Tuesday, March 29, 2016
"Preoccupation with Failure"
Working in any Operating Room presents us with multiple potential opportunities for system failure on a daily basis. Failure to monitor and track "single event" problems will eventually accumulate and likely result in a complete systematic shutdown. At that point, someone will speak up and say "oh, that---- has been an issue for months". The Pediatric Cardiac Surgery Unit at Washington University St Louis recently published the results of their study (J Am Coll Surg Jan 2015) looking at ALL problems (big or small) occurring in the OR's during the course of the study. It was clear, eventually, how many small problems existed that were simply not tended to because everyone was simply overwhelmed with their daily workload to report or deal with these issues. Kudos to the one surgeon who decided to do something about that!! Unlike flying a plane, we simply do not have an electronic "black box" to tell us all the issues that lead to a disaster and we have to resort to more cumbersome techniques to detect these "minor" issues and track and trend their results and eventual correction. To top it off, the team proved what has been said for years about our field: "videotaping the OR environment revealed how often individuals were not paying attention, despite their impression otherwise." This attitude appeared to have occurred during critical event phases as well. Simple changes such as eliminating all distractions during these critical phases were rapidly implemented. While we certainly cannot prevent unanticipated events from developing in our institution, we can detect the multitude of potential nuisance issues from collecting in the drain trap. If left undetected or unresolved, these small problems will eventually clog the system so that when that one final unanticipated event occurs, we are unable to mitigate the event and succeed.
If we do not preoccupy the institution with all the "what if's" that could eventually accumulate to create a failure, we will fail.
If we do not preoccupy the institution with all the "what if's" that could eventually accumulate to create a failure, we will fail.
The Retrospectoscope and "The Weather Channel Special Presentation: Why Planes Crash: Sudden impact"
I was cruising the TV Menu recently and came across "The Weather Channel Special Presentation: Why Planes Crash: Sudden impact", so i got hooked. It was a presentation on several famous airline crashes over the past 40 years, where bad weather played an integral part in the events. I rapidly had two thoughts: I may never fly again and I can emphasize with the pilots who, post-mortem, are blamed for the crash. In each event the FAA sends a crew in and inevitably claim "pilot error". "The pilot should have immediately turned around, the pilot should have changed courses, the pilot should not have touched down but taken another run at the runway."... and so on.
I remembered a conversation with world renown FAA crash inspector Alan Diehl. He seems to agree that it is easy in the midst of an investigation to rapidly conclude that the pilot made a wrong choice and should have chosen an alternate action but made a mistake. I can remember many times in my career whereby the situation in the area rapidly goes sour, adrenaline flows, and either I or another MD makes a decision based on little information and goes with it, and things go right. You are now a hero. It goes wrong and you are crucified. Same with the pilots who make decisions based on what information is in front of them and things go right and they are heroes. People shake their heads and then their hands and say that they are proud of that person, but no one does that when things go wrong. So the lesson passed on by the FAA for these events were "we now teach pilots about updrafts. We teach pilots about short wet runways and the dangers of going full speed for a landing........." etc.
I am told that behind all this, there is team training that allows those in charge, the decision makers, to work with the team to get all the information they need to consider their options and work to come up with a choice of action with a proposed best outcome. Sometimes that lifesaving decision can be to ignore the tower who is telling you to keep flying the plane and not land on a river, and that type of rapid decision processing based on input from those who trust you in the room is what they need. So do we teach folks how to stop for a minute or two, discuss with those around us what we think is the best course of action to take based on the limited information we have or do we just teach them how to deal with that particular scenario- but not a global management process?
While it may be possible to teach a pilot how to deal with every possible weather danger they may face, I just do not think you can teach a Surgeon, fire-fighter or police officer how to deal w/ the multitude of dangers out there. We seem to teach folks to make a decision and there may be a 50:50 chance of surviving and if you live you are a hero. There has to be a better way to do this. There has to be a way to teach individuals and teams how to control panic, assesses the situation, come up with valid options in a few minutes and go with the plan. ALSO, we need a BLACK BOX. We need to know what people are thinking and why the make these choices in the midst of danger so we can understand their decision to forge ahead in spite of the danger we say is "obviously in front of them". I hope to touch base with Pirooz Eghtesady at Wash.U to discuss his paper on this subject.
Risk Tolerance
I recently read a book review for a book titled THE NORM CHRONICLES (yes I read the book review and not the book). It reminded me of one area that has me constantly perplexed - the concept that while it is inevitable that one will encounter a crisis situation in their practice, the common thought process I run across frequently is that these "events are rare and preparation unnecessary" or that "team training is an unnecessary disturbance to our practice".
In some series, crisis events may occur in 100 of every 10,000 cases performed in a busy hospital system, or 1 in 1000 cases (not that uncommon but not frequent enough for most surgeons to bat an eye at). It turns out that risk perception has little to do with numbers and more to do with stories, anecdotes and personal experience. The more horrendous the outcome the more that risk means to us. The odds of dying on a plane are estimated at one in one million people but we worry endlessly about that. We have a 6100 times higher risk of dying immediately after being born than dying on a plane. The more catastrophic events where we have little control seem to torture us more than events that we actually can control. You are more likely to die from complications associated with obesity than most other horrific causes but obesity rates continue to rise.
Previously, I have discussed that physicians (especially surgeons) have been shown to be quite overconfident in their self-assessment capabilities. Perhaps when we think we are always in control, we don't have any fear of a chance occurrence where we have no control. So, now I ask a favor from those out there: I am interested in anecdotal stories whereby an organized response to a totally unexpected event threatening event led to a good outcome. It is not that I am not interested in when massive city wide planning saves multiple lives after a major catastrophe, it is just that those events are planned for specifically and therefore are likely not really considered unexpected threats- that is... you planned an entire city for this. What I am looking for are events that came in out of the blue, in which the team was never prepared for, but because of prior team training or other team work concepts they survived (or if you want where the outcome was not great).
The question remains, how do you train individuals, or teams, to withstand any threatening event and not just specific scenarios. I do not believe you can unless you can get them engaged.
Kenneth A. Lipshy, MD, FACS
Risk Tolerance
I recently read a book review for a book titled THE NORM CHRONICLES (yes I read the book review and not the book). It reminded me of one area that has me constantly perplexed - the concept that while it is inevitable that one will encounter a crisis situation in their practice, the common thought process I run across frequently is that these "events are rare and preparation unnecessary" or that "team training is an unnecessary disturbance to our practice".
In some series, crisis events may occur in 100 of every 10,000 cases performed in a busy hospital system, or 1 in 1000 cases (not that uncommon but not frequent enough for most surgeons to bat an eye at). It turns out that risk perception has little to do with numbers and more to do with stories, anecdotes and personal experience. The more horrendous the outcome the more that risk means to us. The odds of dying on a plane are estimated at one in one million people but we worry endlessly about that. We have a 6100 times higher risk of dying immediately after being born than dying on a plane. The more catastrophic events where we have little control seem to torture us more than events that we actually can control. You are more likely to die from complications associated with obesity than most other horrific causes but obesity rates continue to rise.
Previously, I have discussed that physicians (especially surgeons) have been shown to be quite overconfident in their self-assessment capabilities. Perhaps when we think we are always in control, we don't have any fear of a chance occurrence where we have no control. So, now I ask a favor from those out there: I am interested in anecdotal stories whereby an organized response to a totally unexpected event threatening event led to a good outcome. It is not that I am not interested in when massive city wide planning saves multiple lives after a major catastrophe, it is just that those events are planned for specifically and therefore are likely not really considered unexpected threats- that is... you planned an entire city for this. What I am looking for are events that came in out of the blue, in which the team was never prepared for, but because of prior team training or other team work concepts they survived (or if you want where the outcome was not great).
The question remains, how do you train individuals, or teams, to withstand any threatening event and not just specific scenarios. I do not believe you can unless you can get them engaged.
Kenneth A. Lipshy, MD, FACS
Healthy Organizational Climate: Conversation with Patrick Sweeney
"A healthy organizational climate is one in which: (1) members are aware of and committed to a common, clearly articulated set of values; (2) leaders set the example by demonstrating personal behaviors consistent with those values; (3) members are...
"A healthy organizational climate is one in which:
(1) members are aware of and committed to a common, clearly articulated set of values;
(2) leaders set the example by demonstrating personal behaviors consistent with those values;
(3) members are willing and able to communicate questions and concerns to others in the organization
(4) leaders are open and responsive to concerns raised."
This may seem a little off topic, BUT ties into the importance an institution places on a bonafide culture of safety (ie not just saying that's what they want, and then they do not back up those claims with sincerity).
In the end, it is those safety nets that we rely on, and those only arise when leadership is fully supportive of that environment.
Sweeney et al Leadership in dangerous situations.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
(1) members are aware of and committed to a common, clearly articulated set of values;
(2) leaders set the example by demonstrating personal behaviors consistent with those values;
(3) members are willing and able to communicate questions and concerns to others in the organization
(4) leaders are open and responsive to concerns raised."
This may seem a little off topic, BUT ties into the importance an institution places on a bonafide culture of safety (ie not just saying that's what they want, and then they do not back up those claims with sincerity).
In the end, it is those safety nets that we rely on, and those only arise when leadership is fully supportive of that environment.
Sweeney et al Leadership in dangerous situations.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
Healthy Organizational Climate: Conversation with Patrick Sweeney
"A healthy organizational climate is one in which: (1) members are aware of and committed to a common, clearly articulated set of values; (2) leaders set the example by demonstrating personal behaviors consistent with those values; (3) members are...
"A healthy organizational climate is one in which:
(1) members are aware of and committed to a common, clearly articulated set of values;
(2) leaders set the example by demonstrating personal behaviors consistent with those values;
(3) members are willing and able to communicate questions and concerns to others in the organization
(4) leaders are open and responsive to concerns raised."
This may seem a little off topic, BUT ties into the importance an institution places on a bonafide culture of safety (ie not just saying that's what they want, and then they do not back up those claims with sincerity).
In the end, it is those safety nets that we rely on, and those only arise when leadership is fully supportive of that environment.
Sweeney et al Leadership in dangerous situations.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
(1) members are aware of and committed to a common, clearly articulated set of values;
(2) leaders set the example by demonstrating personal behaviors consistent with those values;
(3) members are willing and able to communicate questions and concerns to others in the organization
(4) leaders are open and responsive to concerns raised."
This may seem a little off topic, BUT ties into the importance an institution places on a bonafide culture of safety (ie not just saying that's what they want, and then they do not back up those claims with sincerity).
In the end, it is those safety nets that we rely on, and those only arise when leadership is fully supportive of that environment.
