This essay is the fourteenth 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. To read earlier essays and learn how to contribute, please click here.

A comparison of safety in aviation and medicine is frightening: aviation disasters are investigated, written up, and every pilot has access to the lessons learned. In medicine, medical errors are investigated, written up, and buried so deeply that no one learns anything. Each surgeon has to repeat every error on their own. On their own patients. This is why now in aviation there is one accident every 2.4 million flights, and why medical errors kill between 44,000 and 98,000 patients per year, according to two good studies reported in the Institute of Medicine report of 1999, To Err is Human. This is the equivalent of crashing a 747 every other day. Would you be willing to fly if this was aviation’s safety record? Yet according to several studies, this is our safety record in medicine. Aviation learned the lesson of Crew Resource Managment in 1979; medicine is just beginning to learn it.

The time-out has been generally recognized as an important contribution to patient safety. However, as these three cases demonstrate, it is not foolproof. I expect that most of us have seen how it can go wrong when the surgeon does not take it seriously, but it can still go wrong when the surgeon takes ownership of the timeout. Situational awareness¹ and awareness of how many ways it can go wrong are still needed. In this spirit, the Patient Safety Subcommittee offers this essay to the membership.

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

Note: The Patient Safety Subcommittee actively solicits scenarios that might be appropriate for future articles. Please send them to: nelsondl@pacbell.net

Rocket Fuel 50 Years after Man Landed on the Moon

Dr. X is a hand surgeon who is highly respected by his peers and is well-known in the community. He sees himself as a leader in the operating room: he runs a particularly tight ship and is demanding of himself. He makes sure to arrive in his room pretty much on time and wastes no time at the end of the case, leaving quickly to dictate and then get back to see patients in the office. He does not have time for nonsense. Not only is he demanding of himself, he is quite demanding of the staff, and they know it. He considers it leadership to tell people what to do and to let them know if they are not doing their job. He has his favorites among the staff, and he is always happy to see the A-Team assigned to his room. But if he gets the B-Team, his impatience shows. Incompetence is not tolerated, and errors are sharply reprimanded. Demanding excellence during his residency by the faculty was effective, and demanding excellence by the surgeon certainly works in the operating room. Patient safety is important to him, so the team better do their job. After all, what are they there for? He frequently discusses shortcomings with the head nurse, so that it does not happen again. Significant errors or repeat errors are written up. The circulating nurse better know the name of the procedure and do the timeout properly. All the instruments and supplies had better be ready, too. As he is quick to point out, it is not the first time he has done this kind of case. He does all the cases in a very similar manner, and he expects everyone to do know his routine and perform their tasks well. He expects prompt action if something is missing. The tenor in the room is that the surgeon is in charge and everyone needs to pay attention. He does not have any time to spend stroking egos or praising staff for what they are supposed to do anyway: that is what they get paid to do. At the end of the case, he thanks them for what they have done, but the superficial way he says it clearly indicates that he does not mean it.

Dr. Y is a very competent hand surgeon and knows exactly what he wants. He always gets to the room on time and greets the staff who are assigned to the room that day. Good planning is the key to a smooth running room, so he likes to arrive early to check the instruments and supplies, so that there is less running around during the case. Patient safety is very important to him, so he makes sure the staff knows any peculiarities of this particular case prior to the start, and he runs the timeout himself. After all, who better knows the patient and the case? He does all the cases in a very similar manner, and if he has someone new in the room, he tries to let them know what he will be needing. He has no time for nonsense. He is the leader, and there is no question about it. He is quite demanding of himself, and is demanding of the staff. He appreciates the work that the staff does, and goes out of his way to acknowledge their hustling during the case. He makes it a habit to occasionally write up someone for praise when he thinks they have done a particularly good job, or mention it to the head nurse. Everyone in the room feels like the A-Team. If someone needs to improve a bit, he tries to counsel them in private. That usually is sufficient to get the performance that he wants, and he only very rarely has to speak to the head nurse about the problem. At the end of the case, he thanks the team for what they have done, and it is clear he really means it. The tenor in the room is always one of mutual respect and teamwork, and this pays off in productivity and safety. He likes to escort the patient to the recovery room and make sure that this transition is accomplished safely, and it gives him a moment to discuss the case with the staff.

