Daniel Kuhn Interview: surgeons, PTSD, Stress and Comfort zones

Daniel Kuhn Interview: surgeons, PTSD, Stress and Comfort zones:
          General Surgery News recently published a piece titled “When a Stressful Event Sticks Traumatic Stress Disorders Can Plague Surgeons; Psychiatrist Describes Technique Helpful in Erasing Ill Effects “ (an interview with Daniel Kuhn, psychiatrist) http://www.generalsurgerynews.com/In-the-News/Article/10-16/When-a-Stressful-Event-Sticks/38146/ses=ogst?enl=true. The topic meshes well with other discussion I have had on physician/surgeon resiliency (http://crisislead.blogspot.com/2016/08/lessons-on-resilience-and-burnoutdr.html).
       In this editorial Dr. Kuhn, a Psychiatrist in New York city, N.Y. developed a method that reportedly can readily clear PTSD and traumatic stress in one to two sessions in most cases.  He reports that when the Yom Kippur war erupted in Israel he returned home to serve as a physician in the Israeli Army. It was in this role that he detected a pattern amongst those who suffered from mental trauma in the battlefield and consequently developed his technique which allowed the patient to erase the charge of the recording of a traumatic event.
          He realized that the negatively charged image of a traumatic experience is stuck like a splinter in one's memory and continues to interfere and even overpower the individual, dictating attitudes, emotions and actions which are derived from the reality of the traumatic experience. The individual is transfixed to and  hypnotized by the traumatic experience. It induce intrusive recollections, bad dreams, avoidant anxiety etc. which  compromise his function, judgment and wellbeing.
Dr. Kuhn describes his technique as deconditioning which erases the charge of the traumatic memory by repeating many times verbal commands or using visualization technique. It is a new paradigm for treating PTSD, that by-passes the need for medications and regular psychotherapy. It is a form of a guided self therapy. It usually produces immediate release and lasting results.
He notes that as a cellist he was looking to enhance his own (as well as other's) performance level and found out that the Kuhn Technique helps to recover, improve and sustain peak professional performance level.
               Dr. Kuhn states that he has helped numerous Surgeons who suffer from a post traumatic stress. He notes that he has treated surgeons who experienced moments of acute stress  and overwhelm while  facing life endangering situations in surgery i.e. like laceration of a major blood vessel in a laparoscopic surgery, or who reacted negatively to being invalidated, humiliated or bullied professionally during residency training.
               Surgeons face stressful conditions and unpredictability on a frequent basis. In his book Forgive and Remember, Bosk, describes the difficulties in a Surgeon’s professional life in handling failure. Essentially our patients and peers (and us) expect surgery to be a quick fix compared to medical therapy of disease. When the outcome is not perfect doubt begins to creep in. If the surgeon does not elicit help or find a solution to break the cycle, then inevitably, performance will be negatively affected. At the ACS NSQIP conference (see Oct 2016Bulletin ACS), Peter Angelos is reported as stating "healing cannot occur without actions that would be illegal in any other context. It is an intensely physical relationship." This intensity likely makes failure extremely difficult to face if one is either not equipped to do so or they are becoming less resilient. At this same conference, Julie Freischlag presented a keynote address on resilience and noted that "despite our best efforts, someone is going to return to the hospital and as a surgeon, you need to generate ways to bounce up".  Diminished resiliency inevitably results in burnout.
             Several recent studies have highlighted the risk for PTSD in Trauma Surgeons and Surgical trainees (Journal of Trauma and Acute Care Surgery 2014;77:148-154;  Surgeon 2015. pii: S1479-666X[15]00099-2). Surgical trainees have been shown to have higher rates of psychological distress than the general population (10% reported PTSD symptoms lasting more than one month). In the Journal of Trauma and Acute Care Surgery Study  40% of trauma surgeons relayed symptoms of PTSD (15% met the diagnostic criteria for PTSD). This risk was increased with the following factors:
.Male trauma surgeons operating on more than 15 cases per month
.more than seven call duties per month
.less than four hours of relaxation per day

       Back in Dec 2015 Carol-Ann Moulton and I discussed a paper their Toronto group published in the Annals of Surgery on Comfort Zones and Risk Taking in Surgery (Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg. 2015); Details of that conversation are at http://crisislead.blogspot.com/2016/10/interview-with-carol-anne-moulton.html. In our discussion of the interviews which led to their publication it appeared that even the boldest appearing surgeons probably have a 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.
                 I was fortunate to speak with Dan Kuhn about this process- why is it we have a risk of becoming too hesitant, too risk aversive, and in some cases frightened to operate as many surgeons have related?

