Effective teamwork in perioperative teams is a prerequisite for patient safety. Yet, what is rarely discussed openly is the special importance of dyads in teams—the relationship between two individuals. If you’re an anesthesia professional, you likely are aware, at least subliminally, of the erosion of patient safety when you are working with a surgical colleague with whom your relationship is not a pleasant one. At the least, it can make for an unpleasant workday experience; at worst, a dysfunctional relationship can be a critical element that enables or causes an adverse outcome. On the flip side, when one is working with a trusted, respected colleague and the feeling is mutual, you are much more likely to have a happy day and your patient is more likely to have an optimal outcome.1* I addressed this topic in a commentary published simultaneously in Anesthesiology and The Journal of the American College of Surgeons (an unusual occurrence) and more recently, in my presentation for the annual Ellison C. Pierce, Jr., MD, Lecture hosted by the APSF and the ASA.2,3 I summarize here key observations and suggestions for action.
In the presentation and the article, I focus on the dyad between the physicians in the team, anesthesiologists and surgeons. I do note that the other dyads are also of high importance to patient safety, i.e., that between surgeon and OR nurse and between surgeon and any anesthesia professional. Yet, my gut tells me that there are aspects of the physician dyad that create the potential for particularly problematic dysfunction; that is my current focus (maybe I’ll get to the others soon). Why did I choose to focus attention on this topic? Over the years (47 plus since I began working in health care), in various quarters, I’d heard one too many anecdotes about adverse events that were either caused by relationship dysfunction or could have been prevented by a positive relationship. More importantly, I’d heard one too many disrespectful remarks that represented stereotypes that anesthesia professionals have about surgeons. I don’t have as much opportunity to hear similar comments from surgeons, but when I’ve probed, I have found similar stereotypes there as well. While the stereotypes and disrespectful remarks are not in themselves potentially harmful to patients, the attitudes they represent can lead to communication failures and lack of collaboration and collegiality that can either cause, enable, or fail to prevent an adverse event.
Some of the specific negative stereotypes are listed in Table 1. These come from years of listening as well as my seeking input from surgeon and anesthesiologist colleagues, near and far, with both private practice and academic experiences. Again, I have no data on which to provide concrete evidence, but no one I’ve presented this to has challenged any of the comments nor pushed back on my assertion that this is too prevalent and not healthy.
Table 1: Negative stereotyping
|Examples of anesthesia professionals’ stereotypes of surgeons:
|Examples of surgeons’ stereotypes of anesthesia professionals:
Considering how important it is that surgeons and anesthesiologists work collaboratively, it is surprising that there is little research about this topic, almost none specifically about the anesthesiologist-surgeon dyad. Lorelei Lingard and colleagues have, in several studies, examined situations where the discourse within the perioperative team revolves around conflict.4 One comment arising from those studies is that “Subjects’ constructions of other professions’ roles, values, and motivations were often dissonant with those professions’ constructions of themselves.” Related to that comment is the observation that “Team members use assumptions about speaker motivation to interpret communicative exchanges.”
Jonathan Katz has specifically addressed conflict in the OR.5 He notes that “cancellation… for additional evaluation… is among the most frequent causes of conflict between surgeon and anesthesiologist.” He also notes that sources of conflict present an opportunity for collaboration. A goal should be to turn all such opportunities into productive collaboration in the interest of the patient, seeking to learn what is right, not who is right.
Diana McLain Smith writes about how functional and dysfunctional dyads in leadership teams are critical to either success or failure in organizations.6 The characteristics and outcomes she describes are clearly applicable to perioperative care and to the leadership team in the OR. What is different about this construct from the usual discussion about teams is that the focus is on relationships between two individuals rather than on the team as a whole.
Both are important. What I’m suggesting is that relationships between individuals are equally, if not more important, to understand and improve.
What are specific ways that the interactions in this dyad impact patient safety for better or worse? I’ve heard many stories in my almost 35 year’s experience as a member of a quality assurance review committee and via many vignettes told to me as I’ve probed more into this topic. Consider an anesthesiologist, who even though junior, may be more expert than the surgeon in physiology, and who tried to communicate to the surgeons that their diagnosis did not comport with the data. Not having an established, trusting relationship with the surgeon, the surgeon disregarded his suggestions. When the anesthesiologist was right, the patient outcome was much worse than it might have been if the surgeon collaborated with him. Or the anesthesiologist who, despite the surgeon’s extensive experience in performing cricothyrotomy, disregarded the surgeon’s suggestion that it was time to move the difficult-airway algorithm along and the situation dangerously went downhill. These were true stories that are likely familiar to you.
There is the flip side: I heard independently from an anesthesiologist and surgeon about a situation where their prior trusting relationship was clearly an enabler for success. A needle with a pop-off suture had separated prematurely. The surgeons, unable to locate the needle, were fixated deep in the wound seeking to find it. The anesthesiologist, watching the struggle, waited for an appropriate moment to suggest a brief regrouping and consideration of options. That led to the use of fluoroscopy to find the needle. I’ve heard of situations as well where a surgeon gave his or her anesthesia colleague a heads-up the day before, or earlier, about a patient issue with anesthesia-related implications that averted a patient safety issue. I suspect that most anesthesiologists reading this have had similar experiences. Indeed, some of you are fortunate enough to have regular experiences of this latter type rather than the former. Every patient should be so lucky.
