Stress and Comfort zones- with Dan Kuhn

Stress and Comfort zones- with Dan Kuhn

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

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

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

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

·         more than seven call duties per month

·         less than four hours of relaxation per day

Back in Dec 2015 Carol-Ann Moulton and I discussed a paper their Toronto group published in the Annals of Surgery on Comfort Zones and Risk Taking in Surgery (Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg. 2015); Details of that conversation are at http://crisislead.blogspot.com/2016/10/interview-with-carol-anne-moulton.html In our discussion of the interviews which led to their publication it appeared that even the boldest appearing surgeons probably have a breaking point.  It is likely that every surgeon has a perception of where their boundary is; the place where they no longer feel comfortable.  Self-assessment literature seems to indicate that we frequently do not openly acknowledge that we have a comfort zone (or may not accept that personally). It may be that the temperamental and angry affect we see in some surgeons is actually a reflection of anxiety. It is unlikely that anyone is immune, but we simply do not discuss it. 

I had some questions for Dr. Kuhn:

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

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

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

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

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

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

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

Any familial risk?

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

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

Kenneth A. Lipshy, MD, FACS

www.crisismanagementleadership.com

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

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

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


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

Ronald Maier MD "Don't be mean!"

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

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

             Ever wondered if the surgeon who appears to never sweat thru a technically challenging procedure or event has any comfort zone concerns at all?  Wonder no more! It appears that we all likely have boundaries that eventually push our buttons. What those limits are may surprise you. In their Dec 2015 paper, Dr. Moulton’s group from the University of Toronto interviewed 18 surgeons regarding their approach to risk-taking and comfort zones. She and I discussed their findings and how this relates our lives as surgeons (I am very grateful for the time she took to discuss this with me).

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

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

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

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

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

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

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

 

 

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

 

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

 

 

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com