How much a risk do Surgeons face for developing what you equate to PTSD?              
           “Most surgeons think their stress is related to a recent trauma, but in actuality it begins much earlier in life. Most of us apparently have a traumatic event early in training- a death, a difficult encounter with a mentor, colleague, training program…. A lot has to do with how we are trained- our education. Punitive drilling, like the Marine Corps, destroys your identity and can shatter you. Degradation and invalidation does not build the frame for one’s own identity. You don’t want to break your children’s spirit. You cannot traumatize them.  You cannot invalidate people into performing. “
       “Surgeons work under a considerable level of pressure and often face unpredictable crises. A Surgeon must be well informed, well trained, and must be alert and analytical at all times during surgical procedures. When faced with unpredictable emergencies like sudden uncontrolled bleeding, patient's unexpected death, operating errors or consequential malpractice suits, etc., such experiences may have a lasting traumatic impact on them, leaving them with a negative experience and conclusions that can become morbid and destructive.
  It is not always possible to shield oneself from such an exposure and when traumatized, it is quite harder to erase the effect of trauma on one's life and health. Furthermore, earlier similar experiences tend to compound the traumatic effect. After having developed chronic anxiety and significant work related stress following exposure to a single or recurrent mental trauma, some surgeons may opt for early retirement or limit their activity.
  A traumatic fixation occurs following an unexpected, overwhelming and life threatening event which impinges on one's performance and composure, i.e. accidents, injury, or high randomness and loss of mental control. At that moment the analytical mind is momentarily frozen as the neo-cortex is overpowered by the Limbic system (the reptile brain's survival mode). facing danger one can go into a hyper-focus and a fight mode, and find a solution to the danger, but another one will frozen by fear, alarmed and disconnect - being in a momentary dissociative state (confusion, disorientation and a state of discontinuity.) The highly charged image of the traumatic experience is then fixated in memory and becomes the seed of a post traumatic condition.    
           Even if a solution was found a moment later, a traumatic experience has already being lodged in one's memory and starts to impinge on the individual; the charged emotions and negative identities within that image will surface from now on in situation reminding one of s traumatic event(s), hitting the individual with a hypnotic force. It will distract  and upset the individual and interfere with his ability to function.
        The post traumatic reactions comes from the 'reptile brain' within us, from the limbic system of the brain, which reacting to a perceived danger in an attempt to protect the organism from a survival threat and a perceived danger.
         The trauma has a hypnotic effect on the individual who is in a state of trance, where his attention is divided between the present time and the past incident. The individual is engulfed and trapped in the traumatic experience like a fish in a fish ball with perception of a way out. Alcohol and psychotropic medications may have a temporary, limited symptomatic relief but do not erase the fixated experience or change the course of the condition that tends often to worsen and become chronic. In most cases psychotherapy is not able to release the trauma fixation and resolve the condition.
     An individual is more prone to develop PTSD if he operates on an unfamiliar territory, lacking a real understanding and mastery of the necessary skills or techniques necessary to solve problems. An opera singer who does not master her voice will be more anxious and prone to traumatic stress regarding her performance. A misinformed or untrained surgeon may be more susceptible to it too. Furthermore, being hungry, tired, and jetlagged or overworked while operating, or being preoccupied with other problems in life such as litigations, divorce or fear of loss of loved ones.
                In addition, similar experiences earlier in one's life are most likely to be stirred up and energize the more recent trauma, a compounding effect that makes the individual more prone to dissociate and develop a post traumatic stress disorder."

How do you know if you have this PTSD syndrome?
“when you have PTSD you know you have PTSD. You recognize you are not the same. Your personality has changed. You become reticent. You are not liking to do things you used to enjoy. You avoid them and get anxiety. Some people dissociate. It is a dissociative condition- you are overwhelmed. BUT you can take control, but that moment is forever a part of your memory. Some result to alcohol, drugs,… For example, look at musicians. They start in music because they enjoyed it. Soon something causes them to not feel enjoyment anymore. Then they start drinking.

