Wednesday, January 10, 2024

AN INTERVIEW WITH BEN AARON, MD - THE TEAM THAT SAVED RONALD REAGAN

 AN INTERVIEW WITH BEN AARON, MD - THE TEAM THAT SAVED RONALD REAGAN

Washington DC March 30 1981, 2:27 pm:

       On March 30 1981, 2:27 pm, John Hinckley Jr shot President Ronald Reagan, White House Press Secretary James Brady, Secret Service agent Tim McCarthy and Washington D.C. police officer Thomas Delahanty using his Röhm RG-14 .22 cal blue steel revolver loaded with six "Devastator" brand cartridges (each with small aluminum and lead azide explosive charges designed to explode on contact). Hinckley fired six shots in 1.7 seconds, first hitting Jamey Brady in the head and then officer Delahanty in the neck. As Special Agent Jerry Parr pushed President Reagan into the limousine, a fourth shot hit Secret Service agent Tim McCarthy in the abdomen. The sixth bullet ricocheted off the armored side of the limousine and hit the president.

         It was initially assumed that The President was uninjured. Thinking he was uninjured, they initially planned to take the President to the White House. Until he coughed up blood, President Reagan assumed the pain in his left chest was due to rib fractures from being pushed into the limousine. Special Agent Parr thought otherwise and directed the motorcade to George Washington University Hospital. Upon arrival the President walked into the Emergency Department unassisted but immediately collapsed. At the insistence of The Physician to the President, Daniel Ruge, the ED team was instructed to treat the President as any other trauma victim. The President was in shock and the Trauma team quickly discovered a bullet entrance wound in his left axilla. Within 30 minutes, he was stabilized and transported to the Operating Room where, with the assistance of Joseph M. Giordano, Chief Thoracic Surgery Benjamin L. Aaron, performed a thoracotomy. Wikipedia

           An interview a few weeks later revealed the anxiety control methods both surgeons utilized when they realized they were operating on the President:

Giordano: ''I looked at him and I could feel myself getting tense, which has happened to me occasionally when I do surgery. When that happens, I talk myself through it. I thought, 'O.K., calm yourself. You want this to go well. Concentrate, and do everything the way you always do it, if you expect to get good results.' But I could not divorce myself from the fact that he was the President and his wound could have been lethal.''

Aaron: “He assessed the seriousness of the President's wounds, and said he too would have had ‘heightened anxiety’ if he had not judged that Mr. Reagan's bleeding could be controlled. Although Dr. Aaron described himself as someone who ''doesn't get anxious about things,'' he acknowledged that he was ''on edge at times.'' ''When I couldn't feel that bullet, and I knew it should be there, I thought it might have embolized through the pulmonary veins, into the heart and gone someplace.'' …The bullet, it turned out, was flat. ''I just couldn't feel it in that spongy lung tissue,'' Dr. Aaron said. ''The X-ray settled me down because I realized that when I was feeling for the bullet it wasn't trapped in one place. It had room to move, and it just squirted away from my fingertips.” ''Then it was just a matter of hanging in there until I could find the blooming thing by passing a catheter along the bullet track. It took about five minutes of very concentrated tactile discrimination until I suddenly pinned it down and got it out.''

 

INTERVIEW WITH BEN AARON, MD:

After Jon White revealed the heroic aspects of the team saving the Presidents life I had questions of Dr. Aaron:

1.       What leadership or crisis management experience /techniques did you discover worked well for you?

2.       What ones did you figure out quickly you had to improve upon.

3.       What preconceptions about your skill or your medical center staffs skill proved correct?

4.       What ones proved false?

5.       What lessons did you rehash with the residents and /or hospital staff in post scenario debriefings?

 

Dr. Aaron was kind to discuss this with me:

“Bear in mind that all this took place 35 years ago and that it is coming from an 83 year old brain.  Also, at the time, things were moving at a fast pace during which time there was not much time for reflection or organization, or to put it another way, much of the time we were "winging it" in dealing with the complexities imposed by the unique nature of the event. “

 

1.  Leadership or crisis management experience/techniques applied?

    The care in the ER was flawless as regards urgent processing, mobilization of staff and systematic application of appropriate care.  This was not an accident, but came about because of aggressive and thorough preparation and training of the ER staff and residents.  In order to take care of the President, James Brady and Tim McCarthy (SS), the area had to be cleared of patients, the ensuing crowd screened and managed, and assignments quickly defined.  No one consulted any manuals on procedures on techniques.  The key was preparation and training, professionally applied.

     I recall insisting, from the get-go, that everyone on my team regard the President first and foremost as a patient in trouble and to put aside any consideration of who he was or what might be swirling around beyond our perimeter of care.  This kept us focused on the task at hand and help quell nervousness.  You might call this the principle of putting first things first.  I did not note it at the time, but have been told since that as the team leader, my calm demeanor, efficiency, decisiveness and apparent lack of nervousness did much to hold things together as this event moved along. (Jon White, MD noted that this was indeed the case- Dr. Aaron maintained a calm demeanor with no yelling and no screaming, which allowed flawless communication and the ability to resuscitate the President and rapidly transport him to the OR).

 

2.  Consideration of changes or alterations.

     One can be persuaded in such a situation that having additional professional experience at the table could be helpful and perhaps diffuse responsibility should things go wrong.  I had many offers of help from fellow surgeons, but quickly put this aside in favor of a three-person team composed of me, my chief Thoracic resident and a surgical intern (just as it would be if the patient came in off the street).  This seemed to me to be the simplest route to good decision making during the operation.  This might be termed good management versus too many "cooks" calling the shots.

     Because of the remote possibility that the bullet might have transited the dome of the left diaphragm, the ER General Surgeons strongly supported an abdominal paracentesis before opening the chest to rule out injury to the spleen, etc. I had seen no evidence of this and had reservations about taking the time to do the procedure (20 minutes or so), but as the President's condition was stable at the time, I agreed to move ahead on this even though had I found a hole in the diaphragm, I could easily have dealt with the problem through the chest.  This gets down to using clinical judgment (was it safe to take the additional time) to forestall a fuss with the General Surgery group.

     Putting the President, post-op, on the ICU was a management mistake, as his presence along with all of his SS entourage and visiting staff rendered the ICU unworkable.  We quickly evacuated a wing of the hospital, tailored it to all the requisites and had the patient moved in 6 hours.  My plan for post-op care was drastically and suddenly altered but I and my team quickly adapted to the new circumstances and moved on. Being flexible, prepared for contingencies, and able to move in different directions effectively is essential to completing the mission.

 

3.  How ready were we?

     Occasionally one hears that University medicine is "sterile", impersonal, isolates a patient from compassionate care and has poor inter-staff communication.  Some of this may be true, but what University Medical centers do provide is well credentialed and experienced staff and first rate facilities.  We were prepared for this challenge at every level of staff, management and resource availability and because of this, the event came off without a significant hitch.  It was a team effort in every regard from beginning to end and a wonderful thing to be a part of.