Sweeney et al Leadership in dangerous situations.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
"Calm Is Contagious" Lessons from Rorke Denver
"Just lead, your behavior will be mimicked & amplified"
"Calm is contagious. If you keep your head, you keep your head,"
In 14 years of training, I've never seen "calm is contagious" proven wrong. Calm is being focused on the job at hand when you need to do it at its most intense moment...
relating to staying calm when leading others on the battlefield, a lesson he learned during his last days in SEAL training.
Rorke Denver former head of basic and advanced SEAL training and author of DAMN FEW: MAKING THE MODERN DAY SEAL WARRIOR
After reading Rorke's book I talked with him about this statement he has made at many a motivational conference. Sounds pretty easy enough to me! Unfortunately in my few years progressing thru medical school, residency, fellowship, and surgery practice, I have not seen this in action. Typically the crises I have wandered into do not resemble this calm confident scenario. I have seen or been told this mantra from one Special Forces Instructor or another. We simply don't have the luxury to weed out the folks in medicine who do not have this natural ability and we have to find a way to teach what seems to be automatic or learned by example in so few in a very short period of time.
Kenneth A. Lipshy, MD, FACS
"Calm Is Contagious" Lessons from Rorke Denver
"Just lead, your behavior will be mimicked & amplified"
"Calm is contagious. If you keep your head, you keep your head,"
In 14 years of training, I've never seen "calm is contagious" proven wrong. Calm is being focused on the job at hand when you need to do it at its most intense moment...
relating to staying calm when leading others on the battlefield, a lesson he learned during his last days in SEAL training.
Rorke Denver former head of basic and advanced SEAL training and author of DAMN FEW: MAKING THE MODERN DAY SEAL WARRIOR
After reading Rorke's book I talked with him about this statement he has made at many a motivational conference. Sounds pretty easy enough to me! Unfortunately in my few years progressing thru medical school, residency, fellowship, and surgery practice, I have not seen this in action. Typically the crises I have wandered into do not resemble this calm confident scenario. I have seen or been told this mantra from one Special Forces Instructor or another. We simply don't have the luxury to weed out the folks in medicine who do not have this natural ability and we have to find a way to teach what seems to be automatic or learned by example in so few in a very short period of time.
Kenneth A. Lipshy, MD, FACS
Military Theology on Crisis Training- Conversation with Rorke Denver and Dave Grossman
I have always found that there are two predominate mindsets on training to respond to a disaster. The one I favor is the “Macgyver” Mindset: Try to improve a person's skill at responding to difficult situations by effecting generalized cognitive enhancement. The other: Train people to respond to the most likely threats they will face.
I had the opportunity to talk with Rorke Denver (former head of basic and advanced SEAL training and author of- DAMN FEW: making the modern day seal warrior) and Lt. Col Dave Grossman (Author of On Combat) last week. As I have suspected, the military response is very similar to the response in medicine regarding training for crisis intervention. That is, you should train individuals to react to the most likely events they will face. Having said that, I did get some intense pauses when I asked what is an inexperienced commander going to do, if his team encounters something they were totally unprepared for and have no prior experience to turn to. Have they had training on analyzing that situation, gathering information, developing a plan based on the information at hand and acting in a matter of seconds? It is a perplexing but not too uncommon problem. Frequently experienced providers can turn to past experience and develop a plan based on what they have seen before and hope it works. Novices hope to find that experienced provider to bail them out. Without a concrete method of sorting thru the facts presented in an organized fashion and shelling out a plan with discrete tasks, failure is a potential outcome. As Dave Grossman said, “he who plans for everything, Plans for nothing”, which I personally take as the opposite of what I believe the author meant. We can try to teach to plan for a multitude of different scenarios but inevitably we will always come across something we never dreamt of and we have to have the ability to think that thru in a calm manner and live (see my prior comment about the US Airways Flight as an example).
Kenneth A. Lipshy, MD, FACSwww.crisismanagementleadership.com
Military Theology on Crisis Training- Conversation with Rorke Denver and Dave Grossman
I have always found that there are two predominate mindsets on training to respond to a disaster. The one I favor is the “Macgyver” Mindset: Try to improve a person's skill at responding to difficult situations by effecting generalized cognitive enhancement. The other: Train people to respond to the most likely threats they will face.
I had the opportunity to talk with Rorke Denver (former head of basic and advanced SEAL training and author of- DAMN FEW: making the modern day seal warrior) and Lt. Col Dave Grossman (Author of On Combat) last week. As I have suspected, the military response is very similar to the response in medicine regarding training for crisis intervention. That is, you should train individuals to react to the most likely events they will face. Having said that, I did get some intense pauses when I asked what is an inexperienced commander going to do, if his team encounters something they were totally unprepared for and have no prior experience to turn to. Have they had training on analyzing that situation, gathering information, developing a plan based on the information at hand and acting in a matter of seconds? It is a perplexing but not too uncommon problem. Frequently experienced providers can turn to past experience and develop a plan based on what they have seen before and hope it works. Novices hope to find that experienced provider to bail them out. Without a concrete method of sorting thru the facts presented in an organized fashion and shelling out a plan with discrete tasks, failure is a potential outcome. As Dave Grossman said, “he who plans for everything, Plans for nothing”, which I personally take as the opposite of what I believe the author meant. We can try to teach to plan for a multitude of different scenarios but inevitably we will always come across something we never dreamt of and we have to have the ability to think that thru in a calm manner and live (see my prior comment about the US Airways Flight as an example).
Kenneth A. Lipshy, MD, FACSwww.crisismanagementleadership.com
"What the OR Can learn from the Cockpit" A Chat with Richard Karl
Who says that flying a plane is not at all like caring for patients? I had the opportunity to talk w/ Dr. Richard Karl (retired Chair Dept Surgery USF Tampa; founding medical director of Moffitt Cancer Center; author of the book Across the Red Line: Stories from the Surgical Life) yesterday. I specifically wanted to speak with him about the response of Captain Sullenberger and copilot Jeff Skiles on January 15 2009 when all engines died after US Airways Flight 1549 hit a flock of geese and was rapidly losing altitude. In less than three minutes, the Captain and copilot ran thru their checklists, assessed their situation and determined that the advice they received from a very shaken control tower to land at an airfield was useless. Less than 180 seconds was all they had to work as a team together and decide what option was likely to save them all. If that is not like the many similar situations I have seen in the hospital, I do not know what is. Dr. Karl is a great mentor and I hope to speak with him more on this topic.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
"What the OR Can learn from the Cockpit" A Chat with Richard Karl
Who says that flying a plane is not at all like caring for patients? I had the opportunity to talk w/ Dr. Richard Karl (retired Chair Dept Surgery USF Tampa; founding medical director of Moffitt Cancer Center; author of the book Across the Red Line: Stories from the Surgical Life) yesterday. I specifically wanted to speak with him about the response of Captain Sullenberger and copilot Jeff Skiles on January 15 2009 when all engines died after US Airways Flight 1549 hit a flock of geese and was rapidly losing altitude. In less than three minutes, the Captain and copilot ran thru their checklists, assessed their situation and determined that the advice they received from a very shaken control tower to land at an airfield was useless. Less than 180 seconds was all they had to work as a team together and decide what option was likely to save them all. If that is not like the many similar situations I have seen in the hospital, I do not know what is. Dr. Karl is a great mentor and I hope to speak with him more on this topic.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
Lessons from Sam Elfassy, Senior Director, Corporate Safety- Air Canada.
This past Summer I was fortunate to have been invited to participate at the North York Medical Center medical Staff Leadership conference. The general theme was all about risk- to the patient, the team and the institution. The first talk was on Canadian healthcare privacy and security concerns in the global electronic healthcare era. The next was an excellent talk by chief of aviation safety at Canadian airways on integration of their Safety Management Systems in many high-risks environments including health-care. Following that was a discussion on several methods of being proactive on team effectiveness. Just after this was a discussion of several legal risks to the institution and Canadian healthcare including the lack of jobs for graduating residents and the aging MD population. I then presented management strategies for crises that can apply to crises at the bedside, ward, hospital, or entire instruction. The final discussion tied everything together thru an institutional risk management model assessing the highest risks the entire institution faces. So as I said previously, this leadership conference covers all extremes of risk a hospital may face and would suffice as a model for others for certain.
During a break and during the meeting I had the pleasure of talking with Samuel Elfassy Senior Director, Corporate Safety, Environment & Quality at Air Canada last week.
Two interesting topics were Pilot Load shedding and Systems issues that creep up on you.
Load Shedding: Like physicians, pilots learn to offload data that seems extraneous to them in an effort to focus on what appears to be most important- like flying the plane- especially when a crisis develops. This can be good and bad depending on what data they are choosing to ignore. Like a surgeon, ignoring the wrong piece of input can prove to result in disaster.
When the team as a whole has a narrow field of view, we can miss very important signs of impending doom so we ought to learn how to work together to assure that while the operator cannot see everything, someone is assuring we are not missing a bad indication.
Subtle Systems issues: We discussed the fate of planes when Jack Screw maintenance routines grow lax due to approved FAA regulations. As the TSA report on the 2000 crash of Alaskan Airways flight into the Pacific Ocean revealed, just because nothing has gone wrong, does not necessarily mean policy that has been in place for a good reason should be changed.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
Lessons from Sam Elfassy, Senior Director, Corporate Safety- Air Canada.
This past Summer I was fortunate to have been invited to participate at the North York Medical Center medical Staff Leadership conference. The general theme was all about risk- to the patient, the team and the institution. The first talk was on Canadian healthcare privacy and security concerns in the global electronic healthcare era. The next was an excellent talk by chief of aviation safety at Canadian airways on integration of their Safety Management Systems in many high-risks environments including health-care. Following that was a discussion on several methods of being proactive on team effectiveness. Just after this was a discussion of several legal risks to the institution and Canadian healthcare including the lack of jobs for graduating residents and the aging MD population. I then presented management strategies for crises that can apply to crises at the bedside, ward, hospital, or entire instruction. The final discussion tied everything together thru an institutional risk management model assessing the highest risks the entire institution faces. So as I said previously, this leadership conference covers all extremes of risk a hospital may face and would suffice as a model for others for certain.
During a break and during the meeting I had the pleasure of talking with Samuel Elfassy Senior Director, Corporate Safety, Environment & Quality at Air Canada last week.
Two interesting topics were Pilot Load shedding and Systems issues that creep up on you.
Load Shedding: Like physicians, pilots learn to offload data that seems extraneous to them in an effort to focus on what appears to be most important- like flying the plane- especially when a crisis develops. This can be good and bad depending on what data they are choosing to ignore. Like a surgeon, ignoring the wrong piece of input can prove to result in disaster.
When the team as a whole has a narrow field of view, we can miss very important signs of impending doom so we ought to learn how to work together to assure that while the operator cannot see everything, someone is assuring we are not missing a bad indication.
