Modern Cardiac Surgical Hero

A report in 1999 by the Institute of Medicine indicated that there are around 100,000 preventable deaths in hospitals every year. This statistic has now become common knowledge, but few really grasp its magnitude. A jumbo jet crash killing all 500 people on-board every other day in US airports would still fall short of the number of preventable deaths in US hospitals. The analogy is appropriate because mishaps in planes are usually almost always preventable and lethal and certainly the image of frequent plane crashes get one’s attention. It is also inappropriate because it seems to grossly overstate the case. Every plane crash anywhere in the world is immediately front page news. But preventable deaths occurring at this magnitude at hospitals run by trusted pillars of our community? How can the process that got us here be going ahead as business as usual? If such a catastrophic loss of life were actually true, how come we aren’t hearing more about this? Answer: it can’t be true.
Part of the skepticism comes from laypeople trusting the competence of their own physicians over press coverage about a complex topic like healthcare. Lawyers are fond of saying: “failure to acknowledge a fact (i.e. 100K deaths), does not make that fact cease to exist.” The first step to acknowledge these facts is to explain the underlying mechanisms. It is not a problem for the healthcare system when a 90 year old grandmother that dies in the hospital after having a massive stroke at home. We are talking about preventable deaths caused by medication errors made by nurses, blood transfusions given for inappropriate reasons that trigger complications, infections from lack of handwashing or central lines left in too long, misdiagnoses by overworked physicians, patient falls, or surgery complicated by a retained sponge or wrong site/wrong procedure. Taken all together, these errors are heartbreaking but constitute a minority of the 100K preventable deaths. Every day hospitals have a tremendous volume of medications and transfusions given, central lines and surgical procedures performed and patients at risk for misdiagnoses and falls. Few actual deaths in the context of such a large denominator means that the risks posed from these categories is exceedingly small. In my 15 years of practice, I haven’t personally seen a patient death that was directly attributable to any one of these categories. Not to say that these problems are irrelevant, but there may be other “low lying fruit” not on this commonly cited list.
Hospitals that want to tackle preventable deaths should look where deaths within their walls occur most frequently. Heart surgery has annual US volumes of 400,000 cases and average mortality risk of 3.5%. At most hospitals, the number of mortalities from heart surgery exceeds any other service they provide. Estimates suggest up to 50% of cardiac surgical deaths are preventable. This adds up to ≈7000 preventable deaths occur each year. It may seem misplaced to criticize a specialty that has made such tremendous gains in the recent past. The mortality risk of heart surgery has been cut in half over the past decade at the same time patient risks for surgery have dramatically increased. These gains have largely been due to sweat and tears of surgical heroes of the past that have given us huge advances in technologies and training in the field. These advances have allowed surgeons across the US to routinely succeed in getting patients through procedures that would have been considered inoperable in the past.
In contrast to advances in high risk cardiac surgery, preventable deaths occurring in routine cases have remained a persistent problem in CT surgery. A recent scientific statement from the AHA suggests that preventable CT surgery deaths are mostly from non-technical issues, mainly poor communication and problems with teamwork. To date, these issues remain unmeasured and unaddressed.
Some criticisms about the nontechnical skills of current-day cardiac surgical heroes may just be confusion about their strong self-esteem. Cardiac surgeons live with the fact that someday they will make a mistake that kills a patient. Those that successfully confront this reality are confident, strong, and extremely disciplined, both mentally and physically. There are unique personality traits that enable a person to have essentially no tolerance for error, a meticulousness to achieve incredible outcomes and the dedication required to be at the top of their game. These are often the same traits that make a surgeon difficult to deal with.
Similar to a General in the battlefield, the cardiac surgical hero gained the respect of their team through a commanding presence in the OR. They capitalized on their gravitas by disciplining their team when patient care was compromised. After establishing a track record of success, the OR team naturally develops that learns the routines of the type of case necessary for success. Armed with this tacit knowledge, communication among the team is effortless and trust becomes a natural byproduct.