 

4.  What plans or preparations proved false?

     We were not prepared for the security requirements by the SS.  There was a SWAT team on the roof at all times during the eleven days he was present.  When he needed good quality x-rays (there was a portable machine in his suite), the halls had to be cleared and explosive sniffing dogs preceded his visit to the x-ray floor.  His food supply was carefully guarded. Bullet proof glass was installed in his room (despite the fact that he was on the 3rd floor of an interior court with a window free wall opposite).  ALL entrants to the 3rd floor had to undergo a SS check, each and every time they entered.  Medical folk, especially doctors, are not particularly patient people by nature, so with great restraint, and resolve, we managed to work it through to a successful conclusion.  The lesson here is to practice situational awareness and be willing to accept imposed restraints, always keeping the mission as our first goal.

 

5.  Post event debriefing.

     Post mortems are standard issue for any medical event.  We had many discussions after the fact, but almost all centered about things like conduct with the intrusive press (residents and especially interns, are full of false info and quite willing to share it).  To relive and relieve tensions. we produced a high quality 30-minute documentary utilizing all the primary participants (doctors and nurses, etc) plus actors as the presidential party.  This process brought out into the open the vital parts played by each participant and highlighted the importance of the synthesis of each performance in attaining a good outcome.  On almost every count, we were satisfied with how our medical center responded to each and every challenge and this was echoed by the AMA in their commendation of our efforts.

 

I hope that this insight into how our medical center and all it's integrated parts dealt with a most unusual and unexpected event will help you develop a useful syntax for your book.  If you have additional questions, fire them my way and I will field them as best as I can.

Sincere regards, Ben Aaron, MD

 

Special thanks to Dr. Jon White, Chief Surgery VAMC Washington DC for filling in the gaps.

https://en.wikipedia.org/wiki/Attempted_assassination_of_Ronald_Reagan assessed 111316

Altman LK. THE DOCTORS WORLD. New York Times. April 21, 1981

 http://www.nytimes.com/1981/04/21/science/the-doctors-world.html assessed 111316

 

CRISIS MANAGEMENT LEADERSHIP: TRAINING TO SURVIVE THE CRITICAL MOMENT

3rd EDITION©

Kenneth A. Lipshy, MD FACS

www.crisismanagementleadership.com

Saturday, August 19, 2023

FIRESIDE CHAT WITH WAYNE MEREDITH, MD: THE FIFTEEN YEAR WAKE FOREST APPROACH TO ESTABLISHING AND MAINTAINING TEAM EFFECTIVENESS AND RESILIENCY.

FIRESIDE CHAT WITH WAYNE MEREDITH, MD: THE FIFTEEN YEAR WAKE FOREST APPROACH TO ESTABLISHING AND MAINTAINING TEAM EFFECTIVENESS AND RESILIENCY.

KENNETH A. LIPSHY, MD, FACS

On August 17, 2023. Dr Wayne Meredith*, graciously agreed to discuss the Wake Forest Baptist Health approach to establishing and maintaining Surgical Team effectiveness and resiliency, which they built over the past 15 years.

(video located at: https://youtu.be/pwiA5nVn2GM )

Dr Meredith and I have had several prior conversations concerning team effectiveness, leadership, resiliency and surgeon ownership of the surgical safety process.

We first discussed this topic after he presented his work with NASCAR on team efficiency and communication some 10-15 years ago at the annual meeting of the Southeastern Surgical Congress.

Recently, we discussed the significant challenges most large institutions face with faculty development across vast expanses of practice with markedly increasing staff dispersion. Inevitably, institutions feel forced to rely on virtual synchronous and asynchronous learning.

On August 9, 2023, after Grand Rounds, we spent an hour in conversation focused on the Wake Forest philosophy for focusing on disparities in healthcare and on the need and the challenges in providing staff tools to respond effectively to microaggressions or outright biases and racism in the workplace. That transformed into a discussion about staff effectiveness, resiliency and a multitude of other topics including:

-Wake wings team training

- Critical incident debriefing

- Identifying and working with marginalized staff

- Second Victims-moral angst

- Team Resiliency

He was very gracious in revealing his process of addressing destructive team practices, including managing team decompensation, creating good habits and understanding bad habits to address situations that can undermine teamwork.

One other area Dr Meredith brought up was his leadership style in organizational change management and decision making, including effective leadership by deconstructing the situation and removing “sides” and finally avoiding organizational distrust by always publicly supporting higher level decisions.

Dr Meredith agreed to recap that conversation on video August 17, 2023.

CREATING AND MAINTAINING STAFF EFFECTIVENESS AND RESILIENCY USING A ROUTINE CRITICAL INCIDENT DEBRIEFING:

LIPSHY:

Wayne, can you please recap our conversation last week about your critical event team discussions?

How do you manage teams that have witnessed a serious critical event and manage the team and individual mental health?

This concern has been identified by the American Society of anesthesia, American College of Surgeons, and countless other organizations as a significant cause of burnout and risk for future errors.

MEREDITH:

What we were discussing was the Wake Forest Operating Room Critical Incident Debriefing.

We have been using this venue to address individual or team concerns and distress for over a decade now. As a trauma surgeon we learned from EMS and the disaster management people, that one of the best techniques for maintaining team cohesion and building resilience in your teams to recognize when you've had a critical incident, and then to carry out a debrief on that issue. That debrief is designed to get those emotions dealt with at the time. It cannot be confused with Morbidity and Mortality conference or a Root Cause Analysis. At Wake, if anyone in the operating room, a surgeon, anesthesia, nursing staff, anybody requests a debriefing, it comes up through the well-versed channel. We find that many it's simply a matter of getting two people together then having them talk?

But sometimes something serious happens that is more global- such as unexpected death in the operating room or some serious team communication breakdown that results in disharmony or bad feelings. If that’s the case, we carry out a team critical incident debriefing. The Debrief is focused on preserving, maintaining, or creating team cohesion - it's pretty simple.

We pull the team together one morning at 6:30 before everything gets started.

We put the whole team together- all the circulators, all the scrub nurses, all the anesthesia people, all the surgeons and all the learners involved in the incident.

I usually have someone to research it - either the fellow or someone who was participating in the case just presented, that way we have some background to work with. At the debrief they go around the room starting with the person who has the least authority in the room. We start with a simple question for that person “when all that was going on, what were you feeling?” I have each of them describe what they felt. Then I make the observation- “OK, you've all told me what you saw, but none of you told me. What you felt.” I'll go back around the room one more time and at the end of that, typically I'll say “that was much better. But you told me what you thought, but you still haven't told me What you felt”.  Then people will start to get it and they'll start saying what’s on their mind. To assist, I'll give some examples such as were you feeling like you were not being listened to, or feeling like you didn't have power. Were you feeling like you're going to be fired. Did You feel like you're going to be blamed? Do you feel responsible?”

Then they go around that room and it's amazing how different everybody's feelings are.

It is almost universal from my experience in doing this that the people in the room have no idea what the surgeon is feeling or even thinking.

One of the spin-offs I've learned is when you're in one of those situations, you must communicate more about what you're thinking and what's going on right now because that can calm you and it needs to be handled then or it will spiral out of control.