Subtle Systems issues: We discussed the fate of planes when Jack Screw maintenance routines grow lax due to approved FAA regulations. As the TSA report on the 2000 crash of Alaskan Airways flight into the Pacific Ocean revealed, just because nothing has gone wrong, does not necessarily mean policy that has been in place for a good reason should be changed.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
West Point Leadership Authors (REPOSTED TO GENERATE INTEREST FOR NEXT YEARS APDS)
I have had the opportunity to speak to Mike Matthews, Patrick Sweeney (West Point Psychology and authors of Leadership in dangerous situations) and Tom Kolditz (Author of In Extremis Leadership and developer of the WestPoint Leadership Program). I am slowly compiling my notes and going thru their books. One of the most interesting comments was by Tom Kolditz (author of in extremis leadership). It seems that while most teams want to work as a democracy and by committee, when everything crashes they want a leader who is authoritarian, makes decisions based on input, is competent and (most of all) a leader who they trust and will take their circumstances into consideration (ie will not throw them under the bus). So we have to have two hats when we lead: 1. in day to day business we need to be able to work by committee and get everyone's buy in 2. In a crisis- we need to be the authority, the one responsible for rapid decisions. If you read Marcus Luttrell's book Lone survivor, you see this in action when they are suddenly discovered on the mountain. In the end, their commanding office makes a decision, and even though they know it is a death sentence, do not complain any further and back up that decision.
Dan Vargo: Nice summary of what and how we lead. Good topic for an APDS discussion for teaching leadership.
KL: I was thinking the same thing! I have not been to any prior meetings so not sure if similar leadership topics have been covered or not. As surgeons we simply have to be able to flow into the bureaucratic type for every day business (we have to get things done by committee) but that won't work during a crisis and we have to teach staff to be able to adapt and make decisions on the fly (ie how to do that). I have found that while you can take bits and pieces of leadership information from aviation, police, fire service, Coast Guard and the rest of the military, medicine just does not fit any particular mold (unless you take into account the events of the US Airways flight 1549 in 2009. Now that sounded like a scene from an OR catastrophe.
Fluid Intelligence: Are we already doomed by the time we finish Surgery Residency?
Regarding the concept of Fluid Intelligence: I recently conversed with Randall Engle who is a pioneer in this area. It appears that our fluid intelligence plateaus at age 22 and drops precipitously at age 42. My comment to him was that by the time we finish an undergraduate degree, MD and surgery residency we are already 31 years old meaning we only have a decade of intuitive problem solving ability according to his research. We discussed signs of reduced fluid intelligence and potential methods to augment that, but unlike working memory, there is not much we can do about it. I am sorting thru my notes, but the more he talks the more I realized that our quandary in medicine for responding to a novel situation as a leader, needs much further investigation.
To me this indicates that we need to provide a basic mental template to allow one to recognize a problem exists, calm themselves and after briefing the team, determining if they need to react or need more information.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
Fluid Intelligence: Are we already doomed by the time we finish Surgery Residency?
Regarding the concept of Fluid Intelligence: I recently conversed with Randall Engle who is a pioneer in this area. It appears that our fluid intelligence plateaus at age 22 and drops precipitously at age 42. My comment to him was that by the time we finish an undergraduate degree, MD and surgery residency we are already 31 years old meaning we only have a decade of intuitive problem solving ability according to his research. We discussed signs of reduced fluid intelligence and potential methods to augment that, but unlike working memory, there is not much we can do about it. I am sorting thru my notes, but the more he talks the more I realized that our quandary in medicine for responding to a novel situation as a leader, needs much further investigation.
To me this indicates that we need to provide a basic mental template to allow one to recognize a problem exists, calm themselves and after briefing the team, determining if they need to react or need more information.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
"Errors upstream and downstream to the universal protocol associated with wrong surgery events"
"Errors upstream and downstream to the universal protocol associated with wrong surgery events". The recent review of the Veterans Health Administration experience with wrong surgery by Paull et al provides much insight into the persistent problem faced nationally with adverse events. The premise of the study was that “the Universal Protocol has been associated with prevention of wrong surgery procedures; however, such events still occur”. In their study, of 308 RCA reports of wrong surgery events, 48 (16%) would have occurred despite adherence to the universal Protocol and a well-performed time out. Their conclusion was that “future prevention of wrong surgery events will require diligence upstream and downstream from the UP, the participation and communication between multiple stakeholders, and application of new technologies and procedures”. Paull DE, et al Am Jnl Surgery July 2015
Following the announcement of this publication we held a discussion with several spine surgeons on this very topic. They relayed to me that the natural assumption today is that when wrong level spine surgery events occur, there was willful violation of known precautions. They reiterated that, in fact, this does not seem to be the case in most instances at this point in time. Their opinion is that by now, in most cases, the universal protocol was likely followed and fixed intraoperative markers were used. In the majority of cases it appears that one or more of the circumstances were likely contributing factors (see below).
The group’s recommendations were fairly straight-forwards:
A. Education to assure everyone is aware that in spite of following protocols, mistakes are still possible due to:
1. Distraction, Fatigue
2. Routineness of procedure: Complacency
3. Communication problems including handoff
4. Equipment or Staff problems during localization.
5. Patient characteristics: body habitus, spinal deformities, vertebral morphological variant.
6. Confirmation Bias: accepting of Inadequate views due to positioning in lieu of alternate / additional imaging or secondary confirmation with additional expert
B. Recommendation that:
1. Repeat localization images if the incision is changed, the patient is moved or the retractors are moved.
2. Assure preoperative and intraoperative images are visible to ALL team members.
3. Routine use of second surgeon / Radiologist who assesses the validity of the level in difficult cases as noted above at a minimum and if possible in all cases (need change in technology so that the radiologist can see the image and see what the surgeon sees).
4. Establish sterile cockpit and absolute concentration w/ no distractions during crucial stages.
In my conversation it was clear that creation of lengthy policies and checklists that do not pertain to a particular institution may likely create bigger problems rather than solve them. It is apparent that many surgeons have come to grips with the fact that no single solution will solve this problem. They acknowledge that utilization of team training, which includes education in human factors and communication, is one of many steps which will ultimately lead to virtual elimination of adverse events. Having said that, the majority of the surgeons conceded that longevity of this training is likely only if the institution utilizes training, policies and checklists designed to fit local needs and personalities. They felt that single episode / one-sized-fits all training is unlikely to have lasting effects as it may not touch the heart and soul of the team. In addition, they were crystal clear that institutional leadership must be aware of the upstream and downstream interferences as noted in the article by Paull et al. They expressed concerns that institutional focus on the surgical team involved in an adverse event, while ignoring systemic issues, will ultimately lead to loss of motivation and subsequent burnout. Clearly as an institution, the healthcare industry has a way to go to reach this goal, but it is a goal within our grasp.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
1. Paull DE,et al Errors upstream and downstream to the universal protocol associated with wrong surgery events in the veterans health administration. AM J Surg, 2015;210:6-13.
Following the announcement of this publication we held a discussion with several spine surgeons on this very topic. They relayed to me that the natural assumption today is that when wrong level spine surgery events occur, there was willful violation of known precautions. They reiterated that, in fact, this does not seem to be the case in most instances at this point in time. Their opinion is that by now, in most cases, the universal protocol was likely followed and fixed intraoperative markers were used. In the majority of cases it appears that one or more of the circumstances were likely contributing factors (see below).
The group’s recommendations were fairly straight-forwards:
A. Education to assure everyone is aware that in spite of following protocols, mistakes are still possible due to:
1. Distraction, Fatigue
2. Routineness of procedure: Complacency
3. Communication problems including handoff
4. Equipment or Staff problems during localization.
5. Patient characteristics: body habitus, spinal deformities, vertebral morphological variant.
6. Confirmation Bias: accepting of Inadequate views due to positioning in lieu of alternate / additional imaging or secondary confirmation with additional expert
B. Recommendation that:
1. Repeat localization images if the incision is changed, the patient is moved or the retractors are moved.
2. Assure preoperative and intraoperative images are visible to ALL team members.
3. Routine use of second surgeon / Radiologist who assesses the validity of the level in difficult cases as noted above at a minimum and if possible in all cases (need change in technology so that the radiologist can see the image and see what the surgeon sees).
4. Establish sterile cockpit and absolute concentration w/ no distractions during crucial stages.
In my conversation it was clear that creation of lengthy policies and checklists that do not pertain to a particular institution may likely create bigger problems rather than solve them. It is apparent that many surgeons have come to grips with the fact that no single solution will solve this problem. They acknowledge that utilization of team training, which includes education in human factors and communication, is one of many steps which will ultimately lead to virtual elimination of adverse events. Having said that, the majority of the surgeons conceded that longevity of this training is likely only if the institution utilizes training, policies and checklists designed to fit local needs and personalities. They felt that single episode / one-sized-fits all training is unlikely to have lasting effects as it may not touch the heart and soul of the team. In addition, they were crystal clear that institutional leadership must be aware of the upstream and downstream interferences as noted in the article by Paull et al. They expressed concerns that institutional focus on the surgical team involved in an adverse event, while ignoring systemic issues, will ultimately lead to loss of motivation and subsequent burnout. Clearly as an institution, the healthcare industry has a way to go to reach this goal, but it is a goal within our grasp.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
1. Paull DE,et al Errors upstream and downstream to the universal protocol associated with wrong surgery events in the veterans health administration. AM J Surg, 2015;210:6-13.
"Errors upstream and downstream to the universal protocol associated with wrong surgery events"
"Errors upstream and downstream to the universal protocol associated with wrong surgery events". The recent review of the Veterans Health Administration experience with wrong surgery by Paull et al provides much insight into the persistent problem faced nationally with adverse events. The premise of the study was that “the Universal Protocol has been associated with prevention of wrong surgery procedures; however, such events still occur”. In their study, of 308 RCA reports of wrong surgery events, 48 (16%) would have occurred despite adherence to the universal Protocol and a well-performed time out. Their conclusion was that “future prevention of wrong surgery events will require diligence upstream and downstream from the UP, the participation and communication between multiple stakeholders, and application of new technologies and procedures”. Paull DE, et al Am Jnl Surgery July 2015
Following the announcement of this publication we held a discussion with several spine surgeons on this very topic. They relayed to me that the natural assumption today is that when wrong level spine surgery events occur, there was willful violation of known precautions. They reiterated that, in fact, this does not seem to be the case in most instances at this point in time. Their opinion is that by now, in most cases, the universal protocol was likely followed and fixed intraoperative markers were used. In the majority of cases it appears that one or more of the circumstances were likely contributing factors (see below).
