Episode #73 Giving Thanks and an Encore: Healthy Relationships Across the Surgical Drapes

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show.

We have a global audience for our podcast which means that many people around the world are interested and dedicated to anesthesia patient safety. For many of our listeners in the United States, it is Thanksgiving this week. So today, we would like to take a minute to express our thanks to you, our listeners, for tuning in each week, for sharing the show with your colleagues and friends, for tweeting about the show, and for emailing in with questions. We are also thankful for our individual donors and supports, for everyone who joined the #APSFCrowd this year and for our APSF Legacy Society members. The APSF Legacy Society was established in 2019 to honor members who make a gift to the foundation in their estates, wills, and trusts. We are thankful to these members who will help to safeguard the future of anesthesiology by ensuring that patient safety research and education will continue going forward. We are thankful for our corporate supporters who have generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. We are also thankful for all of our anesthesia patient safety investigators. We are thankful for these dedicated researchers who are passionate about improving patient safety and working towards prevention of mortality and morbidity during anesthesia care. And we are thankful for all of the authors who contribute articles for the APSF Newsletter and website and provide information, news, updates, case reports, and so much to disseminate this knowledge to anesthesia professionals, perioperative providers, key industry representatives, and risk managers with a focus on anesthesia related perioperative patient safety issues.

And speaking of anesthesia patient safety investigators, you could be the next one. You will need to act fast though because the submission window for letters of intent opens on December 1^st and the submission period will close on January 1, 2022. We hope that you will consider applying for the Joint APSF and Foundation of Anesthesia Education and Research Mentored Research Training Grant. This is an exciting opportunity for the next generation of perioperative patient safety scientists. This is a two-year, $300,000 award with a goal for anesthesiologists within 10 years of their first faculty appointment to develop skills and collect preliminary data to go on an become independent investigators in the field of anesthesia patient safety.

In keeping with our theme of giving thanks, How many of you are thankful for the healthy relationships that you have in the operating room and perioperative areas? We know that healthy relationships between anesthesia professionals and surgeons are vital to patient safety. We talked about it on this podcast for Episode 6 and we have talked about it as part of our series on Clinician Wellbeing. Today, we hope you will enjoy this special encore presentation. Here we go.

[Episode 6]

Today, on the show I am going to discuss one of the most fundamental relationships in medicine. It is the peanut butter and jelly of the operating room.  That’s right today I am going to talk about healthy relationships between anesthesia professionals and surgeons and why this is so important for patient safety. For more information about this topic, you can follow along at APSF.org in the February 2020 Newsletter and I will link to the article in the show notes. The article is written by Jeffry Cooper, PhD. Cooper is the founder of the APSF and this article represents part of his talk for the Ellison C Pierce Jr MD Memorial Lecture at the ASA Annual Meeting on October 19, 2019.

If you attended that lecture, raise your hand or tweet at us using the #APSFpodcast!

Now, let’s get into the article.  Here at the APSF we are all about improving patient safety and one of the ingredients for safe perioperative patient care is effective teamwork.  The team of people in the OR, anesthesia professionals, surgeons, nurses, technologists, and other specialists must all work together and communicate effectively in order to provide safe patient care.  One important component of teamwork that needs a closer look is the dyad, or the specific relationship between 2 individuals.  For anesthesia professionals, you may have been in a situation in which providing safe patient care was difficult due to a challenging relationship with your surgical colleague. Cooper points out that at a minimum this unpleasant working relationship can set you up for a bad day at work and at the other end of the spectrum, it can lead to adverse outcomes for the patient.

Now, think back to the last time you had a pleasant day at work and provided safe anesthesia care…I am willing to bet that on that day you had a very different relationship with your surgical colleague, a healthy working relationship based on trust and respect. In fact, patient outcomes are tied to the relationships between the surgery and anesthesia teams.

Cooper points out that there are multiple dyads in the operating room and all of them are important for patient care. Today, we are going to talk about the dyad between the physician anesthesiologists and surgeons. Other vital dyads include those between the surgeon, the OR nurses, and other anesthesia professionals, and any learners in the OR.

