No, this is not an article on how to spot surgeons on your staff whose skills have begun to decline! Rather, it is a summary of a recently published paper (Moulton 2010a) in the human factors engineering field that focuses on how skilled surgeons refocus their attention at critical times during surgical procedures. And we think that their findings also have some very important lessons from a systems perspective and implications for everyone in the OR.
The authors address (and in this case actually challenge) the premise that “experts” are able to do much of what they do while they are in “automatic modes”. That is, they tend to be able to perform many tasks and sub-tasks without giving much conscious thought to them. Rather, many of those processes are being handled at a subconscious level in the brain. But, obviously, any expert needs to be able to pop out of that “automatic” mode when necessary to take actions when circumstances change or unexpected events take place. So the authors looked at how highly respected surgons handle this transition from “autopilot” to a more focused cognitively effortful state. The authors consider this “slowing down” as the key factor that keeps surgeons from getting into trouble in cases and avoiding complications, adverse events, and near-misses.
The authors selected for their study surgeons at four Canadian academic medical centers who had reputations for having excellent surgical judgment. They conducted one-hour semi-structured interviews with 28 surgeons and further interviews with 8 of those surgeons. They then did direct observation in the OR of 5 hepatobiliary surgeons performing a total of 29 cases.
They found that the responses of surgeons were grouped into four categories on a continuum ranging from “stopping” (the most extreme response) to “fine-tuning” (the most subtle response). Responses in between were “removing distractions” and “focusing more intently’. They point out, however, that one does not really transition through each of these responses.
“Stopping” was the most extreme category. Here the surgeon would temporarily bring the procedure to a halt at a critical moment. Sometimes this stopping was actually planned ahead of time and was simply acknowledgement that a critical phase of the operation had been reached and the stopping was to ensure that all the staff were ready to proceed and that all resources were available for the next critical phase. In others the stopping occurred at a point of uncertainty and the surgeon might stop and look at the patient’s record or images or ask a colleague for assistance. In that type of stopping, use of words like “regroup” and “reassess” were often used.
“Removing distractions” was when, upon encountering a slowing down moment, the surgeon might become irritated and distracted by external stimuli. He/she might tell others in the OR to remove the distractions so that he/she could focus better on the issue at hand. The authors note that sometimes other OR team members might recognize the need for removing distractions but not always. They quote one surgeon as saying “Good nurses get it and residents may not.”
“Focusing more intently” means the surgeon may allow external distractions to continue but becomes more focused on his/her task at hand. Though they let conversations around them continue, they might drop out of those conversations themselves. If in a teaching setting, they might temporarily drop out of the teaching interaction.
“Fine-tuning” is the most subtle category and reflected minor transitions from the routine and might be considered a less intense manifestation of “focusing more intently” or “removing distractions”.
The term “slowing down” is really a misnomer since the surgeon’s hand movements and pace may not appreciably slow down. Rather it refers to the refocusing of attention that is taking place in the surgeon’s mind and transitioning from that more “automatic” mode to one where conscious effort is being focused an a task or situation at hand. This change is in response to some cues apparent to the surgeon that have alerted him/her of the need to change conscious effort. Those cues could be that a crucial stage of the procedure has been reached or that there is a peculiar situation encountered (eg. anomalous anatomy) or that a complication has occurred.
Interestingly, most of the surgeons in the study bristled at the premise they work on “autopilot”. Rather, surgeons felt that they always have a level of background situational monitoring but that, at certain times, they develop a heightened awareness of circumstances. However, they did recognize that sometimes a state of “drifting” might occur. It is during drifting that the background surveillance and situational monitoring may fail and these are times when they become prone to errors and adverse events.
The implications from a system perspective ought to be clear. It becomes critical that all the staff in the OR (or the cath lab or any variety of other sites doing procedures) need to recognize cues that the surgeon has switched to a more focused mode. In all likelihood they, too, need to refocus at such times. It’s similar to what happens in an airplane cockpit. When the pilot (or sometimes the copilot) notes something unusual going on, he or she does a similar “slowing down” or refocusing and others in the flight crew should pick up on this.
The real lessons, therefore, logically are for team dynamics. This may be one factor that experienced teams that have long worked together do naturally. They may more readily recognize cues in the surgeon’s behavior that indicate the need to minimize distractions. The paper noted that sometimes the signs are very subtle and body language may say a lot more than verbal language. One surgeon noted he might start sweating a little bit or might not appear as happy.
So keeping well-functioning teams together makes a lot of sense. While a lot of organizations like to rotate their OR staff and anesthesiology staff so everyone gets to work with everyone else, perhaps the concept of long-term teams makes sense. Particularly in an academic/teaching situation the constant changing of personnel may be a challenge. The same authors also describe how surgeons handle the “slowing down” phenomenon in a teaching setting (Moulton 2010b), balancing direct (hands-on) control with overall control.
Can you teach people to look for cues that indicate “slowing down” has occurred? We don’t know. However, we think that two team dynamics exercises might be of benefit. One is OR simulation. Most OR simulation programs have obvious “disasters” pop up and see how people respond. But maybe programming in some more subtle “transitions” might be useful. The second potentially useful exercise is videotaping OR procedures, then having all the staff view them and see if they can identify the subtle signs of transitions.
There remain many unanswered questions. The surgeons in this study were selected because of their good reputations. Do surgeons with lesser reputations respond in the same ways? Do the same dynamics hold during emergency operations and routine operations? Does fatigue (surgeon or staff) change the levels of background situational awareness or the transitions? Do diversity issues (both language and culture) interfere with recognizing the subtle cues during “slowing down”?
We don’t know these answers. But this is a good paper to share with your surgical staff and your operating room teams. We’ll be it will generate lots of anecdotes about how the staff knows when individual surgeons reach a “slowing down” transition. But hopefully it will generate enough interest that they will begin to look for such transitions and take their own steps to minimize distractions and help the entire team focus during such periods.
Moulton C, Regehr G, Lingard L, Merritt C, MacRae H. Slowing Down to Stay Out of Trouble in the Operating Room: Remaining Attentive in Automaticity. Academic Medicine 2010; 85(10): 1571-1577
Moulton C, Regehr G, Lingard L, et al. Operating from the Other Side of the Table: Control Dynamics and the Surgeon Educator. J Am Coll Surg 2010; 210: 79–86