If what I’m describing rings true for you, what can be done to make this dyad function more routinely effective? I’m not aware of empirical evidence to guide suggestions, but there are some general principles about relationship-building that can apply. I’ve suggested in the article a few things that are practical; yet, taking the first step isn’t easy. In most relationships needing improvement, each party needs to “buy in.” You might think, “it’s not mostly my fault; it’s the surgeons who need to behave better.” I’m not judging who is more at fault when things aren’t going well. But I can say for sure that nothing will get better if at least one person doesn’t try to start a constructive dialogue.
Here’s some suggestions, any one of which you could consider trying (I didn’t make these all up. Many of your colleagues already do some of these. You can think of your own too):
- Take a surgeon to lunch or dinner. (this is an especially productive thing to do when a new surgeon joins your hospital)
- Form a focus group to discuss one of the articles in the references. Listen more than you talk. Seek to understand why behaviors you observe may come from different sources than you imagine.*
- Work together on common issues, e.g., lowering the risk of surgical infection, which anesthesia professionals might contribute to; implement emergency manuals together.
- Assume the best intentions, as in the “basic assumption”7 now widely taught in simulation and modified for this application as: “my surgical colleagues are intelligent, doing things in the best interest of their patients, and trying to improve.” It’s not always so, but it mostly is.
- When someone does something that makes you think “WTF,” the “F” should stand for “frame.”8 Instead of attributing a negative stereotype, be curious, seek to find out what the rationale behind the action is. You are likely to learn something new; even if what the person is doing isn’t optimal or right, it’s usually for a good reason. If there’s not a good reason, you’ll have an easier time getting them to see things differently versus just assuming they are irrational.
- Train together in simulation with the entire team. It’s a proven way to improve the team’s crisis management skills. In addition, it puts you in a position to have dialogue at an equal level. More simulation programs are doing this. You could even take the lead and suggest a team try it out. Sure, it costs money and takes a lot to organize (just getting the people there is tough), but it’ll pay off in lots of ways.
- Read a book about communicating across relationships, e.g., “Difficult Conversations,”9 or “Thanks for the Feedback.”10 Relationships are hard. There’s a lot to learn. Fortunately, there are lots of good models to learn from.
I’m not promising you a rosy world if you work at this. But I think it’s worth your time for your patients’ safety to try as much as you can. Doing nothing will mean nothing will change. If your efforts succeed, you’ll have made a huge advance for patient safety, and you’re likely to find more joy and meaning in your professional daily life.
*If you want to organize a focus group or presentation, I can send you a link to the animations I used during the lecture, including a shortened version of “There is a Fracture.” (You can find the original on Youtube.) The other two animations are of the view surgeons have of anesthesiologists and of what a healthy collaboration would look like.” (No charge. You just have to promise to use them for good.)
Dr. Cooper is professor of Anaesthesia, Harvard Medical School and the Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital. He is a founder of the APSF, retiring from the Board of Directors and Executive Committee in 2018 after 32 years of service. This article is a summary of a portion of his lecture for the Ellison C. Pierce, Jr., MD, Memorial Lecture at the American Society of Anesthesiologists Annual Meeting, October 19, 2019.
Dr. Cooper reports no conflicts of interest.
- Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Qual Saf. 2019;28:750–757.
- Cooper JB. The critical role of the anesthesiologist-surgeon relationship for patient safety. Anesthesiology. 2018; 129:402–405. (Pub ahead of print) (co-publication in J Amer Coll Surg. 2018;227:382–86) http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2695026
- Cooper JB. Respectful, trusting relationships are essential for patient safety, especially the surgeon-anesthesiologist dyad. Ellison C. Pierce, Jr. Memorial Lecture. Annual Meeting of the American Society of Anesthesiologists, October 19, 2019. Accessed November 11, 2019. https://www.apsf.org/news-updates/watch-jeffrey-b-cooper-ph-d-give-the-anesthesiology-2019-asa-apsf-ellison-c-pierce-memorial-lecture/
- Lingard L, Reznick R, DeVito I, et al. Forming professional identities on the health care team: discursive constructions of the “other” in the operating room. Med Educ. 2002;36:728–734.
- Katz JD. Conflict and its resolution in the OR. J Clin Anes. 2007;19:152–158.
- McLain Smith D. The elephant in the room. San Francisco: Jossey-Bass; 2011.
- Rudolph J. What’s up with the basic assumption. https://harvardmedsim.org/search-results/?swpquery=basic+assumption Accessed November 11, 2019.
- Rudolph J. Helping without harming. SMACC, Berlin, June 26, 2017. https://www.youtube.com/watch?v=eS2aC_yyORM Accessed October 29, 2019.
- Stone D, Patton B, Heen S. Difficult conversations: how to discuss what matters most. Penguin Books, Ltd., London, 1999.
- Stone D, Heen S. Thanks for the feedback. Penguin Books, New York, 2014.