While “good leadership” can be difficult to define, most of us recognize it when we see it (or lament its absence when we do not). Regardless, most definitions of “good leaders” include someone being able to manage the entire situation (people, tasks, distractions), someone who is prepared to take responsibility (“okay, I’m taking over, listen to me”), and someone who is empowered to make definitive decisions (the buck stops here). Specifically in trauma, Klein et al. reported that “effective” leaders performed at least four key functions: strategic direction, monitoring the progression of clinical care, providing hands-on treatment, and teaching other team members (not only pertinent facts and procedures but also leadership attributes) [11].

Notably, the terms “leadership” and “management” are used interchangeably (both within medical and organizational literature). However, there are subtle differences. While leadership and management skills overlap—and one without the other can spell disaster—[12] leadership is more precisely defined by personal characteristics and how those attributes affect relationships. In contrast, management refers more to the functions and logistics of the larger team. Notably, the Advanced Trauma Life Support course teaches a useful, universal, and reproducible approach to trauma. However, this otherwise excellent course focuses on individual and technical competencies rather than how to work within or lead a high-performing team.

There are as many leadership styles as there are leaders. However, presumably all good leaders share a singular goal: to guide a group, team, or organization towards a common goal [13]. A recent publication [13]—based on Lewin, Lippit, and White’s 1939 work—outlined three archetypal leadership styles: autocratic, democratic, and laissez faire. The authoritarian, or autocratic leadership style, exemplified clear expectations and obvious division between leader and follower. This leadership style was efficient but rarely fostered creativity within the larger group. Democratic leaders participated within the group and acknowledged input from members. Despite less productivity from the democratic group (compared to the autocratic group), the contributions were of higher quality. Therefore, the democratic leadership style was believed to be the most effective. However, hierarchy still matters and democracy can go too far. The laissez faire, or delegation group, was the least productive. Decision-making was least likely because the group was unstructured and not empowered. Seventy-years on, it is noteworthy that these archetypal leadership styles are still recognizable to modern healthcare workers.

The autocrat seeks little input and leads by control. This has been called a “transactional relationship” and relies upon rewards and punishments. This in turn depends upon obedience of subordinates. In contrast, a “transformational relationship” relies upon engagement and has a flatter authority gradient. This approach includes the need to inspire and motivate, create a shared vision, and foster collective ownership. The acuity of trauma can make it hard to find time for the tact and preemptive engagement required for transformational relationships. However, this only emphasizes the importance of anticipatory team building (including that gained from regular simulation) and the dexterity required of the modern team leader (see below). Bass introduced the term transformational leadership in the 1980s. Accordingly, it has also been called visionary or inspirational leadership. While it clearly requires more effort (including prior to the trauma even occurring), it offers a useful goal for the modern trauma team [14].

In addition to the above, it has been argued that leaders also need to be self-aware, self-assured, and self-confident. This needs to be tempered by emotional maturity, integrity, and acknowledgment of the team’s needs [13]. Effective leadership traits have also been summarized in five broad categories [15, 16]. These “Big Five” include assurgency (extroversion), conscientiousness (dependability), agreeableness (affiliation), adjustment (emotional stability), and intellectance (open minded). ‘Assurgency’ would allow for someone to speak their mind. This is especially helpful in those trauma resuscitations where members are unfamiliar with each other’s working styles, or inexperienced in general. ‘Conscientiousness’ speaks to maintaining a high degree of accountability and ethical standards. This in turn could positively affect patient outcomes in trauma resuscitation. Agreeableness would promote cooperation and bonding within the team. ‘Adjustment’ would allow for emotional neutrality which is crucial in high stress situations. In contrast, when the leader leads in an erratic manner, a potentially calm resuscitation can spin into chaos. ‘Intellectance’ allows flattening of the hierarchy and promotes input from others. This allows for varying perspectives; which is crucial if the trauma team leader is struggling to find solutions: (i.e., why is this patient still in shock?) Specifically in trauma, Andersen et al. concluded that a leader was someone who communicated effectively, delegated tasks, was clinically proficient, and was able to plan and prioritize [17]. Similarly, Cole and Crichton defined a leader as someone “who is responsible for team preparation prior to the patient’s arrival, analysis of findings, development of a management plan, and coordination of patient referral to other specialists” [18].

Regardless of the adjectives used to describe good leaders, it is important to emphasize that leaders are more often made than born. Despite this, leadership skills are insufficiently addressed in traditional curricula. Therefore, we should not be surprised that many junior physicians are uncomfortable being in leadership positions, especially during resuscitations. Hayes et al. found half (49.3 %) of residents felt inadequately prepared to lead cardiac arrest teams [19] and over half (58.3 %) felt unable to lead an emergency department resuscitation [20]. In short, we need to do better. Fortunately, crisis resource management (CRM) (which includes leadership principles) can be taught and measured.

There is a plethora of leadership styles, based primarily on personality traits, personal experiences, and situational context. The best leaders are flexible, and do not assume that one-leadership-style-fits-all. An effective leader can marry different leadership styles, based on the specific situation. The first step is self-awareness: recognizing your personality, how this affects your leadership style, and how you react to stress. For example, do you tend towards hinting, encouraging, or ordering? Is your natural approach to praise, admonish, or say nothing? Do you possess the flexibility to alter your style depending upon the acuity of the situation and the composition of the team? When there is little help or little time, an authoritative style is probably required [11]. When patients are more stable and when senior help is available, a more collaborative approach is typically better. In short, a good leader is dexterous with more than just their hands. A good leader knows how to individualize leadership style just as clinical therapy is individualized.