The Surgeon Fluent in the 'Language of Commitment'

In Memoriam: This week’s "Best of 7" was conducted with Dr. Curtis Tribble, a decorated professor of surgery and cardiothoracic surgeon at the University of Virginia School of Medicine. It’s with great sadness that I learned Dr. Tribble passed away shortly after our interview. This piece is intended to honor his work and larger leadership legacy.

Several years ago, Dr. Curtis Tribble rented a Jeep while on vacation in Saint John with his wife and three sons.

“I’m going to drive because we have to drive on the wrong side of the road,” Tribble told them. “But I want you all to help me if we lose our way.”

Sure enough, after a missed turn or two, Tribble began driving on the right side of the road, carrying on for about 300 feet down a hill before a voice in the back interjected.

“It wasn’t my oldest son. It wasn’t our middle son,” Tribble said. “It was our youngest, the only non-driver in the family.”  

“The four drivers in this group were completely fine with my driving on the incorrect side of the road. But the non-driver, who didn’t have that as his instinct, realized we were doing something wrong.”

Tribble frequently shared that anecdote as a professor of surgery and a cardiothoracic surgeon at University of Virginia Medical Center.

To him, it was an important reminder that critical feedback can come from unlikely sources and that it’s worth seeking multiple viewpoints before choosing a course of action.

“Everybody, whatever it is we’re doing — having a lab meeting about research, talking about a pre-op plan, or we’re in the operating room — will either see things a little differently or have a different perspective,” he said.

“I’m not just giving you permission to offer your opinion, I’m demanding it.”

Best of 7 spoke to Tribble about making decisions amid conflicting opinions, the importance of conveying optimism when there’s little hope, and learning through both successes and disappointments.

This interview has been edited and condensed.

Best of 7: Dr. Tribble, tell me a little about the environment you tried to create in the operating room.

There’s a subtle feeling as a trainee that if you’re doing well, that’s nice, but if something bad happens, it’s the faculty member’s fault — you’re just doing what they told you to do. But once you are an attending faculty surgeon, it’s on you. Even if it’s someone else’s mistake, you have to say out loud, “I must not have told you clearly enough what I wanted you to do.”

I had to put a lot of responsibility on myself. I had to prepare properly. I had to reflect properly. I had to seek advice when appropriate. I had to welcome the observations of others, even from people who were fairly low on the totem pole in a medical or surgical hierarchy.

There are 10 people in the room. Some are anesthesiologists. Some are running the heart-lung machine. Two of us are in the chest doing the operation. Some of us are on the left side, some are on the right side. Everyone literally has a different view. I wanted to hear it.

I demanded everyone in the room call me by my first name. The reason I’d do that is that I didn’t want there to even be a subtle hierarchy by you always calling me “Dr. Tribble.” I want you think of me as a teammate rather than a person controlling everything that’s happening here, because I can’t.

Did you ever worry about losing authority by seeking so many opinions?

I think some people view the language of leadership as authoritative or being confident or demanding. But if you’re thinking about leading other people, what you want to convey as the leader is this is a team. If everybody does everything right, we’ll probably have a good outcome — not necessarily — but we probably will.

Part of what I’m going to do is tell you what I think we should do, but I’m also going to listen. If you see something different, know something different, sense a new approach, tell me. But I am going to tell you at some point that if we have 10 different opinions about what should be done, one person has to make the final decision, and I’m letting you know that’s going to be me.

If I have to make a decision amid conflicting data or disparate opinions, I will do that. This is not going to go as an endless debate in the state legislature. I’ll listen when I can and will make a decision when necessary. Mostly, I’ve found that works well. I try to make sure part of the language of leadership is respect for everybody, for their backgrounds, for their opinions and points of view, figuratively or literally. But the clock is running, and we may not have the luxury of time.

Several great thoughts there. I know “Always be honest” is a core tenet of yours. Why is that so important?

That includes accepting responsibility and acknowledging that what you thought was the right thing to do wasn’t. I will never blame you for not knowing something or making a decision that I wouldn’t have. All I ask in that setting is that you say, “I forgot” or “You told me to read this article about how to do this operation, and I didn’t get to it.”

That’s O.K. We’re starting with human beings and working backwards from there. Every single one of us is imperfect and is never going to get everything right. But you try to learn from it and be open to suggestions. The people you’re trying to lead will respect you if you say, “I didn’t understand what we were up against” or “I didn’t see something I should have” or “I should have read one more article, but I didn’t.”