I've learned that we think they're reading our mind and we're all on the same page but more often we are not. I've been working here 25 years and I've had two of these type incidents before, and they rankled me for years. It would have really helped me. I really think these are good.

Staff always come up and confer it's been pretty effective; it's been pretty useful and building theme that team unison. AND… it doesn't take much time if you don't do it for every single event.  You have to do it for the really major stuff, that’s worth the trouble for everybody.

Having said that I do prep the surgeons typically. I do a lot of espionage about the case from other people before it happens. When something like this happens, basically everybody knows and so more than one type of team member will bring it up.  I'll get the story from all these folks and ask what they think that issues are. We prepare those people ahead of time, especially anybody who hasn't ever been in one -that's new. We don't want people coming into this meeting with a sense of being threatened.

I let them know that we will do a root cause analysis of this in another area to create system catches for the areas where the Swiss cheese lined up for this case, but that we're not here for that- we're here to build team cohesion. We're here to communicate with one another. We're here to bond over a difficult situation and that that that gets them to it. It's pretty effective.

MAINTAINING A SAFETY CULTURE WITH INSTITUTIONAL PSYCHOLOGICAL SAFETY- CHALLENGES WITH FLUID STAFFING STRUCTURE:

LIPSHY

Wayne, it's obvious that your institution has adopted a real safety culture center around psychological safety, and I've talked to a few other surgical department chairs who have also managed to succeed in this.

MEREDITH

I think this is a constant battle and I think it's way harder post-pandemic. We went through years without much social interaction, without face time with our colleagues and with people.

I think we lost ground during that time, and it takes space and time to rebuild it.

We never tried to do one of these with zoom, but I suspect it's doable, but I also suspect that it's too easy to retreat from the process and observe it and not participate in it by zoom, whereas in the room there's a feeling of, caring about what each other feels that I think might be hard to get on zoom.

We do that and everybody must go through Wake Wings. Wake Wings is a crew resource management to create hierarchy flattening and communication. Everybody does that fore they can come into the operating room. We refresh that twice a year with some of it using an outside speaker and internal grand rounds. We review rules that we've changed or the rule that we think we're having trouble with. We have some really good people running that.

LIPSHY

Thanks Wayne! The Director of Anesthesia at Mercy Hospital (Dr Epperson) says that quarterly, they all meet for an hour or two of didactic and group discussions. Then they have breakout sessions where they go to an operating room where they have case based /simulations to discuss these things.

Is that something that's feasible in this institution? Can Wake Forest Baptist Health do that, given the size and the expanse of everybody in the health care system?  Or are you limited to having didactic discussions but not case-based scenario simulation?

MEREDITH

We do that in this department.

We have 13 scenarios that Jeff Carter built in his research here. He was an educator prior to getting into his fellowship and during his research year, he did an amazing volume and quality of stuff.  He and Jim Johnson built a series of simulations of fire in the operating room, blood loss in the operating room, and others. We have a room designed for doing this adjacent to our operating room. I'll have to say that anesthesia started doing this as a part of the anesthesia safety national anesthesia safety program with mannequins 25 years ago. Surgery started doing it 10 or 15 years ago and we will go through those scenarios. We have other parts of the team observe it through one-way mirrors. Then we debrief using structured debrief. Martin Avery does that now for us. Sometimes we used cadavers brought in on an ambulance where the paramedics come in and we've done a whole scenario. I can say that since we started these simulations and Wake Wings, our communications have improved.  Our Med Mal costs, and wrong site surgery retained foreign body incidents have been reduced. There are a lot of tangible benefits from doing this!   The real cost is the time, and it requires a champion that wants to do it. You can't just assign it to people you know. It requires a champion that wants to do it and knows how to do it.

They are very worthwhile.

LIPSHY:

From my conversation with staff across the nation with the given difficulty we have to maintain a stable nursing workforce, in very large organizations, it is a challenge to assure that everyone in the OR has a shared mental model. How do y'all integrate the shifting nursing workforce in the operating room and into this training and into this safety culture so they feel free and mostly obligated to speak up when y'all have these critical incident debriefings? How do you know for sure that they're speaking their mind? Do they feel like part of the team? How do you do that?

MEREDITH

Everybody takes the crew resource management – Wake Wings course. EVERYBODY! Even travelers- even sterile processing people. When we first began it, 15 years ago, we took 1400 people through this from February to July. In the end every single soul that worked in the operating room or came to it, took it. Then the time out is ingrained, and the daily process is performed the same every time. Regarding the timeouts – we are obviously constantly working on this, but those checklists serve as a great source of creating safety tools and investigating mishaps. You must keep your checklists trim, so they are doable. It’s a big deal for us to add something to it, but when we do it’s a consequence of a great deal of debate. We're not going to change to a bigger poster, or smaller print. We're going to figure out how to get this all done and this one little packet of time.

So, to answer your question, everybody who comes on does that, and then in the critical incident debriefing sessions, I've never had anyone that didn't begin to speak up. I have not seen anyone that never spoke, but remember we went through several rounds of it and the more senior people began to open up. Also remember I prep the senior people to assure there is no barrier to free thinking.

LIPSHY

One other common concern surgeons and anesthesia express is that one of the biggest issues is that in any case that lasts longer than an hour, you have multiple staff changes, including anesthesia and nursing changes within the staff. These are staff that do not originally participate in the initial timeout. How do you assure that that shared mental model that was created at the beginning of the case? If we introduce ourselves to the staff at the beginning and then we have staff that replaces that staff, how do we engrain them into the team immediately and effectively?


How do we ensure they don't come in feeling lost and uncertain and not sharing the same mental model that probably the initial team did? That way at the end of the case, everybody can speak the same language, and everybody understands what happened and communicate when these problems exist, right? To make sure that this gets communicated, that this was a particularly challenging case, and we really need to assure that a critical incident debriefing is done.


MEREDITH:
That's a problem, and it's one where people talk about how effective crew resource management training is in the airline industry. I always have the thought that everybody that forms the team when the plane takes off stays on it till it lands, right? Over the years we've created a whiteboard structure in the room. That has everybody's name and role on it and a few other key pieces of information. There's a there's a very short handoff that's done, whether it's circulated or circulator or scrub to scrub. It goes on in the back of the room. I was saying it has incomplete penetrance but our process rules are that you ask before you change. You can't start changing the circuit. It's sometime during the case when you can afford to have that break in concentration from your teammate and they always know that they don't always ask, but they often do and usually do, I guess. Obviously, all the counting goes on as part of the handoff, right? And they gotta redo the counts. That’s partly why it's important to put that in in a time in the operation, when it's OK to do that, right. We do that through the White Board, which has had several evolutions of data that's on it. Based on instances we've had where the holes in the Swiss cheese lined up that we had a communication break now and we've added it, added different things to the to the White Board.


BUILDING A SURGICAL SAFETY PROGRAM

LIPSHY

In 2016, the American College of Surgeons (ACS) and the American Academy of Orthopedic Surgeons (AAOS) hosted the first National Surgical Patient Safety Summit (NSPSS) Program. The mission of the program was to "propose solutions that effectively combine elements of safety science, principles of high reliability and best safety practices across all phases of surgical care." (Summary located at: http://crisislead.blogspot.com/2016/08/national-surgical-patient-safety-summit_8.html ). The topic frequently turned towards our constant shift in medicine to create aviation crew H.R.O. models to improve patient safety. 