Can you do anything?          
 “You cannot get rid of those emotions easily, but you can. You must use visualization and images to reform that memory. I use the Kuhn Technique - A Trauma Deconditioning Paradigm. I can use three questions to get to the right specific incident. You have go to the original event. It could be at a very early age and have nothing to do with surgery. It could be at age 3. You were fixated on it and now trigger the trap later on.” “The treatment aims at locating the moment of traumatic impact and then to repeat verbally repetitive commands to erase the trauma and its negative component (identities) like the angry, fearful, overwhelmed, anxious, avoidant ones.
          It is important to go first to the first traumatic incident, evoke it and then discharge it's with repetitive commands.
         There is a similarity between erasing a mental trauma and erasing a computer file by a command with the key difference being that while the information and recollection of the incident stays the negative charge around it is dissipated. The discharging experience feels similar to deflating a pressured balloon.
              There is a wide spectrum of severity in PTSD cases; many normally functioning individuals experience chronic symptoms of PTSD and are able to function while having negative symptoms of it.
         In summary The Kuhn Technique is a form of self therapy which readily produces distinct results in most cases if correctly applied. Supervision by an experienced person is strongly recommended for better results. Its benefits are lasting and no negative effects have been observed over many years of applications on many hundreds of cases. The Effectiveness of the Technique comes from the observation that repetitive commands erase the recording of charged negative experiences.  Usually it takes one to two sessions to release a condition in most cases. The technique is also very helpful before going on stage to perform or when facing stressful situations. The number of repetitive commands can shift dramatically from one condition to another, and range from very few ones to many dozens of them. A specific process ends usually with a sense of mental release; breathing become deeper and attention becomes free.

What is the trigger?
“Typically, you have a traumatic event and either you feel invalidated and humiliated or others invalidate you or humiliate you. You may deal with life threatening problems daily and handle them all well. Maybe you failed and a patient died. Maybe someone was not nice in their response to your failure. Their comments can seem innocuous to them, but to you this could be a major incident. For example, when I gave a talk, someone will blatantly be rude and argumentative. Someone can call you a charlatan.  Maybe the incident that triggered it really did not seem that significant but it triggered an early memory.“

Why are doctors at such a high risk?
“Doctors are at high risk due to their identification as a Doctor. Their identity is so rigid; they cannot allow it to be broken… like the tin-man. If you are very rigid and do not feel anything, emotionless, with no empathy, mechanical, indifferent- you are actually using a defense mechanism – a type of dissociation.
If you keep your core being and are empathetic and can be connected, you can typically respond adaptively. You have to have “beingness”. Others move to an area where they don’t have to deal with people, patients. Others avoid the emotional aspect. They don’t worry about the supratentorial aspects of patient care. “
“if you have good technique, good knowledge and are sure of it, you are protected. But if you are not sure, you are susceptible. The army can work with you to assure you are not dissociated. You must send people to battle with personal ammunition. Betrayal can have an extremely negative effect. A bad atmosphere can cause a very negative emotional response. If you sense that someone is just waiting for you to make a mistake. For whatever reason, this is traumatic. If you know someone does not like you, the sense of betrayal is always prevalent. You are overly cautious. If you are confident and have not been betrayed, it will sharpen your career.“

Are any of us beyond hope?
“no! I can work with you for 20 minutes. I handled casualties in Israel and traumatic memories in soldiers and restore their faith. I can find the trigger and eliminate the fearfulness. Whatever is scaring you, it can be erased.“

Is there any familial risk?
 “Some people are more prone than others. Some are more histrionic. That can be biological. The real question is if you can control it. “

Daniel Kuhn, M.D., Board Certified Psychiatrist, 200 West 57th Street, Suite 1205.  New York, N.Y. 10019 Phone: (212) 315-1755; Cell: (646) 645-1755 kuhncenter@gmail.com

Bosk CL. Forgive and Remember: Managing Medical Failure. 2nd ed. Chicago, IL: University of Chicago Press; 2003
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.

Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
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Stress and Comfort zones- with Dan Kuhn

Stress and Comfort zones- with Dan Kuhn

General Surgery News recently published a piece titled “When a Stressful Event Sticks Traumatic Stress Disorders Can Plague Surgeons; Psychiatrist Describes Technique Helpful in Erasing Ill Effects “ (an interview with Daniel Kuhn, psychiatrist) http://www.generalsurgerynews.com/In-the-News/Article/10-16/When-a-Stressful-Event-Sticks/38146/ses=ogst?enl=true. The topic meshes well with other discussion I have had on physician/surgeon resiliency (http://crisislead.blogspot.com/2016/08/lessons-on-resilience-and-burnoutdr.html).  In this editorial Dr. Kuhn relates that when the Yom Kippur war erupted in Israel he returned home to serve as a physician in the Israeli Army. It was in this role that he detected a pattern amongst those who suffered from PTSD. He realized that the traumatic event takes over the victims mind and they become obsessed with that event to the point that they can no longer function. Trauma is associated with anger, fear and helplessness which tighten the disruptive cycle. As a cellist he discovered performance inconsistencies so he developed a technique that disrupts that cycle. When his practice was developing he detected a pattern similar to that, in Surgeons. Surgeons tend to bury stress and fixation on error. 

Surgeons face stressful conditions and unpredictability on a frequent basis. In his book Forgive and Remember, Bosk, describes the difficulties in a Surgeon’s professional life in handling failure. Essentially our patients and peers (and us) expect surgery to be a quick fix compared to medical therapy of disease. When the outcome is not perfect doubt begins to creep in. If the surgeon does not elicit help or find a solution to break the cycle, then inevitably, performance will be negatively affected.

Several recent studies have highlighted the risk for PTSD in Trauma Surgeons and Surgical trainees (Journal of Trauma and Acute Care Surgery 2014;77:148-154;  Surgeon 2015. pii: S1479-666X[15]00099-2). surgical trainees have been shown to have higher rates of psychological distress than the general population (10% reported PTSD symptoms lasting more than one month) In the Journal of Trauma and Acute Care Surgery Study  40% of trauma surgeons relayed symptoms of PTSD (15% met the diagnostic criteria for PTSD). This risk was increased with the following factors:

·         Male trauma surgeons operating on more than 15 cases per month

·         more than seven call duties per month

·         less than four hours of relaxation per day

Back in Dec 2015 Carol-Ann Moulton and I discussed a paper their Toronto group published in the Annals of Surgery on Comfort Zones and Risk Taking in Surgery (Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg. 2015); Details of that conversation are at http://crisislead.blogspot.com/2016/10/interview-with-carol-anne-moulton.html In our discussion of the interviews which led to their publication it appeared that even the boldest appearing surgeons probably have a 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. 

I had some questions for Dr. Kuhn:

·         Surgeons are more likely to not acknowledge they are stressed, burned out or in a PTSD state. What are the key symptoms I should be relating to my comrades that indicate they have a high likelihood of having entered or on the cusp of a PTSD state?

·         If they have not quite reached that point, what is your advice to prevent their potential situation from worsening?

·         How do I approach a colleague who I think is either on the cusp of or in a PTSD state?

·         If I am diagnosed and then recover from a PTSD state, are their triggers that I will need to keep away from to avoid a relapse?

·         Without giving your secrets away could you simply describe your technique that you have perfected in dealing with this?

·         Is there a point of no return where you would look at someone and simply state that an alternate career should be a high consideration?

·         Are we genetically predisposed to obsession and PTSD? That is why do some people seem to be teflon coated and let stress run off of them?

Any familial risk?

Bosk CL. Forgive and Remember: Managing Medical Failure. 2nd ed. Chicago, IL: University of Chicago Press; 2003

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.

Kenneth A. Lipshy, MD, FACS

www.crisismanagementleadership.com

Team Organization in Trauma in an Austere Environment: Trauma and Emergency Surgery in Unusual situation

