Saturday, January 28, 2006

Surgical Narcissism, Part II

I recently wrote a bit about the way surgeons may behave, or at least may be perceived, as fairly narcissistic. But, gee, I'm not really that way, am I? Well, a new survey suggests otherwise -- Perceptions of Teamwork in the OR Differ Sharply (go to page 19). It seems that, my own feelings aside, surgeons are not viewed as very good team players -- by the very team members they depend upon.

Dr. Makary surveyed 2,135 surgical team members, including surgeons, anesthesiologists, certified registered nurse anesthetists, scrub nurses, and technicians, about the social dynamics in the operating room that have been proven to affect surgical outcomes.....He found that surgeons rated the quality of their colleagues' collaboration and communications skills in the OR much higher than their colleagues rated them. On a 100 point scale, surgeons rated fellow surgeons at 85, anesthesiologists at 84, and nurses at 87.

Nurses rated surgeons at 48, and anesthesiologists rated surgeons at 70.....Surgeons generally felt all was well, while other team members disagreed.
Well, alrighty then! Give me just a moment to collect the pieces of my shattered ego and put the bloodied shards into the "sharps" container. While Dr. Freud might have a few interesting things to say about why, that kind of makes me feel a bit like the goofy kid nobody wants to play with!

Why is this a big deal? Because if everyone in the operating room does not work as a team, the patient can suffer. According to Dr. Makary:
"This is a topic that speaks to the issue of a nurse in the OR knowing that a sponge is retained in the abdomen but not saying anything because of the hierarchy that we have espoused....not saying anything because the last time she did she was criticized."
I agree that there are many of us, including myself at times, who are controlling and even imperious SOBs. And I agree that in most situations, that is not only bad manners, it creates an atmosphere where mistakes can be made. Communication between all members of the OR team needs to be clear and free from criticism.

However (you just knew I had to throw in one "but-monkey"), there are times when pretenses need to be put aside and decisions are made by one and only one person -- the person with the ultimate responsibility for the patient's care. In a critical situation, the surgeon is the "captain of the ship" and must make sure that the patient's best interests are looked after; he or she is frequently the only team member to know all of the facts regarding the patient's history and preoperative care. There's a bit of finality involved with some decisions made in the OR -- sort of crossing the Rubicon -- and the process at arriving at those decisions has to be respected. The patient bleeding from a major liver laceration may need to be packed, and it does not help to have the scrub or circulating nurse complain loudly that it's "against AORN guidelines" to leave packs in the abdomen --- yeah, I know that, but this is what the patient needs, right now, please don't argue with me!

Now that I got that out of my system, it's pretty obvious that communication between team members is critical. I feel the best ways for a surgeon to facilitate this in the emergent situation is to:
  1. Make the OR a fun place to work -- play music, tell jokes, and above all be nice -- in the non-emergent situation; the staff is more comfortable with the surgeon who is interested in them, rather than in themselves
  2. Educate the staff -- they are almost uniformly interested in learning more
  3. If the staff is educated, they are much more likely to understand what you are trying to achieve in the emergent setting
  4. There is almost always time to explain what you are planning to do or are doing at the time, and why, which once again is helpful in keeping appropriate communication going
  5. Say "thanks," especially if a team member catches a potential hazard (wrong sponge count, etc.), but always say "thanks" when you leave the OR --- and yes, that means you should thank the anesthesiologist too!
One of my personal heroes is Ronald Reagan. Putting politics aside, one thing nearly all of those who knew him recognize is that he was very willing to surround himself with capable, intelligent men and women -- not "yes-men" -- and was not afraid to hear their opinions before making his own final decisions. Surgeons could do far worse than emulating this example.One of my partners is known to ask student nurses in the OR, "who is the most important person in this room?" It's a great lesson for the often timid student to hear this man, who has been practicing surgery for over 30 years, "no, it's not the surgeon -- it's the patient."