One aspect of the dyad that can lead to disrespect and conflict is negative stereotyping.  These negative stereotypes can have a big impact on communication and patient care in the OR.  Some of the negative stereotypes that anesthesia professionals may have of their surgery colleagues include the following:

• They never admit how much blood they’ve lose
• They just want to make a lot of money doing more cases
• They don’t know anything about medical issues
• They always underestimate how long the case will be.

Now let’s flip the script.  Here are some examples of negative stereotypes that surgery professionals may have of their anesthesia colleagues:

• They just want to go home early and don’t care about the patient.
• They are ready to cancel a case at the drop of a hat.
• They’re often distracted and not paying attention in the OR.
• They never tell us about the vasopressors they are using.

While there is very little research on the specific surgeon-anesthesiologist dyad, Loreleli Lingard and colleagues studied situations in the operating room when discourse within the team centered on conflict. The findings revealed that “subjects’ constructions of other professions’ roles, values, and motivations were often dissonant with those professions’ constructions of themselves” and that “team members use assumptions about speaker motivation to interpret communicative exchanges.”

Another investigator Jonathan Katz looked at conflict in the OR between the surgeon anesthesiologist dyad specifically when the anesthesiologist recommends cancelling or postponing a case for further evaluation and optimization.  One thing that we should all consider is how we can use these potential conflicts and turn them into opportunities to improve communication and collaboration all in the name of patient care.  Remember, this is the time when it is important to discover what is right for the patient, not who is right in the situation. Diana McLain Smith examines functional and dysfunction dyads in leadership teams and how these dyads are so important for either success or failure of the organization.  It is an interesting take on evaluating teamwork since in this scenario we are looking at the specific and dynamic relationship between 2 people (the surgeon and the anesthesiologist) who function on a larger perioperative team in the OR.  We have to understand this relationship first if we want to then take the steps to strengthen the collaboration and help our team to provide safe care.

There are many examples in the operating room when the lack of an established, trusting relationship between the anesthesiologist and surgeon impacted patient safety…and the opposite is true as well. When there is collaboration between the anesthesiologists and the surgeon, it is easier to meet the goal of safe patient care. One example of this is a preop huddle between the surgeon and anesthesiologist to talk about the cases and the patients for the day so that everyone is on the same page. As an anesthesiologist, I personally have collaborated with surgeons on a preoperative huddle…either in person or by email on the day prior and it goes a long way for sharing information and building a relationship based on the goal of patient safety.

Now, what if you recognize that you are in a dyad that is dire need of improvement? It may not be easy, but there are some relationship-building principles that can help us out here.  First, you need “buy in” from the surgeon and anesthesiologist who both want to work on improving the relationship.  And then, Cooper gives us 7 examples of ideas that you might want to consider trying.  Here we go:

1. Take a surgeon to lunch or dinner. (this is an especially productive thing to do when a new surgeon joins your hospital)
2. Form a focus group to discuss the views that surgeons may have of anesthesiologists and that anesthesiologists may have of surgeons. Listen more than you talk. Seek to understand why behaviors you observe may come from different sources than you imagine.*
3. Work together on common issues. For examples, you can team up with your surgeon colleague to work towards lowering the risk of surgical infection or implementing emergency manuals together.
4. Assume the best intentions, as in the “basic assumption” 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.
5. When someone does something that makes you really stop and think. 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.
6. 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. In a similar way, combined grand rounds events may be helpful by bringing surgery and anesthesia professionals together learn from each other or to learn together from a guest speaker.
7. 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.

This list is not complete and we want to hear from you.  Is there an activity that you engage in at your institution to strengthen and improve the surgeon-anesthesiologist dyad?  Please let us know by tagging us on twitter and using #APSFpodcast.

Cooper wraps up his article with a disclaimer that even if you work hard to strengthen the dyad, the outcome may not be a rosy world, but it is absolutely a worthwhile investment of your time and effort for your patients safety to give it a try. Just like most things in medicine, there is a risk-benefit analysis and the benefit of improved patient safety  and finding more gratification in your professional life far outweighs the risk that nothing will change.  So, go ahead…give it a try and start strengthening the surgeon-anesthesiologist dyad.

If you have any questions or comments from today’s show, please email us at [email protected]. Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today. We hope that you will let us know what you are thankful for related to anesthesia patient safety on twitter and tag us @APSForg and use the #APSFPodcast. Thank you for listening and sharing.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2021, The Anesthesia Patient Safety Foundation