The group’s recommendations were fairly straight-forwards:
A. Education to assure everyone is aware that in spite of following protocols, mistakes are still possible due to:
1. Distraction, Fatigue
2. Routineness of procedure: Complacency
3. Communication problems including handoff
4. Equipment or Staff problems during localization.
5. Patient characteristics: body habitus, spinal deformities, vertebral morphological variant.
6. Confirmation Bias: accepting of Inadequate views due to positioning in lieu of alternate / additional imaging or secondary confirmation with additional expert
B. Recommendation that:
1. Repeat localization images if the incision is changed, the patient is moved or the retractors are moved.
2. Assure preoperative and intraoperative images are visible to ALL team members.
3. Routine use of second surgeon / Radiologist who assesses the validity of the level in difficult cases as noted above at a minimum and if possible in all cases (need change in technology so that the radiologist can see the image and see what the surgeon sees).
4. Establish sterile cockpit and absolute concentration w/ no distractions during crucial stages.
In my conversation it was clear that creation of lengthy policies and checklists that do not pertain to a particular institution may likely create bigger problems rather than solve them. It is apparent that many surgeons have come to grips with the fact that no single solution will solve this problem. They acknowledge that utilization of team training, which includes education in human factors and communication, is one of many steps which will ultimately lead to virtual elimination of adverse events. Having said that, the majority of the surgeons conceded that longevity of this training is likely only if the institution utilizes training, policies and checklists designed to fit local needs and personalities. They felt that single episode / one-sized-fits all training is unlikely to have lasting effects as it may not touch the heart and soul of the team. In addition, they were crystal clear that institutional leadership must be aware of the upstream and downstream interferences as noted in the article by Paull et al. They expressed concerns that institutional focus on the surgical team involved in an adverse event, while ignoring systemic issues, will ultimately lead to loss of motivation and subsequent burnout. Clearly as an institution, the healthcare industry has a way to go to reach this goal, but it is a goal within our grasp.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
1. Paull DE,et al Errors upstream and downstream to the universal protocol associated with wrong surgery events in the veterans health administration. AM J Surg, 2015;210:6-13.
Following the announcement of this publication we held a discussion with several spine surgeons on this very topic. They relayed to me that the natural assumption today is that when wrong level spine surgery events occur, there was willful violation of known precautions. They reiterated that, in fact, this does not seem to be the case in most instances at this point in time. Their opinion is that by now, in most cases, the universal protocol was likely followed and fixed intraoperative markers were used. In the majority of cases it appears that one or more of the circumstances were likely contributing factors (see below).
The group’s recommendations were fairly straight-forwards:
A. Education to assure everyone is aware that in spite of following protocols, mistakes are still possible due to:
1. Distraction, Fatigue
2. Routineness of procedure: Complacency
3. Communication problems including handoff
4. Equipment or Staff problems during localization.
5. Patient characteristics: body habitus, spinal deformities, vertebral morphological variant.
6. Confirmation Bias: accepting of Inadequate views due to positioning in lieu of alternate / additional imaging or secondary confirmation with additional expert
B. Recommendation that:
1. Repeat localization images if the incision is changed, the patient is moved or the retractors are moved.
2. Assure preoperative and intraoperative images are visible to ALL team members.
3. Routine use of second surgeon / Radiologist who assesses the validity of the level in difficult cases as noted above at a minimum and if possible in all cases (need change in technology so that the radiologist can see the image and see what the surgeon sees).
4. Establish sterile cockpit and absolute concentration w/ no distractions during crucial stages.
In my conversation it was clear that creation of lengthy policies and checklists that do not pertain to a particular institution may likely create bigger problems rather than solve them. It is apparent that many surgeons have come to grips with the fact that no single solution will solve this problem. They acknowledge that utilization of team training, which includes education in human factors and communication, is one of many steps which will ultimately lead to virtual elimination of adverse events. Having said that, the majority of the surgeons conceded that longevity of this training is likely only if the institution utilizes training, policies and checklists designed to fit local needs and personalities. They felt that single episode / one-sized-fits all training is unlikely to have lasting effects as it may not touch the heart and soul of the team. In addition, they were crystal clear that institutional leadership must be aware of the upstream and downstream interferences as noted in the article by Paull et al. They expressed concerns that institutional focus on the surgical team involved in an adverse event, while ignoring systemic issues, will ultimately lead to loss of motivation and subsequent burnout. Clearly as an institution, the healthcare industry has a way to go to reach this goal, but it is a goal within our grasp.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
1. Paull DE,et al Errors upstream and downstream to the universal protocol associated with wrong surgery events in the veterans health administration. AM J Surg, 2015;210:6-13.
STATE OF FLOW VS REMAINING ON-GUARD - LESSONS FROM MIHALY CSIKSZENTMIHALYI AND DANIEL KAHNEMAN
A few years back I fortunate to converse (on line) with Daniel Kahneman (author of Thinking Fast and Slow) regarding the association between our being in a vacation- relaxed mode and our increased susceptibility for mistakes. He explained to me the when we are in a happy and loose mood, our guard is down. Yes, we are more creative and intuitive, but much less vigilant and prone to error (lazy). It is during this low-threat state that we are less likely to double check challenges and solutions (the ‘how many animals did Moses take on the ark' experiment).
I happened to have the opportunity to talk on the phone with Psychologist Mihaly Csikszentmihalyi (founder and co-director of the Quality of Life Research Center) who has spent his life investigating flow or the "optimal experience" (what makes an experience genuinely satisfying; the state of consciousness called flow). It occurred to me that this is the perfect setup to being prone to error and I wanted his take on this. He did not balk. Apparently he has interviewed many in high risk environments about this particular concern: ie how can you simultaneously enjoy an experience and not die rock-climbing, jumping, skiing etc. He said it is simply like skiing; you enjoy the scenery, the terrain, your companionship, but an experienced skier, knows to be wary of the weather and the trees. “If all you think about is the scenery, you will end up in the trees.” He said that during the writing of his book Beyond Boredom and Anxiety, he interviewed surgeons to see how they continued functioning in a stressful environment but enjoyed their work. Seems that the surgeons he spoke with had a knack for being able to simultaneously think of their work as a craft but at the same time be on guard for potential mistakes. The ones capable of focusing positive energy on their success and the enjoyment they had, did well. He likened this to jumpers; as a jumper (he says) you must pay close attention to your mark, elevation etc. You become distracted for a second and it could mean death. The ones who suddenly focus on the potential fall and mistakes that could occur as they are about to perform their feat tend to have near misses, so they focus on the act of flying through the air and perfecting the landing (not the fall or hard ground). So somewhere in the midst of those successful in high risk sports or career is the inherent ability to enjoy their work and “be in the zone” but simultaneously know when potential mistakes could occur and keep an eye out for those situations.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
I happened to have the opportunity to talk on the phone with Psychologist Mihaly Csikszentmihalyi (founder and co-director of the Quality of Life Research Center) who has spent his life investigating flow or the "optimal experience" (what makes an experience genuinely satisfying; the state of consciousness called flow). It occurred to me that this is the perfect setup to being prone to error and I wanted his take on this. He did not balk. Apparently he has interviewed many in high risk environments about this particular concern: ie how can you simultaneously enjoy an experience and not die rock-climbing, jumping, skiing etc. He said it is simply like skiing; you enjoy the scenery, the terrain, your companionship, but an experienced skier, knows to be wary of the weather and the trees. “If all you think about is the scenery, you will end up in the trees.” He said that during the writing of his book Beyond Boredom and Anxiety, he interviewed surgeons to see how they continued functioning in a stressful environment but enjoyed their work. Seems that the surgeons he spoke with had a knack for being able to simultaneously think of their work as a craft but at the same time be on guard for potential mistakes. The ones capable of focusing positive energy on their success and the enjoyment they had, did well. He likened this to jumpers; as a jumper (he says) you must pay close attention to your mark, elevation etc. You become distracted for a second and it could mean death. The ones who suddenly focus on the potential fall and mistakes that could occur as they are about to perform their feat tend to have near misses, so they focus on the act of flying through the air and perfecting the landing (not the fall or hard ground). So somewhere in the midst of those successful in high risk sports or career is the inherent ability to enjoy their work and “be in the zone” but simultaneously know when potential mistakes could occur and keep an eye out for those situations.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
STATE OF FLOW VS REMAINING ON-GUARD - LESSONS FROM MIHALY CSIKSZENTMIHALYI AND DANIEL KAHNEMAN
A few years back I fortunate to converse (on line) with Daniel Kahneman (author of Thinking Fast and Slow) regarding the association between our being in a vacation- relaxed mode and our increased susceptibility for mistakes. He explained to me the when we are in a happy and loose mood, our guard is down. Yes, we are more creative and intuitive, but much less vigilant and prone to error (lazy). It is during this low-threat state that we are less likely to double check challenges and solutions (the ‘how many animals did Moses take on the ark' experiment).
I happened to have the opportunity to talk on the phone with Psychologist Mihaly Csikszentmihalyi (founder and co-director of the Quality of Life Research Center) who has spent his life investigating flow or the "optimal experience" (what makes an experience genuinely satisfying; the state of consciousness called flow). It occurred to me that this is the perfect setup to being prone to error and I wanted his take on this. He did not balk. Apparently he has interviewed many in high risk environments about this particular concern: ie how can you simultaneously enjoy an experience and not die rock-climbing, jumping, skiing etc. He said it is simply like skiing; you enjoy the scenery, the terrain, your companionship, but an experienced skier, knows to be wary of the weather and the trees. “If all you think about is the scenery, you will end up in the trees.” He said that during the writing of his book Beyond Boredom and Anxiety, he interviewed surgeons to see how they continued functioning in a stressful environment but enjoyed their work. Seems that the surgeons he spoke with had a knack for being able to simultaneously think of their work as a craft but at the same time be on guard for potential mistakes. The ones capable of focusing positive energy on their success and the enjoyment they had, did well. He likened this to jumpers; as a jumper (he says) you must pay close attention to your mark, elevation etc. You become distracted for a second and it could mean death. The ones who suddenly focus on the potential fall and mistakes that could occur as they are about to perform their feat tend to have near misses, so they focus on the act of flying through the air and perfecting the landing (not the fall or hard ground). So somewhere in the midst of those successful in high risk sports or career is the inherent ability to enjoy their work and “be in the zone” but simultaneously know when potential mistakes could occur and keep an eye out for those situations.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
I happened to have the opportunity to talk on the phone with Psychologist Mihaly Csikszentmihalyi (founder and co-director of the Quality of Life Research Center) who has spent his life investigating flow or the "optimal experience" (what makes an experience genuinely satisfying; the state of consciousness called flow). It occurred to me that this is the perfect setup to being prone to error and I wanted his take on this. He did not balk. Apparently he has interviewed many in high risk environments about this particular concern: ie how can you simultaneously enjoy an experience and not die rock-climbing, jumping, skiing etc. He said it is simply like skiing; you enjoy the scenery, the terrain, your companionship, but an experienced skier, knows to be wary of the weather and the trees. “If all you think about is the scenery, you will end up in the trees.” He said that during the writing of his book Beyond Boredom and Anxiety, he interviewed surgeons to see how they continued functioning in a stressful environment but enjoyed their work. Seems that the surgeons he spoke with had a knack for being able to simultaneously think of their work as a craft but at the same time be on guard for potential mistakes. The ones capable of focusing positive energy on their success and the enjoyment they had, did well. He likened this to jumpers; as a jumper (he says) you must pay close attention to your mark, elevation etc. You become distracted for a second and it could mean death. The ones who suddenly focus on the potential fall and mistakes that could occur as they are about to perform their feat tend to have near misses, so they focus on the act of flying through the air and perfecting the landing (not the fall or hard ground). So somewhere in the midst of those successful in high risk sports or career is the inherent ability to enjoy their work and “be in the zone” but simultaneously know when potential mistakes could occur and keep an eye out for those situations.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
Ann Wheelock Interview re.Operating Room Distractions
Over the past several decades the majority of high risk industries have investigated the effects of distraction and / or fatigue on performance. This has been most prevalent in aviation. Fatigue, burnout, and environmental stressors are underrated, under-investigated causes of human distraction in the Operating Room.