After that, in 2017, LD Britt and I discussed some of the concepts that came out of this meeting.

I asked him how do we deal with the public pressure regarding the concerns that aviation has reduced fatal incidents and near misses using crew resource management but medicine had not yet seen those same results almost two decades later. Is it unrealistic to have an assumption that simple checklists and CRM training will work due to the fact that health care is substantially more complicated. Dr. Britt did not hesitate, and said we have to start somewhere and that place is to work with the CRM concepts and not focus on the differences between aviation and medicine as a reason not to improve, but as a reason to excel.

In 2015, I spoke with several members of the 2015 South Carolina Surgical Safety program regarding the inconsistency of full completion of their goals. I even contacted members of the South Carolina Hospital Executive Group to discuss this with me. Universally they revealed that failures were due to this being a surgeon driven process in sites who succeeded and an executive driven process where if failed. You have to have a surgeon and or nurse manager and other anesthesiologists. They have to band together and say enough is enough.

MEREDITH:

This is really a model that takes surgery, anesthesia and nursing to form this bond and make it happen. With other hospitals in our system approach us and saying we would like to start a Wake Wings program. The first thing we do is go find out if there's going to be sufficient surgeon champions and anesthesia champions to pull it off, and if they're not there, we don't do it and we help them fine. There would be there would be champions and then we coach those people on it and then we then they start becoming train the trainers, they take the course so then they or they take and then they take the instructor course and we spread it. But we, won't do it without champions.
We had external consultants of that, that came from life wings in Nashville. They spent several days with us. First with five critical people and then 15 critical people. Then we worked for two days with 45 or 50 thought leaders in the operating room going through the course, taking it and then going through the design process, starting with building a common mental model of what wake wings was going to be.
That still started with a little bit of a Big Bang, right?
We had lots of champions who knew understood the plan. There wasn't just one, just me or one other one person, one around selling it to 1400 people, right. We had 50 or 60 champions.
Many of them alternated and became instructors and were former first wake wing steering committee members.

It's still a lot of work to keep it maintained.

Ken, you keep saying this “culture where you have built” but I how would admonish you to think of this in terms of this culture you are trying to build. This culture you are working on. Because I don't think this is not a one and done.  I know we're not there we're not where we need to be. Where I would like to see us be but we're putting one foot in front of the other all the time and trying to work on it yeah.  

LIPSHY:

Some large institutions note that the process of having annual team training unfortunately does not produce enduring results. They recommend ongoing training.  But several consider ongoing, to mean asynchronous learning modules. I believe we know that asynchronous, 1:1 computer modules do not have lasting results and that face-to-face case-based scenario/simulation models work in the long run.

MEREDITH:

We have not figured out how to do that here at scale. we can have segments of it where we take a time that we are already have set aside for learning. Our department and orthopedics and urology have this their educational modules but it’s hard to get a multidisciplinary team free all at one time and in one place.

But having said that, those residents graduate and carry that skill with them.
My mentors used to say you're just one generation away from the Stone Age all the time.

Everybody, on Earth forgot all that. We knew we'd be back in the Stone Age immediately if this was not continuous. That's a challenge, it's going to turn out, for us to do everybody they worked in the operating room at one time. It costs us some money in terms of trainers and people that we paid to do it, but the time of people that will were there came to work that day and their job that day was to go to weaklings training for half a day was hundreds and hundreds of thousands of dollars for that one day for us to do it right.

For me, that's a big thing, for us to do.

On the other hand, I think there's a lot of payback on the other end of it.

 

LIPSHY
Well, you know that's I think your institution has recognized and you already said this once that the payback is, you know, not necessarily in terms of dollars, but you know the prevention of a patient safety incident, the ability of y'all to have a shared mental model.

HELPING THE SECOND VICTIMS:

LIPSHY

Wayne, when you become aware of a highly emotionally triggering event, does Wake Forest Have a process to help individuals process and heal?

General Surgery News recently posted a testimonial of a Surgeon who endured a tragic death of one of his patients, and his story concluded that he was left to his own accord for counseling and help. He recounted that when they published his first account, many surgeons contacted him to thank him for his honesty as the vast majority of surgeons feel as though they are on an island when such events happen. In fact, a recent LinkedIn editorial comments that many physicians constantly feel all alone.

It was the same time Balch and a couple of others wrote a paper for the college about burnout and subsequent risk for suicide, alcoholism and other things. Prior to that the ASA published a study that revealed that it rare that someone in anesthesia was given time off after witnessing an enormous critical event death on the table or something similar. Severe, irreversible neurological deficit due to something that happened and it was it was it.

I interviewed several law enforcement officers asking how does their department handle that situation and they told me that have people that will respond on the scene and talk to someone and they'll talk to the people involved and decide if they're equipped to come back to work or if they need to be reevaluated before they return to duty.

You want to be sure that when something wrong does happen, you're not losing staff in the midst of this, and staff who are distracted by something that occurred that they have no way to resolve it internally, they will eventually create another mistake that leads into my last question for you.

MEREDITH

It was eye opening to me when I realized the number of staff who are involved in that incident, who had to go to work on that case, right and you know, and just the thought that in medicine we don't really have a process and most scenarios to find a way to alleviate that person who now has been traumatized to that team.

LIPSHY

Do you have a team that comes in and works with them to get them fit for duty?

MEREDITH

We send them some to pay anonymous place.

Individually to work through that, and then they have to be signed off on to be fit for duty.

If they're still bothered by and it's way more than just a case, an operating room, workplace violence- someone that's beaten up in the office or the holding room.

It is surprising how many of those people years ago were affected. How seriously and what they need?

How much additional support they needed from the institution to get back to good to go again?

It's really you can't just seal team six your way through some of those tough things.

They're hard to do and I think that's actually true for us as surgeons as well.

We need to be mindful of when we have been put through the wringer of a case that you feel guilty about. Get it off your chest and wait.

M&M is not the answer for that, even if you confess your sins at M&M's that's not the answer You need to go through a process of describing what you're feeling more than and sorting out how to get back to resilient.

I do think it's an important skill.

For trauma surgeons in particular.

But everybody will have one, right?

I think it's very important to develop the skill set to that, elite athletes do.

If you watch some of these documentaries or talk to some of those people there, there's an ability to put aside the bad play right now and finish the game.

And then after the game… Confer with your friends and partners teammates and go over it and hate it. Feel lost from it. Feel remorse about it, then stop feeling that way.

Learn from it and go out and start getting ready for the next game.

And it's a great lesson performing athletes have to have that ability, or eventually they all gets in their head and it messes them up and they can't.

They can't do the game right and so and I've listened to lots of those.

I've read lots of books about uh people talking to.

Talking to the G.O.A.T.s is great book and he and he talks to, you know, Tom Brady, and he talks about his time with Muhammad Ali and the goats.