To some extent, the cardiac surgeons’ image as a hero simply reflects the world’s view of them. Cardiac surgeons generate lots of revenue for the hospital and are among the most comprehensively trained doctors in the hospital, making them attractive models of success to administrators in both hospital operations and academia. Their surgical approach has been well suited to the American temperament to get things done definitively. An ICU nurse that wrote a book about her experience with heart surgery (Opening My Heart, by Tilda Shalof, 2011) described Dr. Tirone David as her “rock star surgeon”. She seemed so infatuated with his skills and status that she brushed off how dismissive he was about her attempts to discuss her living will, to the point of worrying that the mere suggestion she might die offended him. Then there is the Hollywood version. Most of us remember the compelling movie moment created by the cardiac surgeon played by Alex Baldwin in the movie “Malice” (1993): “When someone goes into that chapel and they fall on their knees and they pray to God that their…mother doesn’t suffer acute neural trauma from postoperative shock, who do you think they’re praying to? … You ask me if I have a God complex. Let me tell you something: I am God.”
Even if there isn’t a kernel of truth about the God complex, there is no denying that the image of a cardiac surgeon as the aloof, heroic battlefield General is engrained into medical culture. The market helped define this image as one that gives confidence to patients, referring doctors, administrators and other stakeholders in cardiac surgery. I suggest that this image has also triggered important problems. Almost 50 years ago, another field already proved that a dependence on individual heroics hinders the ability to create a safe and highly reliable system: the aviation industry. Pilots from the 1970’s were often from a military background and had the type of dysfunctional personalities that made their co-pilots reluctant to speak up about concerns. The rate of airline accidents declined sharply over the last 3 decades as deliberate efforts were taken to flatten the hierarchy in the cockpit. Pilots were encouraged to seek out input from co-pilots and other crew and team members were trained to be more assertive. These efforts, called crew resource management, greatly enhanced safety and dramatically reduced accidents. The analogy to the OR is obvious. A terrific surgeon will discuss mistakes with the team and learn when they happen in order to stop preventable harm in the future. A dysfunctional surgeon will manipulate the information to suggest it was not their fault.
What is the evidence for dysfunctional leadership in the cardiac OR? First of all, surveys of OR staff demonstrate that nurses often perceive cardiac surgeons as being unapproachable. This creates a state, described by sociologists as poor psychological safety, which makes nurses and other OR staff reluctant to express their concerns about patient care. The natural progression is that staff eventually lose the feeling that they are obligated to speak up to prevent harm. Stop and think about how personally tragic it is when someone becomes resigned to not speak up about something that could harm a vulnerable patient. Not just that they are afraid to, but eventually they suppress any urge to do so. Careers that started in the cardiac OR with idealistic goals of helping patients through one of the scariest moments of their life then decay into one that accepts that preventable harm is just business as usual. It is impossible to overstate the profound and lasting impact this has on team morale. Even in those cases where the lessons should be obvious, the learning in this type of environment is poor and seldom able to be adopted into future practice. Problems with communication and team learning become amplified when trying to adopt novel technology and techniques like robotic surgery. Acquiring tacit knowledge (i.e. how things have been done in the past) no longer applies when the proposed techniques are new, yet learning for the demoralized team can’t occur any other way.
Being labeled “unapproachable” may not be entirely the fault of the surgeon. The best surgeons have a high demand for their services and are engaged in lengthy surgical procedures and complex management postop, leaving little time to chat with nurses. However, if surgeons wanted to send a signal to their team, they would start by being transparent with the outcomes of their own surgical patients. It takes humility and courage to stand before the team and deliver the truth about adverse events, accept their judgment, and work with them to pick up the pieces and build a better, safer system for the next patient. Evidence suggests that this transparency is not happening. For the last decade, there has been a voluntary reporting system for outcomes of cardiac surgery provided through websites of the Society of Thoracic Surgeons and Consumer Reports. Although every cardiac surgical program in the country was invited to participate, only 30% have chosen to do so. Transparency about harmful errors is the only approach any surgeon would insist on when an error was made in the care of themselves or a family member. But there is no equivalent of an SEC in healthcare to mandate transparency of results, so the majority of surgeons have elected not to do so. Perhaps it is unbecoming of a hero to have to show one’s dirty laundry or to follow the golden rule.
