Management strategies in aortic coarctation.

contribute. Whether you refer to ‘leadership structures’, ‘distributive leadership’ or a ‘systems paradigm’, it does not matter, the message is clear. As Mr Jarvis argues and as we repeatedly emphasize in our review one surgeon cannot perform all the functions of leadership required in modern cardiac surgery and all stakeholders must be empowered to demonstrate leadership, innovate and collaborate. Second, while we agree with many of Mr Jarvis’s observations on medical professional culture, we believe that being philosophical about leadership and models of strategy has utility only when they inform practical and tangible positive action. As Mr Jarvis suggests cardiac surgery is a product of the system, its culture is defined by its history. Positive organizational cultures cannot simply be ‘transplanted’ from other disciplines by ‘regime change’ but must be incrementally developed by tangible action. In our review, we advocated a practical framework of clinical leadership, academic leadership, educational guidance and training and stakeholder engagement. This is perhaps not original, there is obviously overlap between domains and it is perhaps less elegant than generic models of leadership and strategy; however, it can be readily applied to address the fundamental problems that cardiac surgery faces. If other centres have alternative strategies to address these problems then we applaud them and encourage them to contribute to this debate. Our words and model structure are not sacrosanct. Our speciality stands on a precipice, we must debate, we must act and we must do this soon. We must avoid bickering about semantics and models of leaderships; it is now the time for action.