The Black Quarterback

There is something uniquely difficult about being asked to lead people who have not entirely accepted that you are their leader.

You can have the title. The ability. The correct diagnosis. You can be standing in exactly the right position, having read the situation correctly.

And still, when you call the play, there is hesitation.

In American football, hesitation is measured in fractions of a second. That is sometimes enough to lose the game. In surgery, it can feel remarkably similar.

For much of its history, the quarterback wasn't simply another position. He was expected to think, to lead, to read the game, to control the offence, to make decisions under pressure and tell other players what to do. The role carried an assumption of authority. And for generations, that authority was racialised. Black athletes could be fast, powerful, explosive, naturally gifted. But quarterback required intelligence, judgement, composure — qualities that were too often imagined differently depending on who was standing in the pocket. Black players were steered towards positions thought to depend more on athleticism, while their leadership and judgement were quietly, persistently doubted.

So imagine being one of the early Black quarterbacks walking into the huddle. You don't simply have to know the play. You have to persuade everybody else, consciously or unconsciously, to believe that you know it.

This is where leadership becomes interesting to me.

Yesterday's quarterback says, "we're running this play," and everyone moves. Today, a different quarterback says exactly the same words. Same formation. Same instructions. But somewhere there is a fraction of hesitation. Is he sure? Should we really do that? Maybe someone else knows better. Nothing dramatic. Nobody refuses outright. Nobody announces that they don't accept his authority. People simply respond a little differently. And in any environment where timing matters, a little differently can be everything.

The receiver starts a fraction late. The blocker isn't quite committed. Someone improvises because they aren't completely convinced by the call. The quarterback now has two problems — the opposition, and his own team. That is exhausting, long before the whistle blows.

So he adapts. The pocket collapses, he runs. The planned pass isn't available, he finds another angle. The defence has predicted the conventional play, so he invents something else. Commentators get excited. What creativity. What instinct. He's changing the position. Perhaps. But there is another way of reading it. Maybe he learned to create because the conventional system didn't always work reliably for him. If the protection isn't there, you learn to escape. If the route isn't available, you find another one. Creativity can come from freedom. It can just as easily come from necessity.

That idea sits close to home, because I think something similar happens to Black surgeons.

Surgery is a team sport, whatever the theatre list might suggest about who holds the knife. Anaesthetists, scrub practitioners, ODPs, nurses, therapists, radiographers, junior doctors, registrars — everybody has a role, and when the team functions well it is close to beautiful. There is rhythm. People anticipate one another. You ask for something and it's already being passed to you. Everybody moving towards the same outcome, the patient at the centre of it.

But leadership depends partly on trust, and I have spent long enough in this profession to notice what happens when people don't instinctively see you as the one holding it. You make a decision, and someone checks it. You give advice, and they ask someone else. You suggest a plan, and there's a pause before the room moves. Another person says essentially the same thing ten minutes later, and suddenly everyone relaxes.

I want to be careful here, because it would be easy to overstate this. Not every hesitation is about race. Hierarchy matters. Personality matters. Experience matters. Relationships matter. Sometimes I am wrong, and the person questioning me is right to do so — good teams should challenge their leaders, and patients are safer for it. But when a pattern repeats often enough, across enough rooms, you begin to notice something underneath it. Same play. Different quarterback. Different response.

It starts long before consultancy. As a trainee, you can feel as though your decisions require an additional layer of verification that other people's don't. You know the anatomy, the patient, the evidence. You suggest the plan, and still there's a hesitation you can't quite name. You watch someone else at your level make the same call, and the room simply moves.

That difference does something to you psychologically. You start over-preparing. If ordinary competence isn't generating trust, you decide you'll become exceptional instead. Research, teaching, extra qualifications, courses, publications, another examination, another certificate — another way of proving that you know the playbook, in case knowing it once wasn't enough.

Eventually something interesting happens. You've accumulated so much from finding alternative routes that you start seeing options other people never had to look for. The adaptation becomes a skill in its own right.

I have always been drawn to surgeons who think slightly differently — not recklessly, and not ignorant of convention, but not imprisoned by it either. Why does this need a general anaesthetic? Could this be done under local block instead? Could this be taught differently, shared more widely, tested before it becomes a formal study? Could I build something myself rather than waiting for permission to be granted? Some of that instinct, I suspect, comes from a lifetime of discovering that the conventional route isn't always open to you. If the front door repeatedly doesn't give, you get very good at finding the side ones. Eventually you become the person who notices doors nobody else has clocked. Read the field. Adapt. Move.

There is a trap hidden inside all of this, though, and it's worth naming. Black excellence is often praised through the language of exceptionalism — so talented, naturally gifted, inspirational. Those words sound like compliments, and in a sense they are. But they can obscure the work underneath them. A quarterback doesn't improvise successfully because something magic lives in his legs. He has spent thousands of hours studying the game, and the apparently spontaneous decision is built on repetition, pattern recognition, failure, and preparation most people never see. It's the same in surgery. When an experienced surgeon appears to improvise, they are rarely making something up — they're drawing on thousands of prior decisions compressed into a single moment. Creativity without knowledge is dangerous. Creativity built on mastery can be extraordinary. The distinction matters, and it's too often lost.

There's a further discomfort worth sitting with. Sometimes being exactly as good as everyone else isn't enough, because if people begin with different expectations of you, identical performance gets read differently. Confidence from one person reads as leadership; from another, as arrogance. Decisiveness becomes aggression. Questioning becomes difficult behaviour. Ambition becomes entitlement. That creates a quiet pressure to be not marginally good, not debatably good, but unmistakably good — and there is a cost to that. Nobody should have to become exceptional simply to receive the ordinary professional trust that others are given by default. I try not to romanticise the pressure either. Barriers can build resilience, but they can also waste talent. For every person who develops extraordinary powers of improvisation, there is probably someone equally gifted who simply became exhausted and left the game. We rarely tell their stories. We should.