Team Organization in Trauma in an Austere Environment: Trauma and Emergency Surgery in Unusual situation
           Earlier in 2016, COL Robert B. Lim, MD, U.S. Army, edited a landmark text Surgery during natural disasters, combat, terrorist attacks, and crisis situation. I had the opportunity to chat with Dr. Lim about his text. Having been deployed numerous times into the zone of combat, I believe he can be considered an expert in this area. Several chapters peaked my interest (especially the one on unexplored ordinances), but the chapter written by Seon Jones and Gordon Wisbach on "Trauma in an Austere Environment: Trauma and Emergency Surgery in Unusual situation" interested me most due to the details provided on trauma teamwork in the combat environment. Trauma teamwork is difficult enough under normal circumstances, but just imagine managing a team in remote or hostile environments.
           In their chapter Jones and Wisbach reinforce the need for strict organization and planning. There is no room for error. They reiterate that success starts with Mass Casualty Planning and Rehearsal. After arrival to the operational area the team should discuss and rehearse the casualty plan. Preparation includes memorizing the layout of the trauma area, the facility as well as the outlying areas. Defined team positions and roles are key to avoid confusion and delays. In spite of the appearance of redundancy, prior to each incoming casualty, stating names and roles avoids confusion. Continued repetition focuses the team and reminds the team about potentially forgotten measures (PPE, civil closed loop communication). Team member names should be readily visible on each member to assure communication is clear and avoid distractions. Supplies and equipment need to be in standardized placement close to the immediate resuscitation area to avoid excess noise in asking or searching for supplies.  Each team member has an assigned checklist posted at their work station (detailed summary of those checklists noted in their chapter). The trauma team leader (TTL) should stand in a routine position where they have continued observation of the team (i.e. Foot of bed). One examiner is then on one side of the patient and the other examiner or RN on the other. Anesthesia should be at the head of the bed. Prior to patient arrival, each member needs to confirm their checklist has been reviewed. Team review should remind the team that only the TTL should be providing resuscitation instructions thereby avoiding the confusion that results from too many members instructing the team. A hierarchal structure helps to maintain the TTL's situational awareness. The TTL needs to remember to take a pause for summarization prior to and after critical steps in the resuscitation process- preintubation, post-BP stabilization- to avoid missing crucial details. The authors remind us that in spite of combat casualties occurring in austere environments, following standard clinical practice guidelines (CPG's) is vital- just because you may be remote, standard evidence-based protocols avoid conflict and improve team dynamics. Several other reminders of TTL roles are highlighted in this chapter.
              Finally the authors remind us of three vital team leadership roles- 1. watch for and control team stress and conflict 2. Be cognizant of Bruce Tuckman's revised stages of group development (forming, storming, norm ing, performing, and adjourning) to assure your team is developing appropriately 3. Morale retention and support from "compassion fatigue" is necessary to survive the arduous often primitive conditions.

I immediately had a few questions for the authors and when I met up with Gordon Wisbach at the Excelsior meeting in advance of the ACS Clinical congress he agreed to discuss these.
When you first went into action, what preconceived notions were instantly proven false?
When you arrived at a designation, was there anything that totally caught you by surprise?
Describe the most remote, austere operating environment you faced? Any take homes from that experience?
Was there any aspect of team leadership you predetermined you would be adept at but found needed improvement, or a total rehaul?
Any leadership aspect you had not considered or discounted that you found you had to learn on the fly?
When the teams form initially, do the members automatically register this concise preformed process or does the process not always work as well as you wished?
How do you quiet the room when the commotion becomes distracting? Paul Lucha ret. told me he just keeps turning his voice decibels quieter and quieter until everyone has calmed down.
If a team member attempts to take control but is clearly wrong, how do you redirect them?
Any particular lesson learned about combat care you did not expect but sticks with you today?
Have you arrived at a treatment facility and just did not have time for orientation and rehearsals?
Have you missed something that in looking back was obvious?
Did you ever receive a godsend help when you were praying for it that arrived from a source you least expected it?
When you first started, what technique worked best for you in controlling your anxiety? What about controlling another's anxiety? Or maybe you never had a situation that did not pose a threat and therefore was not anxiety provoking?
When you encounter a patient who has no chance for survival but clearly has their mental faculties totally intact what does one say to them?


Lim RB. Surgery during natural disasters, combat, terrorist attacks, and crisis situations. New York. springer. 2016.

Ronald Maier MD "Don't be mean!"

