Patient Safety Scenario #19: Know Your Team
This essay is the 19th installment of the monthly Patient Safety essays, produced by the Patient Safety Subcommittee of the Ethics and Professionalism Committee. The essays are written in the spirit of the aviation industry’s “Black Box Thinking”: in order to inform and improve our medical safety record, we need to analyze our errors. To read earlier essays and learn how to contribute, please click here.
Surgeons often have to work with team members with whom they have never worked before, or possibly even met before. The larger the hospital or surgery center, the greater chance that there will be nurses, surgical assistants, or anesthesia providers who you do not know. Even more concerning, they might not know anything about the problem you are treating or how you like to operate. This is not a unique problem for other high-reliability, high-technology, high-risk industries. Take the aviation industry: the number of active, certified pilots in the US in 2017 was 609,306; of these, 99,880 were commercial pilots. Pilots often fly with another pilot that they have never met before, and their life depends on this stranger! Can you imagine having a co-surgeon you have never previously met? Yet pilots do this routinely for nearly every flight. The aviation industry has demonstrated important ties between teamwork and performance (Helmreich, 2004).
The point is that working with team members you don’t know is commonplace. We can learn a few skills from other teams in different fields. Your skill in how you interact with teammates has a direct effect on the safety of your patient. Teamwork is an important component of patient safety. In fact, communication errors are the most common cause of sentinel events and wrong-site operations in the US (Christian, 2006; Greenberg, 2007). One study showed that nurses rated the surgeons’ collaboration as “high” or “very high” only 48% of the time (Makary, 2006). How would you feel about being a passenger on a commercial flight if the pilots and first officers cooperated well only 48% of the time?
This essay is offered to help you develop your skill in working with unfamiliar team members.
David Nelson, MD Chair, Patient Safety Subcommittee
Scott Lifchez, MD Co-Chair, Ethics and Professionalism Committee
Julie Adams, MD Co-Chair, Ethics and Professionalism Committee
Know Your Team
A new scrub tech was hired to work in the operating room. He had been a medic in the military and had years of operating room experience in difficult cases. Surgeons found that he was quite competent as a scrub tech. With time, however, they also became aware that he held distinct and unshakable convictions in “how things should be done.” The tech would do things the way he was asked initially but then would drift back to what he considered the “proper technique.” The end result was that the surgeons felt the tech was sometimes working with the surgeon and the rest of the team but sometimes it felt like he was working against the surgeon and team. This tech was full of bluster and machismo, and enjoyed his reputation as a hard-partying, hard-riding motorcycle buff; he would tell stories harkening back to his military days about how he “got back at” the officers with whom he worked, making it clear he thought he was his own authority and did not take easily to supervision or guidance.
One particular surgeon tried hard to work with this tech, and generally enjoyed working with someone with this tech’s high level of experience and expertise. The surgeon complimented the tech on his skill and how much he enjoyed working with him. The surgeon thought he was making some progress in developing a working rapport with this scrub tech, but things broke down rather quickly when the surgeon once (accidentally) called the tech “José” when his name actually was “Juan.” The scrub tech took this as an attack on his ethnicity (he was from Puerto Rico), and the mood in the operating room became fairly bleak throughout that case and remained tense whenever they worked together in the future.
The surgeon genuinely regretted the mistake of calling him by the wrong name and made a particular effort to call him by his correct first name whenever they worked together. This helped somewhat, but the damage had already been done. Juan never made eye contact when the surgeon passed in the hallway, and he barely spoke to the surgeon even if he was working with him that day.
