Leadership in cardiac surgery: challenging the paradigms

The review by Rao et al. [1] is a welcome analysis of the chal-lenges that cardiac surgery must overcome if it is to have a secure future, but an analysis that is too limited in scope, depth and subsequent recommendations. The word paradigm is used four times, and yet there is a failure to critique some of the most fundamental paradigms that constrain the current innovative capacity and strategic direction of cardiac surgery [2]. The first paradigm that must be challenged relates to sources of strategy. The review adheres to the classical perspective of strategy formulation as the act of leaders, deliberate strategy formulation and ignores the potentially more important role of emergent strategy, serendipitous change from the middle rather than deliberately planned change from the top, as a factor in long-term competitive advantage [3, 4]. Organizational culture is the product of leaders and its within cultures that value ope