I was lucky to have had Ann Wheelock agree to talk to me today on their June 2015 paper published in the Annals of Surgery. While there have been many papers thus far that look at distractions in the OR and their negative consequences, this group micro-dissected this problem by directly observing the OR cases and then measuring staff stress levels. As most of us suspect, they witnessed about 7 distractions per case which came to approximately one every 10 minutes. Surprisingly, the most prevalent distractor was by external staff entering the OR (81% of which were un- necessary), followed by case-irrelevant conversation within the OR team (often times initiated by other surgeons). Case irrelevant conversation during “non-stressful” periods was very common and associated with poor team performance. Not too terribly surprising was that equipment related distractions created the most intense stress. While these occurred at a lower frequency (1 every 90 minutes) this created much more stress on nursing staff than previously recognized. Overall acoustic distractions (phone calls or pages) were associated with a high stress level on the surgeons and higher workload on the anesthesia team. In the end, the study highlights that even seemingly small distractions, such as misplaced cautery pedals, can create more stress than previously recognized. Dr. Wheelock confided that these studies implicate opportunities for improvements and they are working in that direction in their facility. I look forwards to further communication with their group on those efforts.
KENNETH A. LIPSHY, MD, FACS
Myth or Reality: 1. Operating Room Distractions
Over the past several decades the majority of high risk industries have investigated the effects of distraction and / or fatigue on performance. This has been most prevalent in aviation. Fatigue, burnout, and environmental stressors are underrated, under-investigated causes of human distraction in the Operating Room.
I was lucky to have had Ann Wheelock agree to talk to me today on their June 2015 paper published in the Annals of Surgery. While there have been many papers thus far that look at distractions in the OR and their negative consequences, this group micro-dissected this problem by directly observing the OR cases and then measuring staff stress levels. As most of us suspect, they witnessed about 7 distractions per case which came to approximately one every 10 minutes. Surprisingly, the most prevalent distractor was by external staff entering the OR (81% of which were un- necessary), followed by case-irrelevant conversation within the OR team (often times initiated by other surgeons). Case irrelevant conversation during “non-stressful” periods was very common and associated with poor team performance. Not too terribly surprising was that equipment related distractions created the most intense stress. While these occurred at a lower frequency (1 every 90 minutes) this created much more stress on nursing staff than previously recognized. Overall acoustic distractions (phone calls or pages) were associated with a high stress level on the surgeons and higher workload on the anesthesia team. In the end, the study highlights that even seemingly small distractions, such as misplaced cautery pedals, can create more stress than previously recognized. Dr. Wheelock confided that these studies implicate opportunities for improvements and they are working in that direction in their facility. I look forwards to further communication with their group on those efforts.
KENNETH A. LIPSHY, MD, FACS
SPEAKING UP: Are we enabling our trainees or hindering them?
Anyone familiar with Malcolm Gladwell’s Outliers or the 1990 crash of Columbia Avianca Flight 052’s has read about mitigated speech. For those who have not:
1. Mitigated speech is where we downplay or sugar coat what we say to avoid being deferential to authority or we are embarrassed.
2. The Jan 1990 crash of the 707 Avianca flight 052, involved a Columbian plane that circled the northeast for 90 minutes while they were rapidly running out of fuel and the copilot revealed their dire situation to ground control by stating: “That right to one-eight-zero on the heading and… ah… we’ll try once again… We’re running out of fuel…”
A recent paper from the Surgery Department at the University of Chicago reminded me of this today. I won’t go into detail but clearly the residents expressed the following:
1. A deep sense of overall responsibility for the outcomes of their patients when they are provided direct involvement via delegative or consultative leadership expression by the attending surgeons.
2. The importance of being able to speak up when they have a concern.
3. The dwindling sense of responsibility for the patient when they have concerns that are not heeded in some and self-blame in others if they did not go further to express their concerns.
4. Situational/environmental factors- knowing that the preoperative conference out of the operating room and away from the patient would be the most appropriate place to raise a concern, residents are reluctant to do so when they are in the operating room or at the “bedside”.
I have been known to put this to the test:
Resident: “Dr. Lipshy, the patient we have on the schedule to start the day, had diverticulitis 6 weeks ago and his pain and nausea are back and he feels today like he did back then, what do you want to do?”
Me: “I want to do the scope anyway”
Resident: “ok”
Me: “why did you say 'ok' when you knew that was the wrong decision?”
Resident: “well….. its your patient so….”
Me: “how do you know I even heard what you said or was even listening? You did not ask me to repeat back to you and this is a clear change in the situation and likely dangerous to proceed, Right?”
Resident: “yes”
Me: “so if you have concerns and I clearly did not repeat back what you said don’t assume I was listening and if it is clear I heard what you said but am proceeding down a wrong pathway, ask me why I am moving forwards if it does not make sense to you”.
So from this study we see two contradictions: Residents have a deep sense of obligation to the patient and if we appear to be doing harm and they don’t attempt to understand fully why we are making that decision or they really did not try very hard to assure we are totally comprehending the potential danger, they have much angst when things go wrong.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
Sur MD, Schindler N, Singh P, Angelos P, Langerman A. Young Surgeons on speaking up: when and how surgical trainees voice concerns about supervisors’ clinical decisions. Am Jnl Surg. 2016;211(2):437-444.
SPEAKING UP: Are we enabling our trainees or hindering them?
Anyone familiar with Malcolm Gladwell’s Outliers or the 1990 crash of Columbia Avianca Flight 052’s has read about mitigated speech. For those who have not:
1. Mitigated speech is where we downplay or sugar coat what we say to avoid being deferential to authority or we are embarrassed.
2. The Jan 1990 crash of the 707 Avianca flight 052, involved a Columbian plane that circled the northeast for 90 minutes while they were rapidly running out of fuel and the copilot revealed their dire situation to ground control by stating: “That right to one-eight-zero on the heading and… ah… we’ll try once again… We’re running out of fuel…”
A recent paper from the Surgery Department at the University of Chicago reminded me of this today. I won’t go into detail but clearly the residents expressed the following:
1. A deep sense of overall responsibility for the outcomes of their patients when they are provided direct involvement via delegative or consultative leadership expression by the attending surgeons.
2. The importance of being able to speak up when they have a concern.
3. The dwindling sense of responsibility for the patient when they have concerns that are not heeded in some and self-blame in others if they did not go further to express their concerns.
4. Situational/environmental factors- knowing that the preoperative conference out of the operating room and away from the patient would be the most appropriate place to raise a concern, residents are reluctant to do so when they are in the operating room or at the “bedside”.
I have been known to put this to the test:
Resident: “Dr. Lipshy, the patient we have on the schedule to start the day, had diverticulitis 6 weeks ago and his pain and nausea are back and he feels today like he did back then, what do you want to do?”
Me: “I want to do the scope anyway”
Resident: “ok”
Me: “why did you say 'ok' when you knew that was the wrong decision?”
Resident: “well….. its your patient so….”
Me: “how do you know I even heard what you said or was even listening? You did not ask me to repeat back to you and this is a clear change in the situation and likely dangerous to proceed, Right?”
Resident: “yes”
Me: “so if you have concerns and I clearly did not repeat back what you said don’t assume I was listening and if it is clear I heard what you said but am proceeding down a wrong pathway, ask me why I am moving forwards if it does not make sense to you”.
So from this study we see two contradictions: Residents have a deep sense of obligation to the patient and if we appear to be doing harm and they don’t attempt to understand fully why we are making that decision or they really did not try very hard to assure we are totally comprehending the potential danger, they have much angst when things go wrong.
Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com
Sur MD, Schindler N, Singh P, Angelos P, Langerman A. Young Surgeons on speaking up: when and how surgical trainees voice concerns about supervisors’ clinical decisions. Am Jnl Surg. 2016;211(2):437-444.
MYTH OR REALITY: 2. FATIGUE AND PERFORMANCE REDUCTION VS INVINCIBILITY.
A couple of weeks ago Dr. Wheelock (from the UK) was kind enough to discuss their June 2015 paper published in the Annals of Surgery regarding the negative consequences of OR distractions. It seemed befitting to discuss the recent paper and commentaries I have reviewed concerning the effects of sleep deprivation, fatigue and their effects on surgeon performance, over the past month.
In August, Dr. Carlos Pellegrini, reissued a consensus statement for the American College of Surgeons on “addressing surgeon fatigue and sleep deprivation”. Here he conceded that the evidence regarding sleep deprivation in health care is equivocal at the moment, but advised “I believe a balanced and reasonable approach is needed in addressing this issue.” In this statement he implored surgeons to partner with their Health Care enterprises to work out a viable solution based on sound judgment. He expressed to me the need to for us to be able to simultaneously assure there are surgeons available to our institutions and to provide “support for institutions and systems supporting surgeons who believe they are tired”. In addition, we discussed the fact that measuring sleep deprivation in surgeons is difficult at best due to no effective means of measuring the sleep character of surgeons who are not on call and theoretically getting a good night’s sleep (i.e. what other stressors occurred causing a restless night or fatigue).
Also in August Dr. Nancy Baxter’s group (from Toronto) published in NEJM their results of a review of procedures whereby Surgeons were at the hospital seeing patients between the hours of Midnight to 7am and subsequently performed major operations during dayshift the rest of that day, with no significant morbidity or mortality compared to surgeons doing the same operations but without working during that 7 hour window. This paper has been grossly misquoted all across the internet. Fortunately, Dr. Baxter was gracious to discuss this paper with me today (synopsis of that conversation to be noted in a minute).
