Kelsey Ford, MD; Michael Menchine, MD, MPH; Elizabeth Burner, MD, MPH; Sanjay Arora, MD; Kenji Inaba, MD; Demetrios Demetriades, MD, PhD; Bertrand Yersin, MD


Western J Emerg Med. 2016;17(5):549-556. 

In This Article

Abstract and Introduction


Introduction: Leadership skills are described by the American College of Surgeons' Advanced Trauma Life Support (ATLS) course as necessary to provide care for patients during resuscitations. However, leadership is a complex concept, and the tools used to assess the quality of leadership are poorly described, inadequately validated, and infrequently used. Despite its importance, dedicated leadership education is rarely part of physician training programs. The goals of this investigation were the following: 1. Describe how leadership and leadership style affect patient care; 2. Describe how effective leadership is measured; and 3. Describe how to train future physician leaders.

Methods: We searched the PubMed database using the keywords "leadership" and then either "trauma" or "resuscitation" as title search terms, and an expert in emergency medicine and trauma then identified prospective observational and randomized controlled studies measuring leadership and teamwork quality. Study results were categorized as follows: 1) how leadership affects patient care; 2) which tools are available to measure leadership; and 3) methods to train physicians to become better leaders.

Results: We included 16 relevant studies in this review. Overall, these studies showed that strong leadership improves processes of care in trauma resuscitation including speed and completion of the primary and secondary surveys. The optimal style and structure of leadership are influenced by patient characteristics and team composition. Directive leadership is most effective when Injury Severity Score (ISS) is high or teams are inexperienced, while empowering leadership is most effective when ISS is low or teams more experienced. Many scales were employed to measure leadership. The Leader Behavior Description Questionnaire (LBDQ) was the only scale used in more than one study. Seven studies described methods for training leaders. Leadership training programs included didactic teaching followed by simulations. Although programs differed in length, intensity, and training level of participants, all programs demonstrated improved team performance.

Conclusion: Despite the relative paucity of literature on leadership in resuscitations, this review found leadership improves processes of care in trauma and can be enhanced through dedicated training. Future research is needed to validate leadership assessment scales, develop optimal training mechanisms, and demonstrate leadership's effect on patient-level outcome.


Coordinating doctors, nurses, and ancillary staff to care for patients requires teamwork and leadership. This is particularly true in emergency settings where providers from numerous specialties converge to care for critically ill patients with limited data and under strict time constraints. The most recent Advanced Trauma Life Support (ATLS) guidelines have codified leadership's importance by emphasizing that for a team to "perform effectively one team member should assume the role of the team leader."[1] However, unlike the majority of other key elements of trauma care (e.g. airway assessment), the ATLS manual does not provide specific teamwork training recommendations or guidelines for leadership. As a result, the leadership and teamwork structure for trauma care is generally dictated by provider preference, institutional history, and local culture rather than uniform standards.

Leadership styles are divided into two main categories: directive or empowering. Directive leadership is typical of a military chain of command. The commanding officer explicitly instructs subordinates on which tasks to perform and when to perform them, effectively managing and supervising the decision-making process through role distribution and flow of information.[2,3] This type of leadership is effective when tasks are simple, straightforward, and/or the leader is the only team member with expertise.[4] In empowering leadership, leaders delegate responsibility, allowing colleagues to make decisions while the leader focuses on team communication and coordination. The primacy of directive leadership has been increasingly challenged. Newer theories postulate that empowering (shared) leadership is more effective when tasks are complex.[4] These theories suggest the more complex a task, the more necessary it is for team members to share the responsibility of management of information, communication, and adaptability to achieve success.[4]

However, the optimal leadership style and team structure for trauma is largely unstudied. Trauma resuscitation has elements that are simple/task-oriented and components that are highly complex requiring team member coordination. As such, directive and empowering leadership styles might both play a role. Furthermore, the development of emergency medicine as a specialty has changed the structure of leadership in trauma. Cross-disciplinary and shared leadership structures now exist in which trauma surgeons and emergency physicians mutually make decisions for the benefit of the patient. Research to elucidate the optimal style and structure of leadership in trauma is limited by a lack of validated tools to measure the quality of leadership and teamwork. Once standards are developed, training programs can be created on the basis of strong scientific evidence.

The goal of this paper was to review the scientific literature on leadership and teamwork in trauma and resuscitation patients. Specifically, we evaluated 1) how leadership and teamwork affect patient care, 2) which tools are available to measure effective leadership or teamwork, and 3) what methods can be used to train physicians to become better team leaders/team members.