I was three years into my Stanford residency when my attending handed me the scalpel for a free fibula flap on a patient with mandibular cancer. The recipient vessels were scarred from radiation. I had rehearsed the vascular anastomosis dozens of times, but when I looked through the microscope and saw the irradiated tissue, I froze for exactly two seconds. My attending said, "You have all the information you are going to get. Decide." I chose the superior thyroid artery, completed the anastomosis, and watched the flap perfuse.
That moment in the OR taught me something I thought was universally applicable: when you have assessed the situation and there is no more data coming, act. Do not hesitate. Commit. Own it.
It took me about eighteen months in corporate leadership to realize that instinct was wrong roughly half the time outside the OR.
The instinct that backfires
In surgery, the chain of command is vertical and absolute. The attending decides. The resident executes. When I became an attending, I decided. This is not arrogance -- it is structural necessity. In the middle of a twelve-hour craniofacial reconstruction, you cannot pause to build consensus about whether to use the left or right superficial temporal artery. Someone has to call it. In the OR, that someone is always the surgeon.
A review in Surgical Innovation put it plainly: surgeons hold "near-absolute authority" in the operating room, and that authority is not merely cultural -- it is functionally required by the time-sensitive, irreversible nature of surgical decisions. But the same review noted that this command style "hinders their interactions" outside the OR, where collaborative approaches are necessary.
My first year evaluating AI vendors for a health system, I kept trying to "operate" on business problems. I would assess the situation, identify what I believed was the critical decision point, and push for resolution. In a budget meeting about clinical AI procurement, I once interrupted a stakeholder discussion that had been circling for twenty minutes, laid out what I thought was the obvious path, and asked why we were still talking about it.
The room went quiet. Not the productive quiet of agreement. The quiet of people who had just been told their input did not matter.
My COO pulled me aside afterward. "You were right about the decision," she said. "But you just made three people feel like you do not need them. Next quarter, you will need them. And they will remember this."
She was correct. Two of those three stakeholders slow-walked approvals on my next project for months. Not because they disagreed with the work. Because I had treated a collaborative process like a surgical one -- as if speed and correctness were the only things that mattered.
What the 28% actually means
Hu et al. published a survey in Annals of Surgery (2023) of 847 surgeons who transitioned into administrative or executive roles. The headline finding was that 40% reported higher career satisfaction in leadership than in clinical practice. Good news. But the number that stopped me was the other one: 28% said they felt fundamentally undertrained for the non-clinical demands of the role.
I want to sit with that number. Twenty-eight percent. These are surgeons -- people who completed some of the most rigorous training programs in professional education, who are selected for decisiveness and confidence, who are culturally trained never to say "I do not know how to do this." And more than a quarter of them, when given an anonymous survey, admitted they were in over their heads.
I was in that 28%. I just did not have the survey to tell me so.
The technical decision-making transferred beautifully. Assessing a vendor's clinical AI tool felt structurally identical to evaluating tissue viability in the OR -- incomplete data, time pressure, irreversible consequences. But the organizational politics, the financial modeling, the stakeholder management? Those were foreign languages, and I was not even aware I did not speak them.
Three surgical instincts I had to unlearn
The first was speed. In the OR, faster is almost always better -- assuming equivalent quality. A shorter operative time means less anesthesia, less blood loss, fewer complications. Speed is a virtue. I carried that into meetings, emails, and strategic decisions. I wanted to resolve things. Close the loop. Move to the next case.
In strategy, speed kills. I approved a data partnership in my second month at iMerit because the terms looked reasonable and I wanted to move on to the product work. Six months later, the exclusivity clause in that partnership blocked us from working with a much larger client. A colleague who had been in enterprise sales for fifteen years told me he would have sat on that contract for at least three weeks, let the other side wonder if we were losing interest, and negotiated the exclusivity down. I had never even considered waiting as a tactic. In surgery, waiting means bleeding.
The second instinct I had to unlearn was certainty. Surgeons are trained to project confidence because hesitation in the OR is dangerous. When I commit to a flap design, I do not say "I think this will probably work." I say "this is what we are doing" -- because the team needs that clarity to function. I brought that same certainty into business discussions and quickly learned that in a corporate context, projecting certainty when you are actually uncertain is not leadership. It is a liability. People stop bringing you problems because they assume you have already decided.
The third was the hero reflex. Surgery selects for people who want to fix things personally. The complex hand reconstruction comes in at 2 AM, and you scrub in. You do not delegate the hard case. You want it. That instinct served me well for twelve years and over 12,000 procedures. It served me terribly in management. My first six months leading a team, I kept jumping into individual contributor work -- rewriting annotation protocols myself, debugging data pipelines, sitting in on quality reviews I should have delegated. My team was capable. I was not letting them prove it because I could not stop scrubbing in.
What actually does transfer
I do not want to overcorrect. Some things transfer powerfully, and they are not the ones most "surgeon to CEO" articles focus on.
The most valuable thing I brought from the OR was not decisiveness. It was the ability to function calmly when things go wrong. In surgery, complications happen. A flap does not perfuse. Bleeding starts from a vessel you did not expect. The training is not to avoid these moments -- it is to have a structured response when they arrive. Assess. Stabilize. Replan. Execute the new plan.