The desire to compare aviation and medicine safety has been ongoing for decades and the consequences of sleep deprivation have been at the top of that list for some time. A 2000 study by Sexton and Helmreich compared the beliefs of pilots and surgeons on potential sleep deprivation and fatigue when they were asked "even when fatigued, I perform effectively during critical times." In this survey 26% of pilots agreed to this statement compared to 70% of surgeons.
In 2010 the FAA released an immediate release statement regarding pilot fatigue in response to the outcry after the crash of Colgan Air Flight 3407 on Feb 12 2009. The author of that statement explained to me that the FAA was already in the process of revising their recommendations for pilots prior to this accident (as noted by their 2008 conference on pilot fatigue), but that this pushed the issue to the forefront. The NTSB determined that Colgan Air accident was a result of the pilots’ inability to respond properly to the stall warning regarding their excessively slow speed. That report concluded that “The captain spent the night before the accident sleeping in the company crew room, where he obtained, at best, 8 hours of interrupted sleep…..” In the report, the NTSB chairperson, added that “Fatigue-impaired performance is not unlike alcohol-impaired performance…” whereby she recited lessons learned in a 2003 study in Sleep in which sleep deprived performers did worse than intoxicated performers in tasks.
One of the responses to the 2010 FAA statement was an outcry by some in the medical community for patients to be provided with informed consent when their surgeon was up all night. This includes one from the past president of the American Sleep Society, Dr. Czeisler (Nurok & Czeisler NEJM 2010) in which they quote the American Academy of Sleep Medicine’s endorsement that “model drowsy-driving legislation stipulating that the functioning of a person who has been awake for more than 22 of the previous 24 hours is impaired by sleep deprivation”. This group also quoted a 2009 study by Rothschild whereby providers who were up for 12 hour prior to operating the following day did not have significantly more complications than those who worked less than 12 hours the night before, while those who had less than 6 hours of sleep had close to twice as many complications as those who slept more than 6 hours the night before. The response to these papers varied from “Surgeons don’t get tired and patients don’t need to know if I am tired” to ”we get tired and need regulations to protect us now.” To make matters more complicated a recent study concluded that a junior resident who had been on call (associated with sleep deprivation) had reduced performance efficiency but more senior residents did not seem to be as affected by this. So what do we make of all this? Back to my conversation with Nancy Baxter today….. First of all their group concluded that “sleep loss resulting from the provision of overnight medical care did not measurably affect the short-term outcomes of elective procedures performed the next day.” Next they stated that “broad-based policy shifts in duty hours.. may not be necessary..” But most of all she clearly states that “the effect of profound sleep loss may warrant further study AND it remains important for physicians to critically assess the effects of ALL sources of fatigue…” She clearly pointed out to me that to their group the entire spectrum of issues that affect our ability to care for patients should be assessed more fully before we institute blanket policies. A surgeon who is not up performing patient care the night before may be more stressed over other issues and sleep less soundly than one who was up all night. A surgeon who was up for 6 hours prior to a day in the OR may actually find his awareness and acuity has been heightened for the first 6 hours of the day and then exhausted at the end of the day when no further patient care is required. Experienced surgeons commonly state this to be true. After this awakening conversation I would state that it is difficult at best to develop a true conviction regarding the outcomes of the available studies on sleep deprivation and its consequences. Unfortunately, it is not clear that there is a true transition from other industries to medicine. There is undoubtedly some degree of sleep deprivation that will cause decrease effectiveness in decision making and manual skills in the field of surgery, but it does not appear to be a static period of time, as it likely varies with other physical and mental factors of the physician, the type of care being provided the night prior, the type of care being provided the following day and the total length of wakefulness. Driving a car after being up all night and working all day is a boring tedious task and has been shown by several to be dangerous (at least in residents, per Tan) but doing an exciting case may actually stimulate a surgeon enough to prevent the untoward effects of sleeplessness. Whatever the answer is, it will better for everyone if we develop data and guidelines rather than others.
KENNETH A. LIPSHY, MD, FACS
MYTH OR REALITY: 2. FATIGUE AND PERFORMANCE REDUCTION VS INVINCIBILITY.
A couple of weeks ago Dr. Wheelock (from the UK) was kind enough to discuss their June 2015 paper published in the Annals of Surgery regarding the negative consequences of OR distractions. It seemed befitting to discuss the recent paper and commentaries I have reviewed concerning the effects of sleep deprivation, fatigue and their effects on surgeon performance, over the past month.
In August, Dr. Carlos Pellegrini, reissued a consensus statement for the American College of Surgeons on “addressing surgeon fatigue and sleep deprivation”. Here he conceded that the evidence regarding sleep deprivation in health care is equivocal at the moment, but advised “I believe a balanced and reasonable approach is needed in addressing this issue.” In this statement he implored surgeons to partner with their Health Care enterprises to work out a viable solution based on sound judgment. He expressed to me the need to for us to be able to simultaneously assure there are surgeons available to our institutions and to provide “support for institutions and systems supporting surgeons who believe they are tired”. In addition, we discussed the fact that measuring sleep deprivation in surgeons is difficult at best due to no effective means of measuring the sleep character of surgeons who are not on call and theoretically getting a good night’s sleep (i.e. what other stressors occurred causing a restless night or fatigue).
Also in August Dr. Nancy Baxter’s group (from Toronto) published in NEJM their results of a review of procedures whereby Surgeons were at the hospital seeing patients between the hours of Midnight to 7am and subsequently performed major operations during dayshift the rest of that day, with no significant morbidity or mortality compared to surgeons doing the same operations but without working during that 7 hour window. This paper has been grossly misquoted all across the internet. Fortunately, Dr. Baxter was gracious to discuss this paper with me today (synopsis of that conversation to be noted in a minute).
The desire to compare aviation and medicine safety has been ongoing for decades and the consequences of sleep deprivation have been at the top of that list for some time. A 2000 study by Sexton and Helmreich compared the beliefs of pilots and surgeons on potential sleep deprivation and fatigue when they were asked "even when fatigued, I perform effectively during critical times." In this survey 26% of pilots agreed to this statement compared to 70% of surgeons.
In 2010 the FAA released an immediate release statement regarding pilot fatigue in response to the outcry after the crash of Colgan Air Flight 3407 on Feb 12 2009. The author of that statement explained to me that the FAA was already in the process of revising their recommendations for pilots prior to this accident (as noted by their 2008 conference on pilot fatigue), but that this pushed the issue to the forefront. The NTSB determined that Colgan Air accident was a result of the pilots’ inability to respond properly to the stall warning regarding their excessively slow speed. That report concluded that “The captain spent the night before the accident sleeping in the company crew room, where he obtained, at best, 8 hours of interrupted sleep…..” In the report, the NTSB chairperson, added that “Fatigue-impaired performance is not unlike alcohol-impaired performance…” whereby she recited lessons learned in a 2003 study in Sleep in which sleep deprived performers did worse than intoxicated performers in tasks.
One of the responses to the 2010 FAA statement was an outcry by some in the medical community for patients to be provided with informed consent when their surgeon was up all night. This includes one from the past president of the American Sleep Society, Dr. Czeisler (Nurok & Czeisler NEJM 2010) in which they quote the American Academy of Sleep Medicine’s endorsement that “model drowsy-driving legislation stipulating that the functioning of a person who has been awake for more than 22 of the previous 24 hours is impaired by sleep deprivation”. This group also quoted a 2009 study by Rothschild whereby providers who were up for 12 hour prior to operating the following day did not have significantly more complications than those who worked less than 12 hours the night before, while those who had less than 6 hours of sleep had close to twice as many complications as those who slept more than 6 hours the night before. The response to these papers varied from “Surgeons don’t get tired and patients don’t need to know if I am tired” to ”we get tired and need regulations to protect us now.” To make matters more complicated a recent study concluded that a junior resident who had been on call (associated with sleep deprivation) had reduced performance efficiency but more senior residents did not seem to be as affected by this. So what do we make of all this? Back to my conversation with Nancy Baxter today….. First of all their group concluded that “sleep loss resulting from the provision of overnight medical care did not measurably affect the short-term outcomes of elective procedures performed the next day.” Next they stated that “broad-based policy shifts in duty hours.. may not be necessary..” But most of all she clearly states that “the effect of profound sleep loss may warrant further study AND it remains important for physicians to critically assess the effects of ALL sources of fatigue…” She clearly pointed out to me that to their group the entire spectrum of issues that affect our ability to care for patients should be assessed more fully before we institute blanket policies. A surgeon who is not up performing patient care the night before may be more stressed over other issues and sleep less soundly than one who was up all night. A surgeon who was up for 6 hours prior to a day in the OR may actually find his awareness and acuity has been heightened for the first 6 hours of the day and then exhausted at the end of the day when no further patient care is required. Experienced surgeons commonly state this to be true. After this awakening conversation I would state that it is difficult at best to develop a true conviction regarding the outcomes of the available studies on sleep deprivation and its consequences. Unfortunately, it is not clear that there is a true transition from other industries to medicine. There is undoubtedly some degree of sleep deprivation that will cause decrease effectiveness in decision making and manual skills in the field of surgery, but it does not appear to be a static period of time, as it likely varies with other physical and mental factors of the physician, the type of care being provided the night prior, the type of care being provided the following day and the total length of wakefulness. Driving a car after being up all night and working all day is a boring tedious task and has been shown by several to be dangerous (at least in residents, per Tan) but doing an exciting case may actually stimulate a surgeon enough to prevent the untoward effects of sleeplessness. Whatever the answer is, it will better for everyone if we develop data and guidelines rather than others.
KENNETH A. LIPSHY, MD, FACS
LEADERSHIP STYLES IN SURGERY THAT SERVE AS IDEAL MODELS FOR TRAINEES: DO WE EVEN COME CLOSE TO THE PIN?
There are many days when I examine my behavior during the day and ask: did I even come close to an enabling leader today or was did I act in a counterproductive manner? After, reading several papers on leadership this past month, I do not think I even come close to the pin (and maybe not on the putting green).