They all take responsibility maybe more than they should but they all take responsibility and they all go through this process of internalizing it, grieving at learning from it and then ending it and then being done with it.

that's a hard-fought skill set to learn.
And I think it takes help, right?
I mean, those guys have learned that since there were playing pop Warner, right?
They have been trying to practice dealing with loss.

They're dealing with loss that you're responsible for or dealing with injury.

Has truly elite people have been practicing the mental discipline of doing that and they have.

They have mental discipline coaches on their teams, right?

They have physical coaches on their teams and they have mental discipline coaches on their teams look at a golf pro.

If they can afford it t, that and some of them are just more psychologists, we don't.

We don't do enough that I have seen some mentoring programs written about where senior surgeons go into the operating room with another senior surgeons and they just observed them and then they tell them .. here's some tricks that I observe from watching you.

Not blaming not anything like that, but just having an external eye.

Observe what you're doing and then go over it is.

Yeah, and I get called in a lot to help other surgeons and we will almost and I will push very hard to debrief those cases with the learners and without the learners.

And I've tried to debrief on the pieces that they saw in what I was doing.

What did you learn from what I was doing and what did you learn not to do?

LIPSHY:
Well Wayne we have covered 45 minutes about a very broad range of topics

Dr. Meredith is the Richard T. Myers Professor and Chair of the Department of Surgery, Chief of Clinical Chairs and Chief of Surgery at Wake Forest Baptist Health. He graduated from Wake Forest School of Medicine in 1978. Amongst his many surgical society leadership roles, he recently served as the President American College of Surgeons from 2020 to 2021.

Kenneth A. Lipshy, MD is ACOS Surgery Salisbury VA Healthcare System (Charlotte, Salisbury, Kernersville).  Associate Professor Surgery Wake Forest University.

(Welcome to Crisis Management Leadership).

DISCLAIMER OF REPRESENTATION:

The content of this editorial represents the opinions of the authors and correspondents noted herein and does not represent the opinion of the United States Federal Government or Department of Veterans Affairs or Veterans Health Administration

 

SEE FURTHER DISCUSSIONS BELOW REGARDING OTHER INTERVIEWS WITH SURGICAL LEADERS FOUND IN “CRISIS  MANAGEMENT LEADERSHIP: Training  to Survive the Critical Moment © Sept 2021 ISBN: 978-0-578-98323-3”

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

·         http://crisislead.blogspot.com/2016/09/the-south-carolina-safe-surgery-2015.html?m=1

·         THE SOUTH CAROLINA SAFE SURGERY 2015 INITIATIVE- ADJUNCTS AND BARRIERS TO IMPLEMENTING A STATEWIDE SURGICAL SAFETY CHECKLIST (conversation with the Harvard and SCHA groups). http://crisislead.blogspot.com/2016/08/the-south-carolina-safe-surgery-2015.html

·         DISCUSSION ON ACS COMMUNITY RE. POST NSPSS INTERVIEW WITH AIRLINE PILOTS REGARDING AVIATION CREW TRAINING REQUIREMENTS. http://crisislead.blogspot.com/2016/08/discussion-on-acs-community-re-post.html

·         HOW DO WE IMPROVE PATIENT SAFETY? A LOOK AT THE ISSUES AND AN INTERVIEW WITH DR. BRITT

KENNETH A. LIPSHY, MD, FACS AND L.D. BRITT, MD, MPH, D.SC(HON), FACS, FCCM, FRCSENG(HON), FRCSED(HON), FWACS(HON), FRCSI(HON), FCS(SA)(HON), FRCSGLASG(HON)

PUBLISHED FEBRUARY 1, 2017 • PRINT-FRIENDLY

https://bulletin.facs.org/2017/02/how-do-we-improve-patient-safety-a-look-at-the-issues-and-an-interview-with-dr-britt/

CRISIS MANAGEMENT LEADERSHIP: Training to Survive the Critical Moment © Sept 2021

WHY AREN’T PATIENT SAFETY INITIATIVES WORKING UNIVERSALLY?

One major hurdle for patient safety initiative implementation has been lack of staff buy-in. Staff frequently are hindered by 'checkbox fatigue'. As a result, staff simply may go through the motions.  However, as Berg’s meta-analysis of surgical safety checklist studies concluded, implementation of checklists is more than checking off boxes.

In a review of the implementation of the World Health Organization (WHO) Checklist in the U.K., Russ and colleagues concluded successful implementation of the WHO Checklist required the following: Modification to suit the local context to ensure integration into existing programs and enhance buy-in. Education tailored to the needs of each stakeholder.  Identification of local champions to promote safety in clinical work areas. Executive leadership support. A system of accountability for “improper” behavior or noncompliance. Careful auditing.

STAFF BUY IN-Staff Buy-in is absolutely essential. Richard Karl, MD, FACS, a commercial pilot for JetSuite Irvine CA and Chairman Emeritus, Department of Surgery, University of South Florida, Tampa, stated that though medicine is far more complicated than aviation, many tools

 associated with improved air travel safety could be used for error reduction and improved outcomes in health care if implemented properly.  However, "you can't just slide a checklist under the operating room door and expect it to work," he said (personal communication July 2016).

RETHINKING TEAM CONCEPTS: Douglas Paull, MD, MS, [director,Patient Safety Curriculum and Medical Simulation National Center for Patient Safety (NCPS)] suggested (personal communication July 2016) that considering the dynamic state in which medical teams function, health care organization should introduce the Amy Edmondson's concept of the action of ”teaming.”  (Edmondson).  According to Edmondson, health care are not static groups. The members have different levels of training and competence. Furthermore, team composition is dynamic, with different members performing different responsibilities in the course of care or of a procedure.  Moreover, several leadership units are often at play in an OR, including nursing, anesthesia, and surgery.  Team training in health care, therefore, needs to account for the dynamic interactions between units or special teams. (Edmondson). As surgeons, we ultimately have responsibility for our patients’ outcome and experience. We set the tone for a safety culture.

WHO IS LEADING THE WAY? In addition to communication failures, a lack of leadership is a key driver of sentinel and adverse events. As Dr. Paull said, "Leaders set the tone for safety culture...leaders by their words and actions develop an environment that rewards people for speaking up with safety concerns."  While the captain-of-the-ship model in medicine may no longer be applicable, physicians must take the helm and steer this patient safety process. Leadership is vital to ensuring the team remains focused and on target.

The concept of "oversight of the entire process" would suggest that surgeons should be invested in the entire patient safety venture. However, surgeons frequently become disinterested in an educational program as soon as they hear it is non-technical in nature.

 In 2015, Russ and colleagues noted: that “the  most common barrier to checklist implementation, reported by 51% of the sample was active resistance or passive non-compliance from individuals on the OR team, most frequently (84%) from senior surgeons and/or anesthesiologists. This often made it challenging  for the person leading the checks (often a nurse) to complete them in the intended manner, or without feeling personally attacked.”

 Often only after something untoward occurs, do surgeons take interest.