When iMerit lost a major client in Q3 of my second year -- a contract worth roughly 20% of the division's revenue -- I watched the business development team spiral into contingency planning that felt panicked. I recognized the pattern from the OR. This was a complication, not a catastrophe. We needed to stop the bleeding (identify which other clients could absorb capacity), assess the damage (what the revenue loss actually meant for the next two quarters), and replan (shift resources to pipeline opportunities that had been deprioritized). We recovered the revenue within five months. The surgical framework worked -- not because business is like surgery, but because managing your own nervous system under stress is a transferable skill.
Shanafelt et al. in Mayo Clinic Proceedings (2019) found that physician burnout rates reached 44% nationally, with a significant contributor being the gap between clinical training and administrative demands. What their data points to, and what I experienced personally, is that the problem is not a lack of leadership ability. It is a mismatch between the specific type of leadership that residency develops -- acute, hierarchical, individual -- and the type that organizational management requires -- chronic, collaborative, distributed.
The moment I knew I had adapted
About two years into my time at iMerit, I was in a product review where one of my engineers proposed a radiology annotation approach I disagreed with. The old me -- the surgeon me -- would have overruled him. I had more clinical knowledge. I could see the problem with his approach immediately.
Instead, I asked him to walk me through his reasoning. It took twelve minutes. His approach had a flaw I had spotted, but it also had an insight I had missed -- he had identified a pattern in the rejection data that suggested our existing protocol was creating systematic bias. If I had overruled him, we would have shipped a product with a hidden defect.
That moment was not a leadership seminar. It was not a framework or a methodology. It was the accumulated scar tissue of every time the surgeon's instinct had cost me something in a corporate setting. I had finally internalized that "you have all the information you are going to get -- decide" is sometimes wrong. Sometimes you do not have all the information. Sometimes the information is in someone else's head, and the only way to access it is to shut up and listen for twelve minutes.
Dayal et al. in the Journal of Surgical Education (2020) found that surgeons who maintained active research involvement scored 23% higher on evidence appraisal tasks than those in purely clinical roles. I think research keeps you honest in a way that pure clinical work sometimes does not -- it forces you to sit with ambiguity, to admit that the data might not support your hypothesis, to revise. That is the muscle that transfers to business. Not the decisiveness. The willingness to be wrong.
Topol's review in Nature Medicine (2019) documented that AI tools validated on curated datasets frequently underperformed by 10-15 percentage points when deployed on real-world clinical populations. That gap -- between controlled performance and messy reality -- is the same gap surgeons live in every day. And it is the same gap between what a leadership seminar teaches and what actually happens when you are sitting across from a stakeholder you accidentally alienated three months ago.
What I would tell the 28%
If I could go back and talk to myself in my first year of executive leadership, I would say this: you are not bad at this. You are miscalibrated. Every instinct you have was optimized for a context where decisions are irreversible, hierarchies are vertical, and speed saves lives. You are now in a context where decisions are often reversible, hierarchies are lateral, and speed costs trust. Your hardware is fine. Your software needs an update.
And the update does not come from a course or a book. It comes from failing in small ways, noticing the pattern, and adjusting. The same way you learned surgery, actually. Nobody teaches you to handle a bleeding vessel in a lecture. You handle a bleeding vessel, and then you handle it better next time.
I think about that moment with the irradiated vessels more often than I expected. My attending was right -- at some point, you have all the information you are going to get. The skill I have added since then is knowing that "some point" arrives at different speeds in different rooms. In the OR, it arrives in seconds. In the boardroom, it sometimes takes weeks. And the hardest thing I have learned is that waiting is not weakness. It is a different kind of precision.
Frequently Asked Questions
What skills from surgical training transfer best to executive leadership?
The most transferable skill is not decisiveness -- it is the ability to remain calm and structured when things go wrong. Surgeons develop systematic responses to complications: assess, stabilize, replan, execute. That framework applies directly to business crises. Pattern recognition also transfers well, as does comfort with irreversible decisions. What transfers poorly is the expectation of unilateral authority and the instinct to prioritize speed over stakeholder alignment.
Why do surgeon-executives struggle with the transition to corporate leadership?
A 2023 Annals of Surgery survey of 847 surgeons in leadership found that 28% felt fundamentally undertrained for non-clinical demands. The core issue is a mismatch between surgical leadership -- which is acute, hierarchical, and individual -- and organizational leadership, which is chronic, collaborative, and distributed. Surgeons are trained to project certainty and act fast, both of which can undermine trust-building in corporate contexts where consensus and patience are more effective.
How does clinical experience inform technology evaluation?
Having performed thousands of procedures gives you the ability to distinguish between metrics that look impressive on paper and outcomes that matter to a treating physician. Topol's 2019 review in Nature Medicine showed AI tools underperformed by 10-15 percentage points in real-world deployment versus curated datasets. A clinician evaluating those tools will ask different questions than an engineer -- questions about workflow integration, false positive burden, and whether the tool changes patient management or just generates alerts.
What is the biggest mistake surgeons make when entering the corporate world?
The biggest mistake is treating business decisions like surgical ones -- applying the OR instinct to "decide and move on" in contexts that require building consensus first. In surgery, the attending's authority is functionally required. In corporate settings, overruling stakeholders may produce the correct decision in the short term while destroying the relationships needed for execution in the long term. The adjustment is learning that the decision itself is often less important than the process by which it is reached.