Nice Guys Finish First, NOT last!
            In the past the old adage "nice guys finished last" seemed to hold true. At the American College of Surgeons Clinical Congress 2016, during the panel discussion titled "Principles of leadership for the young surgeon", Ronald V Mair, MD (Seattle Washington) discussed "Leadership in the ACS. how to get involved and how to maintain that involvement over the years". One key leadership pointer he provided us was that "YOU CANNOT BE MEAN! " "You treat people fairly. You are honest. You speak the truth. You are not a thug or a bully."
           For those who are in doubt, an opinion in the Wall Street Journal Oct 20th 2016 titled "Nice people really do have more fun" noted that people who are noted to have nice personalities outperformed jerks 85% of the time (2003 Univ SC study quoted). Just another perception we need to adjust from time to time.

INTERVIEW WITH Carol-Anne Moulton COMFORT ZONES AND RISK TAKING IN SURGERY

             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

www.crisismanagementleadership.com

Fu interview with United Airlines Pilots regarding Pilot and Crew Training

Once again I was able to chat with two United Pilots today regarding their annual training. My questions were- do you train with the entire crew (ground crew, attendants, etc) and is the training amongst all their airlines's Pilots consistent and is the training across airlines consistent?
1. "No we never train with the flight attendants
2. "We pair up with another pilot for simulation every 9 months" "we may never have worked with the pilot we ar training with
3. "Training between different airline is not the same. We have different protocols from other airlines for handling different circumstances."
The goal of our training is to focus on errors, not to eliminate errors, but to manage them when they occur. You cannot eliminate all errors. 
"I would suggest you all get flight surgeons involved in this discussion. They can tell you how flight crews and goals and management differ between medicine and aviation.

Kenneth A Lipshy, MD, FACS
Www.crisismanagementleadership.com

“THE SOUTH CAROLINA SAFE SURGERY 2015 INITIATIVE” ADJUNCTS AND BARRIERS TO IMPLEMENTING A STATEWIDE SURGICAL SAFETY CHECKLIST FU Interview with William Berry

“THE SOUTH CAROLINA SAFE SURGERY 2015 INITIATIVE” ADJUNCTS AND BARRIERS TO IMPLEMENTING A STATEWIDE SURGICAL SAFETY CHECKLIST FU Interview with William Berry

A few months back I spoke with multiple folks responsible for the South Carolina Safety Initiative (for details see: http://crisislead.blogspot.com/2016/08/the-south-carolina-safe-surgery-2015.html)

With several years of experience in implementation of the WHO Surgical Safety project, the Harvard team lead by Atul Gawande, MD, MPH and William Berry, MD, MPA, MPH (Chief Medical Officer at Ariadne Labs) was a natural advisory component for this project.

When I began to inquire more, Dr. Gawande referred me to Dr. Berry, who was gracious to talk with me a few weeks ago about this project and his experience in surgical safety.

 How did you get involved in this project?

Dr. Berry:

I was an actively practicing cardiac surgeon and as I approached 50, I decided I wanted a change in career. That led me to become a student at the Harvard Kennedy School and after that, the Harvard School of Public Health. After graduation I started to work for CRICO – Harvard’s Malpractice Carrier and through met  Dr. Atul Gawande.  Because of that connection, when Dr. Gawande was asked by the WHO to do a project to improve surgical safety globally, he asked me if I could help.  That project led to the creation of WHO surgical safety checklist.  After the checklist project had been launched, a private foundation approached Dr. Gawande with funding and the work in South Carolina with the hospital association and the SC hospitals was begun.

 

What do you see as the major difference between the WHO surgical checklist implementation in third world countries and places like the US and UK?

Dr. Berry:

The biggest difference I think, is the baseline level of quality improvement work that has already been done in the developed world. In an sub-Saharan African country, while there may be a University/Academic Medical Center, that facility will usually not have the same resources devoted to quality improvement. Outside of the academic centers in those settings, primarily because of constrained resources, quality improvement experience is even more limited.  Again, because of resource limitations, they may not even have access to basic surgical supplies. In many countries, certain surgical safety processes like routine sponge counting are not performed.  There are many other drastic differences.  While the surgeons are often very well trained in American/European training programs, they suffer a lack of infrastructure and supplies. In some parts of the world, the availability of well-trained professions is also limited forcing surgical needs to be met with less trained providers.

Finally, while hierarchy in developed world operating rooms can pose challenges to teamwork and patient safety,  in developing world countries where the educational difference between the surgeons and other staff can be much greater, these issues can present even greater challenges.

