Spotlight Case April 2006

1. Spotlight Case April 2006 Is the “Surgical Personality” a Threat to Patient Safety?

2. Source and Credits • This presentation is based on the April 2006 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available through the Web site • Commentary by: Charles L. Bosk, PhD, University of Pennsylvania • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Describe the myth of the “surgical personality” • Identify features of highly reliable organizations • Describe steps that can be taken to improve the culture of safety in medicine

4. Case: Wire we here? A 7-year-old boy with acute lymphocytic leukemia presented for insertion of a portacath. The surgeon utilized a supraclavicular approach for guidewire placement and was having difficulty obtaining venous access. During this time, the surgeon began to yell at members of the operating room (OR) team for a variety of issues, including the degree of chatter in the OR, the failure of the OR staff to anticipate his next request, and their failure to move the patient into his desired position to place a Bovie pad.

5. Case: Wire we here? This behavior did not surprise the OR team as this surgeon had a reputation for being “old school” and possessing poor communication skills. On the next attempt to pass the guidewire, it appeared to pass into the left ventricle. This was noted by both the X-ray technician and the anesthesiologist, neither of whom were willing to speak up, given the senior surgeon’s reputation of berating team members who gave unsolicited input on “his case.”

6. The Myth of the “Surgical Personality” • Surgery requires a specific skill set • Excellent eye-hand coordination, manual skills • Ability to act decisively on uncertain knowledge • Willingness to improvise when unexpected occurs • Creates an aura of a hero who displays grace under pressure • However, neither the aura nor the skill set predicts a “personality”

7. The Myth of the “Surgical Personality” • Features of this stereotype include • Wielding authority in an overbearing way • Treating subordinates in a psychologically abusive manner • Such a “personality” exists among physicians in all specialties • In reality, there is great variation in social skills, interpersonal style, and individual demeanor in any group of surgeons

8. Paradox of the Stereotype • Demand unquestioning obedience and respect for hierarchy from subordinates • But have a near complete disregard for organizational rules and behavior • Surgeon will not compromise patient’s best interest for organizational policies and procedures

9. Paradox of the Stereotype • Demands for quick compliance with orders and intolerance of delay once served the patient’s interest • The “surgical personality” is now counter-productive • Current surgical procedures require complex teamwork among anesthesiologists, nurses, and a variety of specialists • For example, minimally invasive fiberoptic surgery requires 4 hands Zetka J. Ithaca, NY: Cornell University Press; 2004.

10. Case (cont.): Wire we here? The dilator and peel-away covering were placed over the wire and the catheter was threaded into place. The surgeon then injected multiple boluses of saline and Hypaque dye and the child became tachycardic and hypotensive, with narrowing of the pulse pressure. Severe respiratory variation was noted on the pulse oximeter tracing. The anesthesiologist voiced his belief that the surgeon had placed the device in the pericardial space and demanded that he perform an immediate pericardiocentesis.

11. Case (cont.): Wire we here? Instead, the surgeon insisted on removing the portacath and closing the skin incision. Over the next 10 minutes, the child’s cardiovascular status deteriorated, requiring epinephrine. Once pericardiocentesis was finally performed, the child immediately improved, and more than 200 ccs of bloody fluid were drained. Ultimately, the child required two pericardiocenteses and was intubated overnight in the PICU. He was readmitted for a repeat surgery several weeks later. Administration of his intrathecal chemotherapy was delayed.

12. Why Has it Been Tolerated? • When social arrangements seem natural, they go unchallenged • When we cannot imagine an alternative, why aggravate ourselves about things we cannot change? • Wisdom is said to reside in recognizing what we are powerless to change • When can we challenge social arrangements once thought unassailable?

13. To Err is Human • Challenge came with publication of the IOM report on prevalence of preventable adverse events in medicine • To Err is Human: Building A Safer Health Care System • Identified dysfunctional responses to error characterized by “naming, blaming, and shaming” individuals • Such responses inhibit sharing of knowledge that would serve to prevent mistakes being repeated Kohn L, Corrigan J, Donaldson M, eds. National Academy Press; 2000.

14. Complex Interactions • In high technology organizations, accidents are “normal” • Small errors combine with other minor deviations to create unexpected, unpredictable accidents and errors • Normal accident theory suggests that, in complex human endeavors, accidents are inevitable and that efforts at prevention yield limited results

15. Theory of Highly Reliable Organizations • IOM called for attention to industries that had made significant progress in emphasizing safety • Highly Reliable Organizations • Organizations or systems that operate in hazardous conditions but have fewer than their fair share of adverse events

16. Example of Highly Reliable Organization • Achieving safety on flight decks of aircraft carriers • Any member of the crew can wave off a landing • Crew members are rotated through all different assignments of the flight deck • All workers possess not only an understanding of their responsibility but also a global knowledge of flight deck operations • Lessons of experience are communicated through vivid narratives elaborating threats to safety Weick K, Roberts KH. Adm Sci Q. 1993;38:357-381.Roberts KH. Organ Sci. 1990;1:160-176.

17. Critical Elements of Safety Culture • Instill core values in members of organization • Those in charge convey to other team members their important role for early detection and communication of possible problems • Seek wisdom rather than knowledge alone, couple confidence in skill with humility, and promote respectful and “heedful” interactions Weick K. Calif Manage Rev. 1987;29:112-127.

18. Changing Culture • Emphasize the importance of teamwork early in medical training • Teach the dangers that the “captain of the ship” doctrine presents to safety • Create an oral culture that celebrates the benefits to safety and quality care that teamwork provides • Recognize that safety flows from the coordinated action of team members • Outline consequences for overbearing behaviors and disrespect of team members