Toxic leadership

Spartacus

Just about everything in life falls into a bell-shaped curve. As you all know, a bell-shaped curve, also known as a normal or Gaussian distribution, is a statistical concept that represents data clustered around a central peak, with frequencies decreasing symmetrically towards both ends. In my life in anesthesiology, my departmental leaders fell into this curve. Some were outstanding, some were average, and some were awful. The great ones were servant leaders. What’s that you ask? Servant leadership is a leadership style that prioritizes the needs and growth of team members, focusing on empowering, mentoring, and supporting them to achieve their full potential, rather than solely focusing on results. The terrible/toxic ones were narcissistic leaders. Narcissistic leadership is characterized by self-centeredness, a grandiose sense of self, a lack of empathy, and a desire for admiration and power, often at the expense of others.

Today’s PAAD is a bit of a departure from the papers we commonly review. It doesn’t discuss a new finding of great clinical impact, a classic paper with contemporary resonance, or a provocative perspective on pediatric anesthesia care. It does, however, discuss a paper that highlights a disturbingly common problem that has enormous impact on our careers as pediatric anesthesiologists and on our personal well-being, which, in turn impacts our colleagues, our patients, and our families- and offers solutions. Professor Britta von Ungern Sternberg and her research are undoubtedly well known to PAAD readers. She is the chair of the Department of Anaesthesia and Pain Medicine at Perth Children’s Hospital in Australia and Karin Becke-Jakob is Professor of Anaesthesia and Intensive Care at the Cnopfsche Children’s Hospital (Kinderklinik) in Nürnberg, Germany.

I asked 2 prominent members of the PAAD community to review this paper. For legal reasons I did not participate. Because of the times we live in, I felt it best to protect their identities and simply called them Spartacus. I am hoping many of you will respond to today’s PAAD and offer your stories as well. When posted in the Friday reader response, I will post them anonymously (“I am Spartacus”) unless you want your name posted. Myron Yaster MD

Original article

von Ungern -Sternberg BS, Becke-Jakob K. Toxic leadership: when culture sabotages clinical excellence. Anaesthesia. 2025 Feb 16. doi: 10.1111/anae.16561. Epub ahead of print. PMID: 39956644.

In this important and provocative editorial, von Ungern-Sternberg and Becke-Jakob¹ discuss toxic leadership, an issue that creates departmental crises and is certainly not unique to anesthesia departments. Indeed, some the pathological character traits that underly toxic leadership (narcissism and self-entitlement, insecurity, passive-aggressive tendencies, emotional disconnection) are often the ones that drive people to seek power and leadership, all the while bullying, scapegoating and creating an atmosphere of fear, retribution and stress as they attain more authority and responsibility.

Von Ungern-Sternberg and Becke-Jakob note that the traditional nature of medical training and subsequent academic advancement has historically been a major factor in perpetuating the toxic leadership model. This is particularly ironic when one considers that challenges to established norms are often the catalyst to breakthroughs and advancements in medical science. Yet traditional models of strict hierarchy and rewards for adherence to the status quo and existing models play a large role in fostering maladaptive behavior, particularly when it becomes the route to departmental leadership. When leadership roles, and with them, power, become a benefit of the few rather than a means of promoting and developing personal and organizational growth and success, the advancement of those least likely to create a department characterized by openness, collegiality, and mutual respect and support is facilitated. Such leadership not only creates stress and unhappiness among “unfavored” faculty but also stifles the development of the department, of professional satisfaction and of clinical and scientific innovation. It leads to resentment and, eventually to obstacles to retention and recruitment, and fosters turnover and instability.

A second factor is that not all good clinicians or investigators are natural leaders. Some may be promoted to leadership positions leaders with little experience and lack the natural ability to be a departmental leader. Those with the interest in and potential for leadership may not receive the kind of training or mentorship that can compensate for the lack of innate ability. A department that is governed by toxic leaders perpetuates a dearth of modeling and education in good leadership and sets up barriers to change in which a negative culture is internalized and normalized, leading to burnout and fear of retaliation.

In contrast, the authors describe six main principles of ethical leadership:

i. respect, in which others’ skills and contributions are valued

ii. accountability, where one’s errors as well as accomplishments are acknowledged, focusing on systemic solutions

iii. service, a focus on creating programmatic advocacy for the well-being of all department members

iv. honesty, which fosters trust and open communication

v. justice, ensuring that all are treated and rewarded equitably

vi. community, emphasizing and implementing the collaborative nature of what we do among all members of the team, in order to achieve collective departmental as well as individual goals.

How can a department beset by these difficulties change? The etiology of the problem is in itself an impediment to its resolution and requires self-awareness and introspection. Often, external evaluation and support is needed, including coaching, expert review and mediation. The expansion of leadership beyond a small and favored group of insiders is necessary to foster renewed trust. The benefits of such changes are many: to the individual, the faculty, the department and to enhanced patient care. Von Ungern-Sternberg and Becke-Jakob note that “it is a strategic investment in a department’s long-term success as well as the retention and wellbeing of all staff.” Awareness and remediation of these problems renews the focus of a department on the care of our patients and creates an atmosphere of collaboration and purpose that benefits all. In an era in which we are all facing a crisis in staffing, it is even more critical, and will reap rewards as one’s departmental reputation as a collegial and exciting place to work spreads.

Send your thoughts, comments, and personal experiences to Myron who will post in a Friday reader response. And as explained in the introduction, unless otherwise requested, these posts will be anonymous (“I am Spartacus”).

References

1. von Ungern-Sternberg BS, Becke-Jakob K. Toxic leadership: when culture sabotages clinical excellence. Anaesthesia 2025 Feb 16. doi: 10.1111/anae.16561. Epub ahead of print. PMID: 39956644..