 

The literature is wrought with reports that surgeons and anesthesiologists remain as major barriers to implementation in Surgical Safety projects. In the Harvard / Mass General Studies on implementation of the crisis checklist simulation project the attending surgeons were noticeably absent (replaced by fill-ins).   How do you get surgeons motivated to participate?

Dr. Berry:

We learned that a major challenge to doing a simulation trial with clinical team is the difficulty in getting teams to participate without compensating them for lost clinical time. Attending anesthesiologists were easier to recruit because one of the principle investigators could backfill them clinically. The similar approach could be used for nursing staff – substituting one nurse for another.   It was impossible to use that strategy with surgeons – their clinical roles are not easily backfilled. 

We have since published a paper where we were able to recruit surgeons (vascular, CVT, etc.) to participate in a team training program in part by including a 10% reduction in their malpractice premium.  Many surgeons want to be involved but we need to be creative in finding ways to make it easier – more convenient for them.  We need to find a way to use the time that is already put aside outside of the operating room – like grand rounds or departmental meetings.  This is time that is already “paid for” and can sometimes be repurposed to great effect. We have also found that trying “bite sized” training (short lunch time sessions) seems to be more successful. The feedback has been positive. Ideally, it would be great to get into every hospital surgery staff meeting but that is often logistically impossible.

For certain kinds of programs, like those that are webinar based, it can often be easier to reach the nurses and try to use them as a connector to the surgeons- if you help the nurses figure out how to effectively approach the surgeons you may have success.

 

In your experience how does your group gain the interest in participation by very busy surgeons/anesthesia providers who have a low expectation of change from these projects with high expectations of creating more inefficient processes? How do we find ways to implore these very busy surgeons to participate in these exercises and in the implementation phases? If you don’t have the surgeon’s buy in AND support, you will not have success.

Dr. Berry:

I don’t think that we are always making the right arguments to the surgeons and anesthesiologists. We need to promote better checklists use as a way for surgeons and anesthesiologists to lead the team and make care better for their patients. Many surgeons, in particular, believe that they are already doing everything that they can to provide the very best care to their patients even when there is convincing evidence that even the best can improve. To make that point to operating room teams, we designed a safety culture survey to identify the gaps in the existing OR culture prior to the implementation of the checklist. This is based on the work of two pioneers in patient safety, Dr. Marty Makary and Peter Pronovost, who have previously shown a disconnect between perceptions of team members about the level of safety and teamwork in operating rooms – with the surgeons being the most “optimistic”.  This disconnect is further magnified by the difficulty that surgeons have understanding that they are not the only critically important people in an OR.  Every team member is important and surgery cannot take place without that team.   Making matters worse, many surgeons act as if those around them can read minds – making assumptions about things that may not be true. I have found sometimes that surgeons can be convinced to support checklist use – not because it wioll necessarily help them – but because they are convinced that there are other surgeons who do need it.   When I was early in my clinical experience, I had what I called a “ need-know policy” – which translated to – “Don’t ask me so many questions about things that you don’t need to know”. I eventually realized that many times – they did need to know and that even if they didn’t, they needed to know because they were interested and so they felt more a part of the patient’s care. I then started a routine habit of beginning each case making sure everyone knew something about the patient as a person and why the surgery was so important to them.  This eventually became my “preop” briefing too.

 

What surprises you most during these projects? What was most expected?

Dr. Berry:

How hard the projects can be and how much time it can take to change practice and culture.  Before we started the work in South Carolina, I had extensive experience in quality improvement and patient safety work through IHI and CRICO – and I knew already that change was hard. But every time I am involved in work like this – I learn again that moving practice and the culture along with it – is really hard.  I think that I have also been surprised by how hard it can be to change things even with very simple tools. Simple doesn’t mean easy.

 

What has been the biggest disappointment thus far?

Dr. Berry:

The checklist is a way to help patients get better care and teams to provide that care.  It is filled things that we should do, with process checks and prompts for discussions that stand on evidence – sometimes evidence that is decades old.  That gap – between things that we know we should do – and what we actually do – needs to be closed. My greatest disappointment is in how hard it is to close that gap and get change implemented.  Getting physicians actively involved in closing these care gaps is also difficult and that is disappointing too.  That said, it is getting better. I think that we are on the right road and that the next generation may have it easier.

 

Kenneth A. Lipshy, MD, FACS

www.crisismanagementleadership.com –