(RUSS) Edmondson recently noted that in a prior study on the development of minimally invasive cardiac surgery (MICS) programs, the key to success hinged on how the lead surgeon viewed their stance as a member of the team. In the instances where the lead surgeon viewed themselves as part of a partnership aimed at the benefit of their team and patients, the project succeeded. These surgeons tore down the silos and ensured everyone had an equal role in the success and failure of the project. However, when the lead surgeon practiced authoritarian (top-down) leadership and simply expected everyone to execute their job as directed, the project failed. (Edmundson)

RETHINKING HRO PRINCIPLES IN HEALTHCARE:

One final area of contention is the continued use in the scientific community of James Reason’s "Swiss Cheese Model" as a model for healthcare HRO’s.

 (REASON) However, this model, which suggests that that there are stepwise processes where errors occur and are easily detected, may be too simplistic for use in health care. In complex systems such as medicine multiple cogs move simultaneously. The process that we believe we have put into check may change the second we move onto the next task.  (Cook and Rasmusen)

RELATIONSHIP OF ERRORS ON STRESS, FATIGUE, BURNOUT, ALCOHOLISM, AND SUICIDE

Balch et al. related that burnout and other measures of surgeon distress correlate directly with increasing work hours over eighty hours a week and nights on call over twice a week among American surgeons. They noted that “when physicians are in distress, their performance in delivering care can be suboptimal” which increases risk for a home-work conflict and lapse in judgment. In patient care (and especially surgery) there is always the expectation of a quick success. As Bosk reminds us in “Forgive and Remember: Managing medical Failure” the first question asked after any failure is, “what did you do wrong?” On top of that, unfortunately, most of us harbor maladaptive behavior in times of failure or significant change.

A recent American College of Surgeons survey on burnout revealed a tight relationship between causing a patient error and stress, fatigue, burnout, alcoholism, and suicidal ideation. In this survey, 8.9% reported committing a medical error within the preceding three months. The majority of these contributed this to a lapse in judgment, fatigue, lack of concentration, and other distractions. Further assessment of the responders noted that a prior medical error was independently predictive of high alcohol use and suicide ideations.

Similar findings are noted above from a recent ASA study on the effects of negative outcomes in the operating room on anesthesia providers.3

Bernstein’s group at the University of Toronto conducted a survey in 2015 assessing the mechanisms whereby residents learn to recover from a traumatic impact during their residency. The study confirms that residents are still distraught over the lack of formal mechanisms around to assist them in that recovery process. That is, the idea of helping the second victim, does not appear to be universal.  (Balogun et al). Thus, anything that reduces errors reduces distractions from the team and creates a safer environment for patients and staff.

 IMPACT OF PERIOPERATIVE CATASTROPHES- 2012 AMERICAN SOCIETY OF ANESTHESIOLOGISTS SURVEY:

84% experienced more than 1 unanticipated death or serious injury over career.

70% experienced guilt, anxiety, and reliving of the event (88% requiring time to recover emotionally & 19% never fully recovered, 12% considered a career change).

67% believed that their ability to provide patient care was compromised in the first 4 hours subsequent to the event.

Only 7% were given time off.

CONCLUSION: A perioperative catastrophe may have a profound and lasting emotional impact on the anesthesiologist involved and may affect his or her ability to provide patient care in the aftermath of such events.

 

Thursday, June 1, 2023

WHY AM I A DREAMER AND OTHERS INNOVATORS?

HOW DO SOME BECOME INNOVATORS WHILE OTHER REMAIN DREAMERS?

During her May 31st 2023 Grand Rounds talk titled “Hybrid Corn and Common duct Stones” Maggie Bosley, MD Chief Resident Wake Forest University Chief Resident was asked the following question by Kenneth A. Lipshy, MD:

What makes a person an Innovator and not just a Dreamer?

One of your slides proposes that innovators tend to arise from a successful background- well to do family, higher society level. This raises the question “What is the magical characteristic / key trait of the person who becomes a successful innovator and not just someone who dreams of change but never sees it through? You know, the trait where they consistently win with Resiliency and Grit rather Risk aversion after a failure? What makes that one kid on the field The finisher! The kid that always takes the shot? Always follows thru till the ball is in the Goal with no hesitation in spite of past failure! What makes one person risk averse due to thoughts that they have too much to lose vs the person who is resilient and able to rebound to take another shot and score a goal? What could explain the leaky pipe scenario? Where a kid in an underprivileged environment who has potential never applies to medical school and another person in a privileged environment applies and is admitted?

 

Dr. Bosley’s Response was dead on:

“More than likely it’s a nurturing healthy environment. The community / family around that person who motivates them to continue forwards. My advice is to find people who have common interests who can motivate you. The environment here locally is very supportive. Also I tend to Stay away from those who don’t support me-the negative people. As far as being an innovator, It is far easier to diffuse an idea with money than where there’s no financial benefit.”




Thursday, October 13, 2016

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.

 

Wednesday, November 4, 2020

INTEGRATION OF RESILIENCE / MINDFULNESS TRAINING INTO A DEPARTMENT OF SURGERY: Interview with Carter LeBares, MD Director UCSF Aging, Metabolism and Emotion research Center

 

INTEGRATION OF RESILIENCE / MINDFULNESS TRAINING INTO A DEPARTMENT OF SURGERY: Interview with Carter LeBares, MD Director UCSF Aging, Metabolism and Emotion research Center.

Historically, surgeons deemed themselves highly resilient and resistant to the effects of stress. Over the past decade, it has steadily been recognized that surgeons are very susceptible to the effects of fatigue including burnout. Fortunately, I have had the pleasure of discussing this concern with several surgeons who are experts in the field of burnout, resiliency and mindfulness.

Following our collaborative efforts during the 2017 ACS panel, Crisis Management in the Operating Room, Dr. Sharmila Dissanaike, MD* (Chair Dept Surgery at TTUHSC), met with me to discuss her work in mindfulness training and its importance in developing resilience to burnout. She explained to me that she had positive experiences with teaching mindfulness and helping trainees develop more secure emotional intelligence.

After a Duke University Feagin Leadership Conference, I met with LTG (Ret) Eric B. Schoomaker, MD** (Surgeon General of the US Army 2007 to 2011) to discuss his thoughts about resiliency and the benefits of mindfulness training during his tenure in his Army leadership positions. During that moment he revealed that he developed the skills of mindfulness towards the conclusion of his US Military leadership role. He said, in retrospect he felt that if he had mastered this early on, he would potentially have felt less stress during the many challenges he faced.

Previously, Deanna Chaukos (Harvard) discussed in their paper, Risk and resilience factors associated with resident burnout, that 33% of first year residents experience burnout and of that group, they exhibited lower levels of mindfulness and coping skills and higher levels of depression symptoms, fatigue, worry, and stress.***

Fortney noted that in primary care physicians even brief mindfulness training was associated with prolonged improvements in burnout, depression, anxiety, and stress in physicians.****

During the 2020 ACS Clinical congress, Dr. Carter C Lebares, MD ***** (Director Center for Aging, Metabolism and Emotion Research, Dept Surgery University of California, San Francisco, CA.) participated on a panel discussion on Surgeon Well-being. Her topic, “Mindfulness for Surgeons: promoting evidence d-based practices through culture change”, was an eye-opener for me!

