Ever
wondered if the surgeon who appears to never sweat thru a technically
challenging procedure or event has any comfort zone concerns at all? Wonder no more! It appears that we all likely
have boundaries that eventually push our buttons. What those limits are may
surprise you. In their Dec 2015 paper, Dr. Moulton’s group from the University
of Toronto interviewed 18 surgeons regarding their approach to risk-taking and
comfort zones. She and I discussed their findings and how this relates our
lives as surgeons (I am very grateful for the time she took to discuss this
with me).
From
these interviews it appears that even the boldest appearing surgeons probably
have their breaking point. It is likely
that every surgeon has a perception of where their boundary is; the place where
they no longer feel comfortable.
Self-assessment literature seems to indicate that we frequently do not
openly acknowledge that we have a comfort zone (or may not accept that
personally). It may be that the temperamental and angry affect we see in some
surgeons is actually a reflection of anxiety. It is unlikely that anyone is
immune, but we simply do not discuss it.
So,
what are some of these conditions that create a rift in our comfort zone- the
conditions that push us close to, or past that boundary? While these vary from
person to person, several common themes seem to appear.
1. As suspected, alterations in the environment such as an
unfamiliar hospitals (OR), change in the OR team personnel, or assistant staff
can create anxiety. While the
experienced surgeons have no qualms at the hospital they tend to work in daily,
they seem to shy away from similar cases at other less familiar hospitals.
Environment may also come into play when one is performing elective as opposed
to emergent or trauma surgery. Experienced surgical oncologists reveal that the
same operations they perform without hesitation in an elective circumstance
would be anxiety provoking in a traumatic scene. Presence or absence of specialized surgeons
on the premises can alter the surgeons comfort in performing certain
procedures. Other surgeons felt more confident with certain equipment (such as
certain headlamps).
2. Another common theme was the performance of infrequently
performed procedures by surgeons who do extremely complex cases on a daily
basis but rarely if ever do the more mundane procedures (hernia repair).
3. A theme that most surgeons typically will not discuss is our
aversion to complications based on past experiences. That is, some abhor
complications while others accept them as a potential and mentally prepare to
avoid them where they can. Some of us
may be more anxious about the potential harm we may create due to past
experience such as the peer review process, morbidity and mortality
conferences, litigation, being berated by a colleague, etc. There is likely a link between our reaction
to a stressful procedure and how we manage the potential for complications- we
may become so anxious about doing harm it affects our care because we now take
the complication very personal. This leads to a lack of tolerance for
complications and potentially to limitations of the procedures we are willing
to tackle. Your reaction is dependent on culture around you – a blaming culture
causes you to focus on your errors… your latest nightmare affects your future
case care. .. Your peer reactions to you influence future response. In addition, surgeon stereotype probably
affects us. We are taught to be bold and not focus on our feelings but to push
ahead in spite of the potential for a complication. So we then block out our
ability to accept we have a boundary until maybe it is too late and that
episode overshadows our future care.
So
what do people do to avoid the anxiety of approaching or crossing that boundary
and be more risk taking as opposed to risk aversive. Preparation, preparation, preparation seems
to be the key. These surgeons gather the team and talk over the case. They may
call upon experts to have them weigh in on the case. They mentally walk through the case to see
where they may be at risk and develop plans to get past that potential barrier
to success.
Dr.
Moulton relayed to me that ultimately we have to find a way to help manage
people at the extremes- that is the person who is anxious about even the most
minimal risk or the person who has no recognition that they have a comfort zone
whatsoever. How do we teach experienced surgeons and trainees to recognize
their boundaries and how to prepare themselves for the potential for risk
taking? That is the ultimate question that the Toronto group is working
towards.
Zilbert NR, Murnaghan L,
Gallinger S, Regehr G, Moulton C. Taking a chance or playing it safe: reframing
risk assessment within the surgeon’s comfort zone. Ann Surg. 2015;
262(2):253-259.
Carol-Anne Moulton, MBBS,
Med, PhD. Hepatobiliary Surgeon University Health Network, Toronto, associate professor of Surgery at the
University of Toronto. Scientist at the Wilson Centre [TGH, University of
Toronto] conducting research on surgical judgment and the social psychology of
surgeons.
KENNETH A. LIPSHY, MD, FACS
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