I think if you model it, they will do the same thing back.

What does “leading from the front” mean to you?

I’m trying to treat everybody — not just team members but patients and their families — with respect. Often, I’ve been asked to see a patient preoperatively. They’re in the clinic, and we’re having a conversation about what we’re going to do. When they come, it seems more often than not that they manage to bring a person who the family thinks is the smartest in the family. Frequently, they’re from somewhere else.

So, I’d try to figure out who the out-of-towner was who was considered to be the smartest. Usually, they would say something that was a bit challenging or a bit acerbic. “Are you sure you know how to do this?” My response to them is always to use a martial arts move. I’d say, “You know, I’m so glad you’re here because I know you have some experiences and perspectives that maybe your family members don’t. I’m going to depend on you to help me understand where they’re coming from and what they’re asking.”

They would almost always pop out their chest and look at everybody else in the room. “See? This doctor knows I’m the smartest person in the family and he’s asking for my help!” I’ll chuckle to myself. My first reaction isn’t to argue with you. It’s to compliment you and get you on my team.

If you become a leader, your job is not to get other people to serve you and make your life easier. Your job is to serve them through education and support them through tough times.

How do you maintain optimism when a situation is very likely to have a negative outcome?

There are two parts to it. The first is what you think in your own head. The other is what you exhibit to others. If everybody in the room is exhausted and frantic and you convey to them that we have no chance, then we’re going to stand in there for a while and watch them bleed to death.

There are times when there’s nothing else to do, but you have to convey at least some optimism. How do you go about doing that? Language is such an important thing. There’s the language of commitment versus the language of complaint. You want to convey not just in words but in deeds and how you carry yourself. “I believe that we can win this battle. I believe that we can figure something out.” It might be that we need to think about it some more or we need another person with fresh eyes and a fresh back to come in. It might be for energy or moral support. It might well be for new ideas.

What does “remember and forgive” mean to you?

The old saying is “forgive and forget.” It’s the other way around, in essence. They say the steepest learning curve of your life is right after you finish your residency when you can’t blame things on your attending surgeon. “Everything is your fault if you’re any damn good,” is the old saying.

When I got to UVA to train, every Wednesday we had what we called morbidity and mortality conference. I thought, “God almighty, this is really interesting.” It’s not infrequently said that one hour of those conferences is the most important hour of the week because people are trying to learn from something that didn’t go the way they wanted.

What I didn’t appreciate at first is there was sort of an unspoken absolution, a forgiveness that occurs because you did your best with the actual care of the patient and to learn from it. You also furthered that process by sharing what you think you learned with others with the hope that you figured out what went wrong. Sometimes, nothing went wrong.

My thought about changing the order from “forgive and forget” then to Dr. Charles Bosk’s version, “forgive and remember” to “remember and forgive” is that you analyze, and you think, and you wonder, and you ask for advice, and you read about it. Then, you continue that process by sharing with others. If you start with the fact that you’re not going to save everybody, and all of us are imperfect and are going to make mistakes — we’re upset and we should be — but if we learn from it and share what we learn with others, we sort of earn some redemption.

You touched on it before, but how do you fight perfectionism when millimeters or inches matter so much in an operation?

When I was a senior resident, I was sewing tiny arteries on the heart. I had a couple of attendings who were just kind and gentle souls. “You’re doing good, man. That looks good. Keep going.” Then, on the other end of the spectrum, I had a couple of younger attendings. One in particular was like the Bobby Knight of surgery, just yelling and livid. He would say stuff I couldn’t even believe. “It’s obvious to me now you’ve been sleeping with this guy’s wife! You’re trying to kill him!”

I never said anything, but what I realized I had to be able to do with someone saying stuff like that to you — and there might be 16 to 20 stitches in an anastomosis — I had to keep moving. I can’t let what that guy just said to me affect the next stitch. And, of equal importance, no matter how he talked to me, or what he said, or what I thought of what he said, I have to forget that completely so that I am totally focused on the next stitch. I have to stick that needle through the just right cell layer. If I don’t, then this thing he’s accusing me of, trying to kill the patient, might be true.

I had to go through the cycle in seconds. Assess, plan, act, judge, learn, forget. Nobody ever told me about forgetting, but I realized the process of talking to your friends and asking for advice is long and drawn out. Here I was, and I had to put this into a microcosm like a metronome was going.

If I’m not learning, I’m not getting better. And if I’m still stuck on the critical comment, I can’t perform properly.