Dr. LeBares previously forwarded me a paper her team wrote in 2018 (Journal American College of Surgeont). In their paper, Burnout and Stress Among US Surgery Residents: Psychological Distress and Resilience, their group assessed burnout and several psychological characteristics that can contribute to burnout vulnerability or resilience in surgical residents. They concluded that dispositional mindfulness was associated with lower risk of burnout, stress, anxiety, suicidal ideation, and depression. We both meant to get together for us to discuss her mindfulness research but unfortunately we forgot.

Since then Dr. Lebares recently shared with me several concepts her group has been working on. One interesting area is the use of Enhanced Stress-Resilience Training to reduce generalized anxiety among surgery trainees to reduce burnout, depression and potential for suicide.

Enhanced Stress-Resilience Training (ESRT), teaches surgeons mindfulness and affective regulation skills.

In another recent paper “The efficacy of mindfulness based cognitive training in surgery: additional analysis of the mindful surgeon pilot randomized trial (Labares C et al, JAMAOPEN access 2019:2(5):e194108) Dr. Labares described resilience as “a means of adaptive coping that changes perceived stress through the development of cognitive habits. Mindfulness based interventions have been shown to enhance resilience and approve affect, executive function and performance in the military, police, and athletes. Mindfulness meditation training involves the cultivation of key cognitive skills, including the moment to moment awareness of thoughts, emotions and sensations, and the conscious awareness of cognitive processes.” In this study her group has been utilizing a modified mindfulness-based stress reduction program (including classes and home practice). Their team examined the effects of mindfulness training on subject MRI’s when the subjects viewed negative images. Subjects who participated in MMBSR had a higher activation in the medial frontal gyrus, superior frontal gyrus and precuneus/posterior cingulate cortex signifying the act of emotional regulation.

WHILE LISTENING TO HER RECENT PRESENTATIONS DURING THE AMERICAN COLLEGE OF SURGEONS VIRTUAL CLINICAL CONGRESS (Oct 2020), SEVERAL QUESTIONS CAME TO MIND THAT I ASKED TO DISCUSS WITH HER ON NOVEMBER 2nd 2020:

WHAT IS MINDFULNESS?

Dr. LeBares:

Mindfulness is a set of cognitive skills that one has inherently or trained in to allow one to experience stressful events in a less reactive way.

Three skills come to play during mindfulness:

1.      Awareness training- this is the moment to moment clear perception of one’s thoughts and emotions.

2.      Emotional regulation- aka affective regulation- not getting psyched out- when we are upset/scared but have the ability to not immediately react.

3.      Metacognition-aka perspective taking- the consciousness of recognizing how you feel and how to not react to those emotions. Surgeons have all experienced stress events/crises- we have an inherent manner to remain calm and take control.

 

 

HOW DOES YOUR PROGRAM DIFFER FROM OTHER MINDFULNESS PROGRAMS? WHAT IS THE BEST WAY TO INTEGRATE A MINDFULNESS PROGRAM INTO A SURGERY PROGRAM? IE SURGEONS TEND TO REFRAIN FROM ACKNOWLEDGING THEIR STRESS LEVELS UNTIL AN INCIDENT OCCURS. HOW DOES ONE SYSTEMATICALLY INTEGRATE THIS INTO A PROGRAM THAT HAS NO CURRENT FOUNDATION? HOW DO YOU TEACH AND OLD DOG NEW TRICKS?

Dr. LeBares:

ENHANCED STRESS RESILIENCE TRAINING (ESRT) is a formal mindfulness-based stress resilience training. The theory is that this can modify the hypothalamic pituitary adrenal axis.

1.      SURGERY ORIENTED: The whole purpose of ESRT is to capitalize on excellent research on mindfulness used by high stress high performance individuals (ie Army and Marines- comprehensive soldier fitness- resilient warrior training). However, the problem with surgery residency is the minimal time to add in this training. We had to figure out how to integrate this proven training into our limited hours. We trimmed the training down to a more reasonable process that can be effective in the limited time.  Everything is geared to surgery. We use relative scenarios such as ‘Where I used this in my OR, or my personal life”. We focus on real examples and reinforcement. We really try to take advantage of mindful walking- Learning to take those minutes to take advantage of clearing your mind before you go to work. Learning how one can manage the interruptions in life more effectively and break up the stress that we face.

2.      MODULAR TRAINING: must be taught with fidelity.  We use the anatomical context ie starting with the skeleton, then muscles and then skin. You can suit this to different situations. This process allows for modification. The skin is the video, and audio references.

Each training site takes this format and then personalizes it to their institutions.

One Instructor has taught police force and military specialists.

For this to work, you need matching personalities.

 


WHAT IS THE PROCESS TO INTEGRATE ESRT INTO ANOTHER INSTITUTION?

Dr. LeBares:

Most of the course will be available remotely starting in April. We have trained Surgeons and ED MDs in military and academic institutions.

Institutions can use their instructors and teach their people. Its best to do this in small groups. Then we then identify someone locally as local instructor who is then observed.

We are currently working with Lorrie Langdale at the University of Washington and Pierre F. Saldinger, MD New York-Presbyterian Hospital


HOW LONG DOES IT TAKE TO PERFECT THESE TRAITS AND PASS ONTO OTHERS?

Dr. LeBares:

Best way would be to take the course. It takes time! And you must continue to practice and learn.

DOES ONE NEED TO CONSCIOUSLY EXERT AN EFFORT TO UTILIZE MINDFULNESS TO MINIMIZE THE NEGATIVE CONSEQUENCES OF A NEGATIVE EVENT OR ARE THESE INGRAINED AND NATURAL AND SUBCONSCIOUS?

Dr. LeBares:

At first it is very effortful, but after 6 months it is commented that they are surprised about their subconscious use of these skills. The more you practice the more it is first nature.


CAN YOU EXPLAIN THE MRI STUDY TO ME PLEASE? WHAT DOES THIS MEAN? “HIGHER ACTIVATION IN THE MEDIAL FRONTAL GYRUS, SUPERIOR FRONTAL GYRUS AND PRECUNEUS/POSTERIOR CINGULATE CORTEX SIGNIFYING THE ACT OF EMOTIONAL REGULATION.”

Dr. LeBares:

·         Activation of ventrolateral prefrontal cortex (which includes the inferior frontal gyrus) is associated with reinterpretation of the affective stimuli to alter emotional impact. Our study proves that these images are provocative regardless who the person is. Provocation was seen in both intervention and control.

·         Activation of the Dorsolateral prefrontal cortex (which includes the middle and superior frontal gurus) is associated with the functioning of the executive control hub of higher order cognition. This is the area of filtering and responding to stimuli.

·         The precuneus (which is within the posterior Cingular’s cortex) is associated with mental imagery/ Interoception, Visio spatial motor skills/ bimanual skills and self-awareness/self-reference. It is the seat in the brain for our inner awareness. It allows you to comprehend “how might I solve this problem”.

Both areas are activated during mindfulness stress reduction. 

When ESRT trained residents are shown these images, they are able to recruit these areas of the brain to engage into problem solving.


