Thursday, August 11, 2016

COMFORT ZONES AND RISK TAKING IN SURGERY- A Discussion with Dr. Moulton Dec 2015


        Ever wondered if the surgeon who appears to never sweat thru a technically challenging procedure or event has any comfort zone concerns at all?  Wonder no more! It appears that we all likely have boundaries that eventually push our buttons. What those limits are may surprise you. In their paper, Dr. Moulton’s group from the University of Toronto interviewed 18 surgeons regarding their approach to risk-taking and comfort zones. She and I discussed their findings and how this relates our lives as surgeons (I am very grateful for the time she took to discuss this with me).

          From these interviews it appears that even the boldest appearing surgeons probably have their breaking point.  It is likely that every surgeon has a perception of where their boundary is; the place where they no longer feel comfortable.  Self-assessment literature seems to indicate that we frequently do not openly acknowledge that we have a comfort zone (or may not accept that personally). It may be that the temperamental and angry affect we see in some surgeons is actually a reflection of anxiety. It is unlikely that anyone is immune, but we simply do not discuss it. 

         So, what are some of these conditions that create a rift in our comfort zone- the conditions that push us close to, or past that boundary? While these vary from person to person, several common themes seem to appear.

1.         As suspected, alterations in the environment such as an unfamiliar hospitals (OR), change in the OR team personnel, or assistant staff can create anxiety.  While the experienced surgeons have no qualms at the hospital they tend to work in daily, they seem to shy away from similar cases at other less familiar hospitals. Environment may also come into play when one is performing elective as opposed to emergent or trauma surgery. Experienced surgical oncologists reveal that the same operations they perform without hesitation in an elective circumstance would be anxiety provoking in a traumatic scene.  Presence or absence of specialized surgeons on the premises can alter the surgeons comfort in performing certain procedures. Other surgeons felt more confident with certain equipment (such as certain headlamps).

2.         Another common theme was the performance of infrequently performed procedures by surgeons who do extremely complex cases on a daily basis but rarely if ever do the more mundane procedures (hernia repair).

3.         A theme that most surgeons typically will not discuss is our aversion to complications based on past experiences. That is, some abhor complications while others accept them as a potential and mentally prepare to avoid them where they can.  Some of us may be more anxious about the potential harm we may create due to past experience such as the peer review process, morbidity and mortality conferences, litigation, being berated by a colleague, etc.  There is likely a link between our reaction to a stressful procedure and how we manage the potential for complications- we may become so anxious about doing harm it affects our care because we now take the complication very personal. This leads to a lack of tolerance for complications and potentially to limitations of the procedures we are willing to tackle. Your reaction is dependent on culture around you – a blaming culture causes you to focus on your errors… your latest nightmare affects your future case care. .. Your peer reactions to you influence future response.  In addition, surgeon stereotype probably affects us. We are taught to be bold and not focus on our feelings but to push ahead in spite of the potential for a complication. So we then block out our ability to accept we have a boundary until maybe it is too late and that episode overshadows our future care.

So what do people do to avoid the anxiety of approaching or crossing that boundary and be more risk taking as opposed to risk aversive.  Preparation, preparation, preparation seems to be the key. These surgeons gather the team and talk over the case. They may call upon experts to have them weigh in on the case.  They mentally walk through the case to see where they may be at risk and develop plans to get past that potential barrier to success.

Dr. Moulton relayed to me that ultimately we have to find a way to help manage people at the extremes- that is the person who is anxious about even the most minimal risk or the person who has no recognition that they have a comfort zone whatsoever. How do we teach experienced surgeons and trainees to recognize their boundaries and how to prepare themselves for the potential for risk taking? That is the ultimate question that the Toronto group is working towards.



Zilbert NR, Murnaghan L, Gallinger S, Regehr G, Moulton C. Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg. 2015; 262(2):253-259.


Carol-Anne Moulton, MBBS, Med, PhD. Hepatobiliary Surgeon University Health Network, Toronto,  associate professor of Surgery at the University of Toronto. Scientist at the Wilson Centre [TGH, University of Toronto] conducting research on surgical judgment and the social psychology of surgeons.

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