Analysis

We all have our own styles in the operating room, and there are many ways to do a great job. It is also true that all hospital staffs are human and respond to carrots and sticks in predictable ways. You can imagine which surgeon in the above scenarios gets the best from their team, or can be described as having an operating room that meets the definition of a high reliability environment with a well-functioning, mutually supportive team.

Who do you think was the real leader? Leadership is not telling people what to do. Eisenhower said that leadership is the art of getting people to do what you want them to do, because they want to do it. Which surgeon gets the staff to do what he wants them to do, because they want to do it? And which surgeon gets the staff to do what he wants them to do because they do not want to be yelled at? In your own experience, what is works better: carrots or sticks?

Surgeon X in the first scenario probably thinks of himself as an excellent surgeon. However, the AAOS, The Joint Commission, the American College of Surgeons, and multiple other governing bodies have another word for it: bullying. In his room, we see the quintessential components of bullying—power imbalance, misuse of that power, and doing harm. What is the harm? It is not just that disruptive behavior and belittling of the staff interferes with teamwork in the room, crushes morale, increases burnout, and increases the turnover of staff. It has also been shown to decrease patient safety. According to a review article reported in JBJS in 2011, “Episodes of disruptive surgeon behavior adversely affect team dynamics and patient outcomes because they diminish communication, collaboration, and information exchange with the patient and staff.” The review cited a study by Rosenstein and O’Daniel who conducted a survey of staff at 102 hospitals in the United States. They found that that episodes of disruptive physician behavior were often associated with an adverse event or medical error, and 27% of staff interviewed indicated that disruptive behavior in their experience had been associated with patient mortality.¹ High-quality patient care requires effective teamwork, open communication, and a collaborative work environment. The Joint Commission became so concerned about “behaviors that undermine a culture of safety” that it issued a Sentinel Event Alert on the topic and developed a leadership standard requiring all hospitals to have a code of conduct as well as a process for managing disruptive and inappropriate behaviors.²

It is not rocket science to know that managing people is a challenge. However, it is also not rocket science to recognize that people always produce their best work in a positive atmosphere with positive reinforcement. Fear of punishment is not good motivation and is not good leadership. As a senior nurse recently remarked, “Positive reinforcement and respect for your surgical team are rocket fuel.”

If you want to “aim for the stars” like Apollo 11, use rocket fuel.

References:

1: The Orthopedic Forum. The Disruptive Orthopaedic Surgeon: Implications For Patient Safety And Malpractice Liability. Patel P, Robinson BS, Novicoff WM, Dunnington GL, Brenner MJ, Saleh KJ; J Bone Joint Surg Am. 2011 Nov 2;93(21):e1261-6.

2: Revisiting Disruptive and Inappropriate Behavior: 5 Years after the Standards Introduced. Wyatt, RM. In: The Joint Commission, High Reliability Healthcare. Https://www.jointcommission.org/jc_physician_blog/revisiting_disruptive_and_inappropriate_behavior/

3:  Systematic review of the prevalence, impact and mitigating strategies for bullying, undermining behaviour and harassment in the surgical workplace. U. A. Halim , D. M. Riding Br J Surg. 2018 Oct;105(11):1390-1397. doi: 10.1002/bjs.10926. Epub 2018 Jul 14. Available at: https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.10926

4: Sexual Harassment and Bullying: A Conversation  https://www5.aaos.org/aaosnow/2018/May/Cover/cover01/

5:  Workplace Bullying among Surgeons-the Perfect Crime
https://journals.lww.com/annalsofsurgery/Fulltext/2019/01000/Workplace_Bullying_Among_Surgeons_the_Perfect.11.aspx#pdf-link