Leveling the Playing Field


Following several tragic aviation disasters in the 1970s, the airline industry adopted a training method called Crew Resource Management (CRM) to enhance safety of commercial flights. The essentials of this new concept included checklists, briefings, and a flattening of the hierarchy in the cockpit that encouraged all crew members to express their opinions, even when in conflict with those of the captain.

The results of CRM training have been astonishing. There were no deaths secondary to airline crashes during 2007 and 2008, a period in which commercial airliners transported 1.5 billion passengers. And according to Arnold Barnett, Ph.D., a professor at Massachusetts Institute of Technology, Cambridge, who has written extensively about airline fatality risks, it’s more likely for a young child to be elected president than to die in an airline accident in the United States or similar industrial nations (USA Today, Jan. 11, 2009).

Considering the similarities between the cockpit and the operating room – intense environment, dependence on elaborate equipment, multidisciplinary team dynamics, a historically rigid hierarchy, and the potential for catastrophic results – there has been considerable interest in using CRM training to improve safety in the OR. In fact, a mini-industry of CRM training consultants has arisen and made themselves readily available to those hospitals desirous of pursuing this course. Early results suggest that such an approach improves communication among OR team members, enhances efficiency, and decreases the incidence of complications.

Practices such as checklists and briefings are relatively easy to transfer to the operating room. But what about flattening the rigid hierarchy that has long been a central component of surgical culture? As soon as a surgeon enters the OR, a steep power differential develops between that surgeon and all other members of the team. This power differential can inhibit team members who are often hesitant to express their opinions. Unfortunately, many surgeons enjoy their exalted positions. In a survey of airline pilots and surgeons, 97% of pilots, but only 55% of surgeons, rejected hierarchies (BMJ 2000;320:745-9).

Leveling the playing field within the OR can occur only if the surgeon exhibits strong, inclusive leadership. After the time-out (briefing), during which the surgeon must be present and OR team members are introduced to the anesthesia and nursing staff, the need for open communication in the name of safety should be stressed. The surgeon should share examples of times in the past when observations by junior members of the team helped resolve difficult situations. While not relinquishing the team leader role, the surgeon should emphasize that thoughtful input by all team members is highly valued and is likely to enhance the safety and the outcome of the procedure.

To further encourage those who may be timid about sharing their observations, the surgeon should directly solicit input from team members as the operation proceeds. If their opinions are off the mark, the surgeon should avoid public criticism and instead offer feedback constructively and in private after the operation is concluded. Harsh public criticism is an effective way to permanently silence a nurse or junior colleague.

Actions often speak louder than words. Calling or inviting a colleague into the OR for his or her opinion during a procedure is a powerful statement that the surgeon is willing to be guided by the advice of others. Even when it was not necessary, I sometimes did this to emphasize to my residents that inviting advice or assistance can be a wise choice rather than a sign of weakness.

To replicate the impressive record of safety achieved by the airline industry, surgeons must move away from an authoritative and commanding style of leadership, and instead adopt an inclusive style that encourages and values input from everyone – even those on the lowest rungs of the surgical hierarchy. The result will be enhanced communication, better efficiency, a safer environment, a more congenial atmosphere and, most importantly, improved outcomes for our patients.

Dr. Rikkers is editor in chief of Surgery News, a publication of Elsevier.

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