Interventional Cardiologists at the Helm: Leadership Skills Aren’t a Given

MUNICH, Germany—Interventional cardiologists come to the cath lab equipped with technical skills, but to be an effective leader requires an entirely different set of tools that bring out the best in team members and promote quality care.

A workshop at the recent European Association of Percutaneous Cardiovascular Interventions (EAPCI) Summit offered perspectives on why interventionalists should cultivate nontechnical skills throughout their careers.

Cath labs are “high stakes” environments, where “things can change in an instant,” said Gill Louise Buchanan, MD (Cumberland Infirmary, Carlisle, England), in her talk on building trust. Each of the team members—nurses, fellows, imagers, and others—“is essential,” she specified, but it’s incumbent on operators to be the leader who ensures the cath lab is a “safe place to be” for not only staff but also patients.

“It’s really important to maintain that professionalism, to maintain the collaboration within all members of your team . . . , but also take accountability and responsibility for what goes on in that lab,” Buchanan emphasized.

J. Dawn Abbott, MD (Brown University, Providence, RI), incoming president of the Society for Cardiovascular Angiography and Interventions (SCAI), focused her presentation on the topic of leadership during change. Interventionalists tend to think of “technical excellence and knowledge” when building their careers, but leadership will ultimately “determine the impact you have on clinical care, on the research you want to perform, on your administrative roles, and what we can accomplish in the field,” she said.

In the cath lab ecosystem, “you’re the one setting the tone,” stressed Abbott. “The shift from trainee to attending is not just technical—it is relational.”

Not Just Technical Skills but Trust

At conferences like the EAPCI Summit and others, interventional cardiologists are keen to learn the latest data on best practices that will positively impact patient outcomes. Yet “what we often don’t think about is the behaviors in the lab itself and how things such as being rude, being uncivil, etc, within the cath lab can really impact upon the outcomes of our patients,” said Buchanan, adding, “Less stress means fewer errors.”

The ability to have a safe environment is built upon trust, which is bolstered by “communication, competence, and compassion,” she noted.

To start, of course, “a patient must trust the operator” in order to be on the table in the first place, Buchanan noted. Before the case, ease their anxiety by engaging with them, she advised. “Let them know what’s happening, the risks and benefits, what to expect within that cath lab. . . . Just be absolutely consistent and clear, and tell the patient, ‘This is our fabulous team. They all know what we are doing. We’ve dealt with this so many times, and you’re very safe with us.’”

Then, “throughout, remember the patient is awake. So please remember to reassure them, update them,” she suggested.

Less stress means fewer errors. Gill Louise Buchanan

Trust is necessary within the team, as well, said Buchanan. “The operator must trust the scrub nurse because if we don’t know that they’ve prepared things properly, if there’s error in the manifold, if they haven’t prepped the stent correctly or the device correctly, we’d be struggling to perform our cases. The scrub nurse must trust that somebody has ordered the kit and that the kit is available. . . , and then the other members of the team must trust each other and be able to speak up [if they see something’s amiss].”

This is where “softer” skills are crucial, she said, advising that cath lab leaders:

• Form positive relationships with colleagues by asking how they are, thanking them for their contributions, being respectful, and actively listening
• Encourage the team to speak up about any concerns
• Maintain a consistent demeanor from day to day
• Be calm and visible throughout cases
• Take accountability when something goes wrong and discuss with the team, without blame, how to avoid the issue going forward
• Seek out feedback from colleagues on how the lab is performing

EAPCI President Alaide Chieffo, MD (San Raffaele Scientific Institute, Milan, Italy), who co-moderated the session, highlighted mentorship as a first step towards gaining leadership skills. Professional societies are the place to start, she said.

Resources include programs from the EAPCI, SCAI, the British Cardiovascular Society, the American College of Cardiology, and the European Society of Cardiology,

Leading Through Change

Abbott noted that as cardiovascular medicine has evolved over the decades, it has widened its scope: from endovascular to structural interventions, for example, plus rapid-response teams in pulmonary embolism and cardiogenic shock. With this growth, interventional cardiologists are now engaging across increasingly more subspecialties. This diversity matters when attempting to navigate change, she said.

“You have to understand who the stakeholders are in order to have them come along with you on the journey to the ultimate goal,” said Abbott. “What is the goal of the change I’m trying to lead? What is the goal of developing this team? What is the goal of doing this research project? And then you can help everybody understand.”

She cited three tools that interventionalists can apply as leaders:

• Coaching to develop judgement (whereas teaching simply transfers information)
• Feedback to improve performance
• Influence to shape culture

These concepts can manifest in many ways when working in the lab. For example, said Abbott, it’s important for interventionalists to openly state when they see a potential issue ahead, so that others on the team feel comfortable speaking up and can quickly act.

[It’s] not just, ‘I did 8,000 PCIs in the last 20 years,’ but the people you trained [and] the patients you took care of. J. Dawn Abbott

“Model vulnerability” when coaching, she suggested.  “You have to put yourself out there. You have to have a risk. You have to be open to it. When I’m in a crisis situation, when I’ve gone through the algorithm of what I know to do, I look to those next to me and say, ‘Team, [can] anybody think of anything I’m not thinking of? Am I missing anything? And we make sure we’re not missing something. . . . If you normalize their critiques, then you’re going to go farther.”

Then, at the end of a case when debriefing, “I always like to ask open-ended questions,” Abbott said. “Why did you choose this device? What do you think the alternatives are? What could we have done differently? Does anyone have suggestions? . . . It’s hard to move forward and learn if you’re very pedantic about it.”

For feedback in the opposite direction—from the interventionalist to the team members—Abbott provided a framework. “Begin by describing the specific situation to help clarify the context for your feedback,” she advised. When communicating, “focus on the person’s observable actions, avoiding judgment or assumptions to keep feedback objective,” and finally, address the impact by describing “how the behavior affected others or results, making the feedback actionable and meaningful.”

Influence, where people trust a person’s leadership, matters more than simple authority, which comes from a job title alone, Abbott explained.

Although competence, consistency, fairness, and emotional intelligence all contribute to that trust, leaders can still encounter resistance. Something as simple as changing a manifold, said Abbott, can take months to finish.

“ I think people resist change because they’re scared. They don’t want to lose their mastery. They might not be competent in whatever you’re asking them to do. Maybe that’s been their identity to do something the way they’ve done it,” she observed. In these instances, explain the reason behind the change, whether it’s to be more patient-centered or efficient, for example, and acknowledge that it’s going to be hard.

At the end of the day, what kind of leader do you want to become? Are you going to be feared? Are you going to be respected? Are you going to be trusted? Are you going to be influential? The legacy that you leave will depend on this,” Abbott said. “[It’s] not just, ‘I did 8,000 PCIs in the last 20 years,’ but the people you trained [and] the patients you took care of. Your own family and friends.

“How did you lead your life? That’s how you will be judged. So make sure it’s a good one,” she concluded.