Pernkopf Anatomy: Atlas of Topographic and Applied Human Anatomy : Head and Neck (Pernkopf Anatomy, Vol 1) (English and German Edition) (German) Subsequent Edition by Werner Platzer (Editor), Harry Monsen (Translator); Urban & Schwarzenberg; Subsequent edition (August 1, 1989)


HOW DOES MINDFULNESS TRAINING RELATE TO STATE VS TRAIT ANXIETY?

Dr. LeBares:

Only looking at State Anxiety as trait anxiety would require subgroups which would take a very long period to accrue. It is likely most effective in state anxiety (as opposed to those who are under constant stress/anxiety).

In the UK, mindfulness training is the gold standard for mental illness (they call it MBCT training).


KNOWING THAT STRESS INCREASES THE RISK FOR CHRONIC DISEASES AND BURNOUT WITH POTENTIAL SUICIDAL IDEATIONS OR ALCOHOLISM, ARE YOU SEEING A REDUCTION IN THESE CONDITIONS IN TEST SUBJECTS?

Dr. LeBares:

We have shown in the recent Annals Surgery article there is a diminished depersonalization by stress. In a single cohort study (no control) there was a reduction in alcohol intake, depression, and burnout in their first year. The stress of resident training is worse in the first 8 months. In their cohort, those with the training did better but without continued training the effects were not sustained. We learned that you need to practice continued mindfulness.

The question is how? Do you have to practice daily?

Is this feasible in isolation, or is it better with a group or with a guide or moment to moment during the day? Our advice is that participants practice daily up to 15 minutes.

Informal mediation seems to be the best connective pathway.


WHAT IS THE IMPORTANCE OF
ESRT EFFECT ON GENE REGULATION (TRANSCRIPTION FACTOR ACTIVITY) > 50% REDUCTION IN THIS RESPONSE”. CAN YOU EXPLAIN THE SIGNIFICANCE OF A REDUCED PRO-INFLAMMATORY RNA EXPRESSION IN YOUR ESRT SUBJECTS COMPARED TO CONTROLS? ANY CHANCE THIS COULD RELATE TO A REDUCTION IN ARTHRITIS, LOW BACK OR CERVICAL SPINE PAIN, MIGRAINES ETC

Dr. LeBares:

Steve Kohl, a molecular geneticist, assessed a collection of genetic measures for transcription levels of inflammatory proteins. He assessed the magnitude which these effector proteins are affected. Epigenetics is a real time activity. Regardless of origin of stress, all of these stressors activate the same pattern of gene transcriptions for fight or flight syndrome, inflammatory pathway and antiviral pathways. This is part of the hypothesis as to why people who are chronically stressed are sicker, that is they have worse medical comorbidities. This molecular genetic profile fits the effects of these disease states.

This team looked at these parameters in the control group who had gene pattern dysregulation alongside of decreases in antiviral activity. This magnitude of protein increase can be found in other types of stress groups.

We found that ESRT decreased that level by 50%. Your gene expression is not subjective- it is entirely objective.


Kenneth A. Lipshy
Www.crisismanagementleadership.com

www.crisislead.blogspot.com

 


* Dr. Sharmila Dissanaike is the Professor and the Peter C. Canizaro Chair of Surgery at TTUHSC. She is the former Medical Director of the John A. Griswold Level 1 Trauma Center and the Assistant Director of the Timothy J. Harnar Burn Center at UMC. She is active in clinical surgery, with a focus on critical care, trauma and burns.
**LTG (Ret) Eric B. Schoomaker Surgeon General of The United States Army 2007 to 2011 (prior to that he was the Commander of the N. Atlantic Regional Medical Command and Walter Reed Army MC). https://crisislead.blogspot.com/2016/06/lessons-on-resiliency-in-leadership-by_7.html
***Chaukos D, Chad-Friedman E, Mehta DH, et al. Risk and resilience factors associated with resident burnout. Acad Psy- chiatry 2017;41:189-194.
Deanna Chaukos dchaukos@partners.org
****Fortney L, Luchterhand C, Zakletskaia L, Zgierska A, Rakel D. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med. 2013;11:412–420.
*****Carter Lebares- Assistant Professor of Surgery Division of General Surgery Director, UCSF Center for Mindfulness in Surgery
Lebares CC, Guvva EV, Ascher NL, O’Sullivan PS, Harris HW,  Epel ES. Burnout and Stress Among US Surgery Residents: Psychological Distress and Resilience. J Am Coll Surg 2018;226:80-90.
The effect of mindfulness-based cognitive skills training on anxiety among general surgery residents during covid-19 Caitlin R Collins MD, MPH, Micaela L Rosser MD, Anya L Greenberg MBA, Carter C Lebares MD, University of California, San Francisco
A Feasibility trial of formal mindfulness based stress resilience training among surgery interns JAMA 2018/sur/08292018
Key factors for implementing mindfulness based burnout interventions in surgery Am J Surg 2019 in Press
Enhanced stress resilience training in surgeons: iterative adaptation and biopsychosocial effects in 2 small randomized trials. Annals Surgery In press 2020
Efficacy of mindfulness based cognitive training in surgery: additional analysis of the mindful surgeon pilot randomized clinical trial. JAMA 2019/05 24 2019.
Publications 
Enhanced Stress Resilience Training in Surgeons: Iterative Adaptation and Biopsychosocial Effects in 2 Small Randomized Trials.
Annals of surgery
Lebares CC, Coaston TN, Delucchi KL, Guvva EV, Shen WT, Staffaroni AM, Kramer JH, Epel ES, Hecht FM, Ascher NL, Harris HW, Cole SW
Key factors for implementing mindfulness-based burnout interventions in surgery.
American journal of surgery
Lebares CC, Guvva EV, Desai A, Herschberger A, Ascher NL, Harris HW, O'Sullivan P
Efficacy of Mindfulness-Based Cognitive Training in Surgery: Additional Analysis of the Mindful Surgeon Pilot Randomized Clinical Trial.
JAMA network open
Lebares CC, Guvva EV, Olaru M, Sugrue LP, Staffaroni AM, Delucchi KL, Kramer JH, Ascher NL, Harris HW
Feasibility of Formal Mindfulness-Based Stress-Resilience Training Among Surgery Interns: A Randomized Clinical Trial.
JAMA surgery
Lebares CC, Hershberger AO, Guvva EV, Desai A, Mitchell J, Shen W, Reilly LM, Delucchi KL, O'Sullivan PS, Ascher NL, Harris HW
Mindful Surgeon: A Pilot Feasibility and Efficacy Trial of Mindfulness-Based Stress Resilience Training in Surgery.
Burnout and gender in surgical training: A call to re-evaluate coping and dysfunction.
American journal of surgery
Lebares CC, Braun HJ, Guvva EV, Epel ES, Hecht FM
Burnout and Stress Among US Surgery Residents: Psychological Distress and Resilience.
Journal of the American College of Surgeons
Lebares CC, Guvva EV, Ascher NL, O'Sullivan PS, Harris HW, Epel ES
Burnout in US Surgery Residents: Do Year of Training and Mindfulness Matter?.