mentoring should be formally included in resident training programs. It provides wisdom, guidance, and insight
essential for the successful development of a surgical
leader. Which of the following statements is FALSE about
mentees and mentors?
A. The benefits of mentorship are unidirectional.
B. Mentees have enhanced research productivity.
C. Mentees have increased probability of obtaining
grants/funding.
D. Mentees have increased probability of obtaining
desired academic/practice positions.
Answer: D
The past decade has seen a demonstrable increase in our
knowledge of how to develop leadership skills, particularly
through simulation, as well as leadership evaluation through
OSCE and other tools. Multiple groups have assessed multidisciplinary teams, typically composed of nurses, anesthesia
groups, and surgeons for the leadership-associated nontechnical skills of communication, teamwork, and situational
awareness. Through increasingly validated instruments
and assessment tools, these nontechnical skills have been
found to be trainable. The OSCE has been established as the
gold standard for the training and assessment of a wide range
of clinical and nontechnical skills with high reliability and
validity. (See Schwartz 11th ed., p. 14.)
Answer: A
In academic medicine, evidence-based studies have shown
benefits to the mentees that include enhanced research productivity, higher likelihood of obtaining research grants, and
greater success in obtaining desired positions in practice or
at academic institutions. Mentoring provides benefits to the
mentors themselves, including refinement of their own personal leadership skills and a strong sense of satisfaction and
accomplishment. (See Schwartz 11th ed., p. 18.)
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CHAPTER 2
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Systemic Response to Injury
and Metabolic Support
1. C-reactive protein (CRP):
A. Is secreted in a circadian rhythm with higher levels in
the morning.
B. Increases after eating a large meal.
C. Is a soluble pattern recognition molecule of the pen-
traxin family.
D. Is synthesized in lung and kidney in response to IL-6.
2. Which of the following is TRUE regarding the inflammatory response following traumatic injury?
A. There is an acute proinflammatory response caused
by stimulation of the adaptive immune system.
B. There is an anti-inflammatory response that leads to
a return to homeostasis accompanied suppression of
the innate immune system.
C. An acute proinflammatory response secondary to
activate of innate immunity, an anti-inflammatory
response, and suppression of adaptive immunity
occur currently following injury.
D. Systemic inflammation following trauma is related to
the immune response to microbes.
3. Which of the following is TRUE regarding damageassociated molecular pattern (DAMP) molecules?
A. DAMPs function early in the immune response to
trauma by activating adaptive immunity.
B. Pathogen-associated molecular patterns (PAMPs)
and DAMPs have different signaling characteristics
and do not bind the same types of receptors.
C. DAMPs are ligands for a group of receptors broadly
term pattern recognition receptors (PRR), which
includes toll-like receptors (TLRs).
D. DAMPs signal only to immune cells.
Answer: C
Pentraxins are a group of soluble pattern recognition molecules that act to activate complement, agglutination and neutralization, and opsonization. CRP belongs to the pentraxin
group of molecules. CRP is low in normal circumstances, but
is synthesized in the liver in response to IL-6 with serum levels
increasing 1000-fold. In this way, CRP is a marker of acute
inflammation. CRP levels do not vary with circadian rhythms
or with caloric intake. (See Schwartz 11th ed., Ch. 2, p. 34.)
Answer: C
Traumatic injury rapidly induces multiple responses from
the immune system. There is (1) an acute proinflammatory
response that is triggered by activation of the innate immune
system via DAMPs, (2) an anti-inflammatory response that
likely serves to modulate the pro-inflammatory response and
return the host toward homeostasis, and (3) suppression of
cellular-mediated adaptive immunity. Recent studies indicate
that these three responses occur concurrently immediately
following injury. (See Schwartz 11th ed., Ch. 2, p. 28.)
Answer: C
DAMPs are endogenous molecules that are produced during tissue damage or cellular stress. These molecules interact
with both immune and nonimmune cells and function to
activate the adaptive immune response early following injury.
DAMPs are similar to PAMPs in both types of receptors they
bind and their role in signaling during the immune response.
Both DAMPs and PAMPs signal via PRRs, which includes
receptors such as TLRs, RAGE, calcium-dependent receptors (CLRs), and nucleotide-binding domain, leucine-rich
repeat-containing proteins (NLRs). (See Schwartz 11th ed.,
Ch. 2, p. 28.)
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