The group from Boston has produced yet another set of exceptional papers analyzing leadership styles in the Operating room and how these affect other individuals and the team. (1,2). Hopefully, I can review these with the authors in person, but until then this is what I took home from them:
The JASC paper assessed a range of leadership/teamsmanship styles via grading performance seen during video recording of five different surgeons comparing transactional and transformational leadership. The premise behind this study was that no prior studies assist us in understanding how one particular leadership style cultivates or inhibits specific team responses. In my observations of many surgeons, it appears that many of us tend to have a higher TRANSACTIONAL LEADERSHIP character (predominately goal or task focused with concentration more on rewards or failures) which overshadows any TRANSFORMATIONAL LEADERSHIP qualities (influenced on the collective mission and focus on inspiration and intellectual stimulation of our teammates). The question we all have had is there any detriment or attribute in displaying one style predominately over the other. In other words, does one style lead to reduced or improved safety? Does one style stymie or produce enhanced psychological safety- where our teammates feel encouraged to speak up when safety issues arise. To assess this, the Boston group used a previously described scoring system on leadership during an observation of intraoperative videos of five different surgeons.
So did this group discover anything significant we can use in our own personal growth? They noted that the surgeons with high transformational scores tended to enter the room and immediately engage all the members of the team. The sense of a collective mission became apparent at the onset. Enthusiasm and support of others reigned during the entire case. It was clear that those in the room felt comfortable asking for clarification or alerting others about safety issues. Those with lower scores showed the least amount of engagement with others even during dire circumstances. More importantly was the discovery that one type of leadership style is NOT mutually exclusive of the other, but in fact typically additive. One can be a strong transactional leader (goal oriented) but also be a strong transformational leader (engaging).
So I had to ask myself a question “for those of us who are clearly task oriented, is there any hope for us to become more team oriented?” I am sure I am not the only one out there who sees a situation as a task to be overcome and utilize our team as a set of tools to accomplish that task…OOOO I am sure that will not be viewed as politically correct. As I discussed last week, General Van Riper and I discussed the need to assure that team members actually know and understand what the objective is, during a mission or they may carry out a task either incorrectly or achieve the goal but at a cost that was not necessary. In the end that communication style will result in better morale. This study showed that you actually can be good at both and if you strive to be more translational in style, it should not negate your transactional methodologies, but will likely improve your ability to utilize the team to meet your objective.
The other Boston study I mentioned assessed leadership behavior in terms of how the leader utilizes available team members (authoritative, explanatory, consultative, and delegative). They then assessed Junior Resident preferences to see which style meshed with their inherent learning preferences. As expected, us older surgeons were typically used to authoritative (autocratic) and some explanatory (explains their decisions to the team, but makes the decision) leadership during our training. We were typically told what was going to happen and grateful when the attendings explained why. The residents clearly indicate that they prefer consultative (team is consulted for an opinion) and delegative styles (the problem is put to the group and the majority wins) intraoperatively. I personally felt we were in a win-win situation when an attending asked my opinion on an approach I would prefer when managing an isolated aortic aneurysm with no distal occlusive disease (“hey I really want to do some properitoneal aortic approaches in case we have to operate on a patient with a frozen abdomen from prior surgical adhesions”). I had knowledge of differing approaches and felt it would be good to have this in my toolbox, just in case (which in fact it did several months later) so when my opinion appeared to be important I LEARNED THAT TECHNIQUE!
But, does any of this really impact patient care? Well of course it does! Poor leadership, poor teamwork, unnecessary distractions, and a slew of other problems have been linked in multiple studies to poorer outcomes, increased stress on the team, and reduced morale. Once upon a time we could shirk our shoulders and say that we just did not have decent models that would fit in surgery or just say “well that’s easy for you to say! You don’t have to deal with the tough circumstances I have to!” but these studies are rapidly putting an end to that defense....... There are good models and while some circumstances are more stressful than others we can all adapt stress management strategies that include leadership approaches that foster teamwork, and improve morale but do not negatively impact patient care.
Hopefully, the folks that have put these fantastic papers together have time in the near future to discuss them.
Hu YY, Henrickson Parker S, Lipsitz SR, Arriga AF, Peyre SE, Corso KA, Roth EM, Yule SJ, Greenberg CC. surgeon's leadership styles and team behavior in the Operating room. JACS 2016. 22(1):41-51.
Kissable-lee NA, Yule S, Pozner CN, Smink DS. Attending surgeons' leadership style in the operating room: comparing junior residents' experiences and preferences. JSE 2016. 73(1):40-44.
The group from Boston has produced yet another set of exceptional papers analyzing leadership styles in the Operating room and how these affect other individuals and the team. (1,2). Hopefully, I can review these with the authors in person, but until then this is what I took home from them:
The JASC paper assessed a range of leadership/teamsmanship styles via grading performance seen during video recording of five different surgeons comparing transactional and transformational leadership. The premise behind this study was that no prior studies assist us in understanding how one particular leadership style cultivates or inhibits specific team responses. In my observations of many surgeons, it appears that many of us tend to have a higher TRANSACTIONAL LEADERSHIP character (predominately goal or task focused with concentration more on rewards or failures) which overshadows any TRANSFORMATIONAL LEADERSHIP qualities (influenced on the collective mission and focus on inspiration and intellectual stimulation of our teammates). The question we all have had is there any detriment or attribute in displaying one style predominately over the other. In other words, does one style lead to reduced or improved safety? Does one style stymie or produce enhanced psychological safety- where our teammates feel encouraged to speak up when safety issues arise. To assess this, the Boston group used a previously described scoring system on leadership during an observation of intraoperative videos of five different surgeons.
So did this group discover anything significant we can use in our own personal growth? They noted that the surgeons with high transformational scores tended to enter the room and immediately engage all the members of the team. The sense of a collective mission became apparent at the onset. Enthusiasm and support of others reigned during the entire case. It was clear that those in the room felt comfortable asking for clarification or alerting others about safety issues. Those with lower scores showed the least amount of engagement with others even during dire circumstances. More importantly was the discovery that one type of leadership style is NOT mutually exclusive of the other, but in fact typically additive. One can be a strong transactional leader (goal oriented) but also be a strong transformational leader (engaging).
So I had to ask myself a question “for those of us who are clearly task oriented, is there any hope for us to become more team oriented?” I am sure I am not the only one out there who sees a situation as a task to be overcome and utilize our team as a set of tools to accomplish that task…OOOO I am sure that will not be viewed as politically correct. As I discussed last week, General Van Riper and I discussed the need to assure that team members actually know and understand what the objective is, during a mission or they may carry out a task either incorrectly or achieve the goal but at a cost that was not necessary. In the end that communication style will result in better morale. This study showed that you actually can be good at both and if you strive to be more translational in style, it should not negate your transactional methodologies, but will likely improve your ability to utilize the team to meet your objective.
The other Boston study I mentioned assessed leadership behavior in terms of how the leader utilizes available team members (authoritative, explanatory, consultative, and delegative). They then assessed Junior Resident preferences to see which style meshed with their inherent learning preferences. As expected, us older surgeons were typically used to authoritative (autocratic) and some explanatory (explains their decisions to the team, but makes the decision) leadership during our training. We were typically told what was going to happen and grateful when the attendings explained why. The residents clearly indicate that they prefer consultative (team is consulted for an opinion) and delegative styles (the problem is put to the group and the majority wins) intraoperatively. I personally felt we were in a win-win situation when an attending asked my opinion on an approach I would prefer when managing an isolated aortic aneurysm with no distal occlusive disease (“hey I really want to do some properitoneal aortic approaches in case we have to operate on a patient with a frozen abdomen from prior surgical adhesions”). I had knowledge of differing approaches and felt it would be good to have this in my toolbox, just in case (which in fact it did several months later) so when my opinion appeared to be important I LEARNED THAT TECHNIQUE!
But, does any of this really impact patient care? Well of course it does! Poor leadership, poor teamwork, unnecessary distractions, and a slew of other problems have been linked in multiple studies to poorer outcomes, increased stress on the team, and reduced morale. Once upon a time we could shirk our shoulders and say that we just did not have decent models that would fit in surgery or just say “well that’s easy for you to say! You don’t have to deal with the tough circumstances I have to!” but these studies are rapidly putting an end to that defense....... There are good models and while some circumstances are more stressful than others we can all adapt stress management strategies that include leadership approaches that foster teamwork, and improve morale but do not negatively impact patient care.
Hopefully, the folks that have put these fantastic papers together have time in the near future to discuss them.
KENNETH A. LIPSHY, MD, FACS
Hu YY, Henrickson Parker S, Lipsitz SR, Arriga AF, Peyre SE, Corso KA, Roth EM, Yule SJ, Greenberg CC. surgeon's leadership styles and team behavior in the Operating room. JACS 2016. 22(1):41-51.
Kissable-lee NA, Yule S, Pozner CN, Smink DS. Attending surgeons' leadership style in the operating room: comparing junior residents' experiences and preferences. JSE 2016. 73(1):40-44.
LEADERSHIP STYLES IN SURGERY THAT SERVE AS IDEAL MODELS FOR TRAINEES: DO WE EVEN COME CLOSE TO THE PIN?
There are many days when I examine my behavior during the day and ask: did I even come close to an enabling leader today or was did I act in a counterproductive manner? After, reading several papers on leadership this past month, I do not think I even come close to the pin (and maybe not on the putting green).
The group from Boston has produced yet another set of exceptional papers analyzing leadership styles in the Operating room and how these affect other individuals and the team. (1,2). Hopefully, I can review these with the authors in person, but until then this is what I took home from them:
The JASC paper assessed a range of leadership/teamsmanship styles via grading performance seen during video recording of five different surgeons comparing transactional and transformational leadership. The premise behind this study was that no prior studies assist us in understanding how one particular leadership style cultivates or inhibits specific team responses. In my observations of many surgeons, it appears that many of us tend to have a higher TRANSACTIONAL LEADERSHIP character (predominately goal or task focused with concentration more on rewards or failures) which overshadows any TRANSFORMATIONAL LEADERSHIP qualities (influenced on the collective mission and focus on inspiration and intellectual stimulation of our teammates). The question we all have had is there any detriment or attribute in displaying one style predominately over the other. In other words, does one style lead to reduced or improved safety? Does one style stymie or produce enhanced psychological safety- where our teammates feel encouraged to speak up when safety issues arise. To assess this, the Boston group used a previously described scoring system on leadership during an observation of intraoperative videos of five different surgeons.
So did this group discover anything significant we can use in our own personal growth? They noted that the surgeons with high transformational scores tended to enter the room and immediately engage all the members of the team. The sense of a collective mission became apparent at the onset. Enthusiasm and support of others reigned during the entire case. It was clear that those in the room felt comfortable asking for clarification or alerting others about safety issues. Those with lower scores showed the least amount of engagement with others even during dire circumstances. More importantly was the discovery that one type of leadership style is NOT mutually exclusive of the other, but in fact typically additive. One can be a strong transactional leader (goal oriented) but also be a strong transformational leader (engaging).