As for hospital administrators, their silence has been deafening. I know of no hospital in the US that has formal procedures for evaluating and correcting poor leadership in the cardiac OR. To do so would require someone (frequently without a medical background) to get knee deep in the weeds and really understand what causes preventable deaths. It also requires that same someone to act when they learn the answer is the attitude of your greatest money maker. Instead of promoting a just culture that emphasizes safety, most administrators seem more comfortable with the idea of blame and shame used by old school surgical heroes.
Sure, most hospitals now enforce the WHO checklist used during the “timeout” at the beginning of a case. Unfortunately, enforcing slavish compliance to checklists is not an effective strategy for reducing harm. The checklist tends to become an end rather than a means to achieving an end. Without a commitment to culture change, forcing this perfunctory activity is no different than taking a ride in a theme park. It is a curious distraction while happening, but once it is done the team soon snaps back to the same reality that caused 100K deaths/yr.
Skeptics suggest that past success in the cockpit of a plane is not applicable to healthcare. Aviation has a unified command structure with the pilot as the commander of cockpit crew members while an OR requires a more complex coordination of individuals accountable to a variety of different departments (anesthesia, medicine, surgery, nursing and administration). In my experience, members of any OR team willingly hold themselves accountable to authentic team leaders who admit their faults and have a compelling vision regardless of where their paycheck originates. On the other hand, the issue of one’s department is likely to crop up as an issue when leaders seek compliance and agreement with the old worldview of the infallible surgeon.

The leadership and vision required to motivate the team is the courage to break from the norm and challenge the status quo. The heart surgeons of my era that I know are grateful for the invaluable and sometimes painful lessons learned by those ahead of us that we generally refer to as the “cardiac surgical giants”. They didn’t keep their knowledge to themselves but were willing to hand it down in order to help the next generation. However, we owe it to them to make the tough decisions and should cut our losses from the paradigms of their past that have failed. It is time that a new generation of modern cardiac surgical heroes to be honest that our approach towards preventable deaths in our ORs has been inadequate. The modern hero is willing to speak loud and clear about this truth on behalf of those that either are not capable (i.e. patients) or not willing (i.e. demoralized staff) to speak about it themselves. We emulate the airline pilot when each case is preceded by a thorough briefing to the team about all the potential hazards that can be predicted for each case and followed by a debriefing where the “gloves are off” and we give honest appraisals so that the next case is performed better. One flight at a time is how the airline industry changed. One case at a time is how the culture of the cardiac surgical OR can change.
At the start of the US financial crisis of 2008, chief of staff Rahm Emanuel said: “You never let a serious crisis go to waste. And what I mean by that it’s an opportunity to do things you think you could not do before.” Modern surgical heroes don’t let failure dampen their spirit but see it as creating a chance to learn that is more powerful than if failure hadn’t occurred in the first place. For instance, all surgical innovations go through an initial adoption phase known as “the learning curve” that has been found by many to be brutally tough on the surgeon, team and (often) the patient. This period creates a mandate for excellent communication and teamwork in order for learning to be accomplished as quick and safe as possible. This mandate can then trigger changes in the way the team performs all other cases, even those that are routine and don’t involve a learning curve. Efforts to succeed with innovative cases like robotic heart surgery can have a halo effect of making routine cases safer.
It certainly isn’t going to be easy. It is a tough decision to admit your faults because cardiac surgery is a fiercely competitive field. The powerful, entrenched and often close-minded surgical heroes of the past aren’t actively seeking new people to take their place. It is possible they would exploit this transparency for competitive advantage.
The type of leader needed to tackle preventable death is actually far more heroic but will be celebrated far less than the cardiac surgical hero of the past. The modern hero knows it’s not about the leader, it’s the efforts of team that is what deserves to be celebrated.

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