Then Hurricane Maria, a Category 5 hurricane, hit Puerto Rico in September 2017. It was the deadliest Atlantic hurricane since 1998 and the worst natural disaster in recorded history to hit Puerto Rico. Before the next case, the surgeon asked Juan if he had family in Puerto Rico, and how they were affected by Hurricane Maria. Juan was quick with answers: he had a lot of family in Puerto Rico, and his uncle’s roof had been torn off. He was leaving the next week to help out with family and was quite concerned. The surgeon asked further follow-up questions, and obviously cared about the disaster that had hit Juan’s family. It was clear Juan appreciated the concern, and a substantial first step was taken in mending their relationship. The surgeon was careful to see Juan just prior to his departure and wished him good luck with the journey and the work Juan would need to do in Puerto Rico. When Juan returned, the surgeon asked follow-up questions about how his family was doing and showed genuine interest and concern. Although the roof had been torn from his uncle’s home, Juan’s family had immediately placed tarps over it and thus they were able to preserve most of the furnishings. Juan helped to put on a temporary corrugated aluminum roof, although final repairs would have to wait for more supplies to be brought to the island. Through these interactions, it became clear to Juan he was not just some “José” from Puerto Rico to the surgeon, but a valued person with everyday concerns, just like everyone. Their relationship in the operating room improved, and it seemed as if Juan now actually heard the surgeon when he complimented him at the end of the case.
Some months later, the surgeon needed some advice about how to approach another new hire, who just did not seem to understand how a scrub tech was supposed to function. The new tech had the right heart, he just did not have a good understanding of what to do. The surgeon decided to ask Juan, who clearly understood the scrub tech function, to take this new scrub aside and try to help him learn the ropes. When he approached Juan, the surgeon explained that the reason he was asking him to take this on was because he seemed to have the best understanding out of all of the techs on how to function and how to think ahead of the surgeon. Juan recognized the compliment was genuine and took on the task of helping the new hire.
The teamwork between the surgeon and Juan continued to grow, and they would always say hello as they passed in the hallway, even if they were not working together that day.
Teamwork in the operating room is essential for both efficient operation as well as patient safety. As the airline industry and other high-reliability, high-technology, high-risk industries have learned, success depends on teamwork. The surgeon still needs to have an excellent knowledge base and surgical skills, but it is important to realize that the surgeon is only one part of the team. If the rest of the team does not function well individually and together as a group, the surgeon is almost guaranteed to get a lesser result. The surgeon is the leader of the team and their behavior sets the tone for the room, but the surgeon is not the entire team. Surgeons often have a hard time incorporating this concept into their thinking and their approach to surgery. In this case, this surgeon made a blunder and accidentally insulted a sensitive scrub tech, which torpedoed any possibility of teamwork. The surgeon, recognizing the importance of optimum working relationships on the team, strived to establish a mutually respectful working relationship.
Have you ever gone into another operating room while case is going on and just observed the atmosphere? Rooms that run well are led by a surgeon who understands teamwork and values and appreciates the contributions of everyone in the room. In contrast, rooms where the staff feel like they are being “forced” to be in that room for that day and are just trying to survive the day never get the same kind of results.
Studies have looked at the surgeon’s perspective on how well they are functioning as a leader and how well the team is functioning in the room, and contrast that to how the rest of the staff feels that the team is functioning. Surgeons typically think they are doing a great job, but the staff share a different perspective: they are undervalued, and often demeaned, and are unable to perform up to their potential. If you want to perform to your full potential as a surgeon, it might be wise to try to initiate dialogue with your teammates to understand what their perspectives are. If you do it humbly and with an open mind, it is almost guaranteed that you will learn something that will make you a better surgeon.
Christian CK1, Gustafson ML, Roth EM, Sheridan TB, Gandhi TK, Dwyer K, Zinner MJ, Dierks MM. A prospective study of patient safety in the operating room. Surgery. 2006 Feb;139(2):159-73.
Full paper at https://www.ncbi.nlm.nih.gov/pubmed/16455323
Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, Gawande AA. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007 Apr;204(4):533-40. Full paper at https://www.ncbi.nlm.nih.gov/pubmed/17382211
Helmreich R, Sexton J: Group interaction under threat and high workload, Group Interaction in High Risk Environments, Chapter 1. Edited by Dietrich R, Childress T. Aldershot, United Kingdom, Ashgate, 2004, pp 9–23Helmreich, R Sexton, J Dietrich R, Childress T Aldershot, United Kingdom Ashgate. Online copy not available for free.
Makary MA, Sexton JB, Freischlag JA, Holzmueller CG, Millman EA, Rowen L, Pronovost PJ. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg. 2006 May;202(5):746-52. Online copy not available for free. Abstract at: https://www.sciencedirect.com/science/article/abs/pii/S1072751506001177.