So I had to ask myself a question “for those of us who are clearly task oriented, is there any hope for us to become more team oriented?” I am sure I am not the only one out there who sees a situation as a task to be overcome and utilize our team as a set of tools to accomplish that task…OOOO I am sure that will not be viewed as politically correct. As I discussed last week, General Van Riper and I discussed the need to assure that team members actually know and understand what the objective is, during a mission or they may carry out a task either incorrectly or achieve the goal but at a cost that was not necessary. In the end that communication style will result in better morale. This study showed that you actually can be good at both and if you strive to be more translational in style, it should not negate your transactional methodologies, but will likely improve your ability to utilize the team to meet your objective.
The other Boston study I mentioned assessed leadership behavior in terms of how the leader utilizes available team members (authoritative, explanatory, consultative, and delegative). They then assessed Junior Resident preferences to see which style meshed with their inherent learning preferences. As expected, us older surgeons were typically used to authoritative (autocratic) and some explanatory (explains their decisions to the team, but makes the decision) leadership during our training. We were typically told what was going to happen and grateful when the attendings explained why. The residents clearly indicate that they prefer consultative (team is consulted for an opinion) and delegative styles (the problem is put to the group and the majority wins) intraoperatively. I personally felt we were in a win-win situation when an attending asked my opinion on an approach I would prefer when managing an isolated aortic aneurysm with no distal occlusive disease (“hey I really want to do some properitoneal aortic approaches in case we have to operate on a patient with a frozen abdomen from prior surgical adhesions”). I had knowledge of differing approaches and felt it would be good to have this in my toolbox, just in case (which in fact it did several months later) so when my opinion appeared to be important I LEARNED THAT TECHNIQUE!
But, does any of this really impact patient care? Well of course it does! Poor leadership, poor teamwork, unnecessary distractions, and a slew of other problems have been linked in multiple studies to poorer outcomes, increased stress on the team, and reduced morale. Once upon a time we could shirk our shoulders and say that we just did not have decent models that would fit in surgery or just say “well that’s easy for you to say! You don’t have to deal with the tough circumstances I have to!” but these studies are rapidly putting an end to that defense....... There are good models and while some circumstances are more stressful than others we can all adapt stress management strategies that include leadership approaches that foster teamwork, and improve morale but do not negatively impact patient care.
Hopefully, the folks that have put these fantastic papers together have time in the near future to discuss them.
Hu YY, Henrickson Parker S, Lipsitz SR, Arriga AF, Peyre SE, Corso KA, Roth EM, Yule SJ, Greenberg CC. surgeon's leadership styles and team behavior in the Operating room. JACS 2016. 22(1):41-51.
Kissable-lee NA, Yule S, Pozner CN, Smink DS. Attending surgeons' leadership style in the operating room: comparing junior residents' experiences and preferences. JSE 2016. 73(1):40-44.
The group from Boston has produced yet another set of exceptional papers analyzing leadership styles in the Operating room and how these affect other individuals and the team. (1,2). Hopefully, I can review these with the authors in person, but until then this is what I took home from them:
The JASC paper assessed a range of leadership/teamsmanship styles via grading performance seen during video recording of five different surgeons comparing transactional and transformational leadership. The premise behind this study was that no prior studies assist us in understanding how one particular leadership style cultivates or inhibits specific team responses. In my observations of many surgeons, it appears that many of us tend to have a higher TRANSACTIONAL LEADERSHIP character (predominately goal or task focused with concentration more on rewards or failures) which overshadows any TRANSFORMATIONAL LEADERSHIP qualities (influenced on the collective mission and focus on inspiration and intellectual stimulation of our teammates). The question we all have had is there any detriment or attribute in displaying one style predominately over the other. In other words, does one style lead to reduced or improved safety? Does one style stymie or produce enhanced psychological safety- where our teammates feel encouraged to speak up when safety issues arise. To assess this, the Boston group used a previously described scoring system on leadership during an observation of intraoperative videos of five different surgeons.
So did this group discover anything significant we can use in our own personal growth? They noted that the surgeons with high transformational scores tended to enter the room and immediately engage all the members of the team. The sense of a collective mission became apparent at the onset. Enthusiasm and support of others reigned during the entire case. It was clear that those in the room felt comfortable asking for clarification or alerting others about safety issues. Those with lower scores showed the least amount of engagement with others even during dire circumstances. More importantly was the discovery that one type of leadership style is NOT mutually exclusive of the other, but in fact typically additive. One can be a strong transactional leader (goal oriented) but also be a strong transformational leader (engaging).
So I had to ask myself a question “for those of us who are clearly task oriented, is there any hope for us to become more team oriented?” I am sure I am not the only one out there who sees a situation as a task to be overcome and utilize our team as a set of tools to accomplish that task…OOOO I am sure that will not be viewed as politically correct. As I discussed last week, General Van Riper and I discussed the need to assure that team members actually know and understand what the objective is, during a mission or they may carry out a task either incorrectly or achieve the goal but at a cost that was not necessary. In the end that communication style will result in better morale. This study showed that you actually can be good at both and if you strive to be more translational in style, it should not negate your transactional methodologies, but will likely improve your ability to utilize the team to meet your objective.
The other Boston study I mentioned assessed leadership behavior in terms of how the leader utilizes available team members (authoritative, explanatory, consultative, and delegative). They then assessed Junior Resident preferences to see which style meshed with their inherent learning preferences. As expected, us older surgeons were typically used to authoritative (autocratic) and some explanatory (explains their decisions to the team, but makes the decision) leadership during our training. We were typically told what was going to happen and grateful when the attendings explained why. The residents clearly indicate that they prefer consultative (team is consulted for an opinion) and delegative styles (the problem is put to the group and the majority wins) intraoperatively. I personally felt we were in a win-win situation when an attending asked my opinion on an approach I would prefer when managing an isolated aortic aneurysm with no distal occlusive disease (“hey I really want to do some properitoneal aortic approaches in case we have to operate on a patient with a frozen abdomen from prior surgical adhesions”). I had knowledge of differing approaches and felt it would be good to have this in my toolbox, just in case (which in fact it did several months later) so when my opinion appeared to be important I LEARNED THAT TECHNIQUE!
But, does any of this really impact patient care? Well of course it does! Poor leadership, poor teamwork, unnecessary distractions, and a slew of other problems have been linked in multiple studies to poorer outcomes, increased stress on the team, and reduced morale. Once upon a time we could shirk our shoulders and say that we just did not have decent models that would fit in surgery or just say “well that’s easy for you to say! You don’t have to deal with the tough circumstances I have to!” but these studies are rapidly putting an end to that defense....... There are good models and while some circumstances are more stressful than others we can all adapt stress management strategies that include leadership approaches that foster teamwork, and improve morale but do not negatively impact patient care.
Hopefully, the folks that have put these fantastic papers together have time in the near future to discuss them.
KENNETH A. LIPSHY, MD, FACS
Hu YY, Henrickson Parker S, Lipsitz SR, Arriga AF, Peyre SE, Corso KA, Roth EM, Yule SJ, Greenberg CC. surgeon's leadership styles and team behavior in the Operating room. JACS 2016. 22(1):41-51.
Kissable-lee NA, Yule S, Pozner CN, Smink DS. Attending surgeons' leadership style in the operating room: comparing junior residents' experiences and preferences. JSE 2016. 73(1):40-44.
Leadership Styles and Team Behavior -FU conversation with Caprice Greenberg and Steven Yule
Last month Steven Yule was kind enough to talk with me about their January 2016 paper in the JACS: Surgeon’s Leadership Styles and Team Behavior in the Operating Room. Dr. Yule explained that a transformational leader is a leader who converses with his team at crucial aspects before, during and after the procedure to assure that everyone is aware of his thoughts and concerns and vice versa. This is not necessarily the same as the type of leader who engages in unrelated conversational topics which have no real bearing on the case itself (that may help in relaxing the team if it is carried out in a productive manner, but likely will lead to distractions if not done in a productive manner- See my conversation with Anna Wheelock regarding distractions in the OR). He also alleviated my anxiety by assuring me that any leader who is already transactional (task focused) can learn to become more transformational. Transformational leadership is more conducive to team efforts and resident learning so it is in all our best interest to learn.
As a follow-up to that conversation, I talked with Caprice Greenberg about her investigations into communication styles as they relate to effective or ineffective leadership in the hospital. Her focus is working with established surgeons on performance improvement in the areas of technical, interpersonal / cognitive skills and stress recognition / management (yes! Right up my alley).
Dr. Greenberg reinforced the idea that transactional leadership is a basic component of surgeon personality and transformational leadership is layered on top of this. As noted in the study, the surgeons who empowered the team appropriately, were more effective. These are the surgeons who establish rapport at beginning, shared decision making, engaged all members (residents and techs). One example was they wrote everyone’s name on the white- board to assure they knew everyone in the room. This tends to be the totally opposite perspective most surgeons hold, whereby they express that it is the not their responsibility to know who is in the room, but the hospital’s responsibility to give them the same team all the time. Dr. Greenberg expressed that we need to share this so we can improve all aspects in the OR. It is a subtle act that turns out to have profound implications. Turns out, that we all complain about having new people in the room and how that negatively affects the flow. Successful businesses use this staff rotation to an advantage for new ideas, fresh perspectives, etc. In actuality teams that work together all the time have a tendency to stop communicating; they assume so much that they stop asking questions and sooner or later things fall thru the cracks. New players don’t assume anything- they ask!
Another problem area we discussed was standardization of error reduction protocols as a huge potential problem… we take everything for granted, but in reality if it is not personalized then we missed the opportunities to detect problem areas. (Why do sports teams do better when they have been together for a long period of time? Maybe do not have to be as adaptable, not as reactive. Or maybe in reality their performance declines as team membership becomes stagnated- a question for another profession another day). There are things about medicine that makes it more complicated than other systems. There are similarities but we need to dive deeper and collaborate with others to design our system. For example: hospital leadership never asks the question of “Why is person getting angry” and what are the implications for downstream tasks by that surgeon. If we don’t ask those questions and simply apply outside standardized non-personalized protocols, we miss the point (see Doug Paul’s Paper on upstream and down-stream errors). From here we began to discuss handoff pitfalls and strategies in medicine that work when designed by the people who use them in lieu of designs by organizational staff who do not practice in the area the protocol was meant for (brought back memories from a paper published in October by Pugh et al “People like to say patient safety is so paramount, and ‘if only we were more like the commercial aviation business.’ Well, yes, but if taking care of patients were the same as commercial aviation, I would never operate, because pilots don’t fly into a storm…. The reality of being in an ICU is they get three admissions at once and they are ALL really sick… so I don’t think (eliminating interuptions) should be mandated, because it could potentially NOT make things worse for that patient, but make things worse for the other patients also under your care.”).
I look forwards to future conversations on this topic.
KENNETH A. LIPSHY, MD, FACS
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