As a cardiac surgeon, must I work closely with nurses from time to time on patients at imminent risk of death. It can be an intense, almost overwhelmingly emotional, task. Even if one nurse is able to manage all the technical tasks and one physician can make all the right decisions, the two have to work together closely. If nothing else, it is critical for morale reasons when handling that kind of grueling job. Without that support, you can go crazy. When I drop a sick cardiac surgery patient off in the ICU, I have found our nurses at Mercy are excellent at detecting when a patient that starts to do poorly. That nursing skill is irreplaceable and what I depend on the most as a surgeon hoping my sick patient does well. What nurses need from me in return is to help them figure out why things have gone bad so it can be corrected. They will likely have their own idea on how to make things better but need me as a teammate to help with a final decision that takes their judgments into account. At the start of my surgical career, the most common advice I got from senior cardiac surgeons on how to be a good teammate was to be approachable. Ability—the skills and knowledge to come up with the correct plan of attack—is never as important as approachability. Nurses think differently than doctors; it is an unnatural act to work with those that think differently. Approachability makes those interactions far easier and effective.
Imagine you are Capt. Sully, the United Airlines pilot that became famous for flying a commercial jet into the Hudson River after hitting a flock of birds right after takeoff. In this alternate reality, you quickly diagnose a double engine failure after the bird strike. However, at the exact time you need support the most, your copilot Capt Skiles is acting unapproachable. Rather than calmly helping you go through critical checklists and being supportive of your decisions, he is second-guessing, nitpicking and criticizing you: “Why land in the Hudson?”, “How could you get us into this mess?!” It is doubtful anyone would have survived that flight. Such misbehavior, no matter how fleeting, would hurt Sully’s decision making ability and the chance of a safe landing. Similarly, nurse performance can suffer after perceiving a disgruntled response to a call for help. Any physician behavior that smells like unapproachability, even when subtle and unintended, hurts teamwork because further calls for help won’t (and probably shouldn’t) happen. Lack of effective communication among healthcare teams is strongly linked to adverse events and medical errors.
My frame of mind when I get a call at night by an ICU nurse is to see it as a complement. It means someone talented is seeking my input because they believe it will help their patient that depends on them. When the judgment of one of our ICU nurse is off track, I try to use the episode as a teachable moment, not a time to criticize or make them feel bad. Approachability means responding in the middle of the night without a hint of annoyance or disapproval. However, it is not enough to have this frame of mind, be friendly and avoid being critical as we pursue the ideal of becoming a high performance team. The final hurdle is that we must not leave conflicts unresolved.
Conflict is inevitable among those taking care of cardiac surgery patients. Not seeing it is a bad sign. Most likely in that case, the conflict is either being covered up or your staff is too burned out to bring it up. One of the more common sources of conflict that I have seen as a surgeon at a community hospital is disagreements about case selection. Transferring a patient needing surgery to another center because their procedure carries a high risk for mortality often feels like an intuitively correct decision. Showing discretion and restraint is consistent with our oath to “first, do no harm”. I have the moral obligation to consider whether it is necessary to send a patient referred to me to another center with a higher volume of cases (>500 cardiac cases per year). They seem more likely to do a better job. After all “practice makes perfect”. If you are doing >500 cases per year, it is only logical to expect better results.
Outcomes are clearly better at high volume centers for specific unusual operations. For instance, oncologic operations – like the removal of the pancreas or the esophagus – have better outcomes at high volume (academic) compared to low volume (community) centers. This happens because volume creates ‘economy of scale’, which leads to a more robust infrastructure and the ability to recruit the necessary highly specialized physicians, surgeons, allied healthcare providers, and other ancillary personnel. Scale yields more extensive resources– the most up to date equipment, greater expertise in the blood bank and pharmacy. If complicated surgery doesn’t work out as expected, there are back up options available such as left ventricular assist devices and even heart transplant. When there is a residency/fellowship training program involved, there is 24 hr in house coverage with surgical residents and intensivists. All of these benefits allow for more comprehensive care.
Now for my contrarian point of view. Regarding the case of cardiac surgery, the concept of practice makes perfect is only half true. When we understand how volume improves results, we recognize that case volume improves patient outcomes for some cardiac surgical procedures but not others. Certain cardiac surgery cases such as CABG or isolated valve surgery have seen reproducible success at small centers just as often as large centers. Unlike rare cases such as aortic dissection or congenital heart surgery, the link between hospital volume and mortality is not as strong for the routine cardiac cases and that relationship is confounded by surgeon experience. It is well established that an experienced cardiac surgeon can get just as excellent mortality numbers for CABG and valve cases at a low volume program as compared to a high volume one. Compared to oncologic operations, outcomes after cardiac surgery are influenced by significant standardization in perioperative processes of care. Standardized processes reduce postoperative complications at both low and high volume programs.
When analyzing the problems at those programs with highest mortality rates, the problem is rarely their compliance with standardized processes. Instead, the problem is usually with a metric called “failure to rescue”: patients that suffer major complications after surgery have a high death rate. The term ‘rescue’ refers to getting patients back to full health after a complication. Successful rescue requires detecting problems early before they get out of hand (talented ICU nurse) and efficient implementation of the right plan (approachable doctor). The synergy of interdisciplinary communication, like standardized processes, tends to promote rescue irrespective of the volume at a program. Without that synergy, having high volume at a program just increases the frequency of deaths and exposes problems.
Based on these data, tackling a high risk case safely at our center requires me as the leader to focus the team on getting better at patient rescue. Excellent teamwork involves both give and take. What I am willing to give to our ‘rescue project’ is to be available 24/7/365. Along with 22 yrs of experience, this commitment to being available gives me credibility with the nurses. They know I have the broadest possible perspective on sick patients as the only one who has seen them in all phases of care: preop, intraop, and postop. Minimizing the need for handoffs to other surgeons enhances situational awareness, which is a critical aspect of picking up on bad trends early before a complication gets out of hand. Large academic centers are going the other way on this issue. Recent attempts to reduce resident work hours have not had the improvement on patient safety that was intended. Less hours worked per resident without hiring more people increased the frequency and number of patients handed off between residents that remain overworked. Handoffs remain the Achilles’ Heel of patient safety. I have always sought out feedback on my plan at our Heart Team conference before scheduling high risk cases for surgery.
Another area of focus is to provide informal coaching for our ICU nurses. We have implemented a unique OR-ICU handoff protocol that I call “running in parallel”. It has become increasingly popular among our team because of how much having a nurse receive the handoff within the operating room improves information exchange. We arrange for regular ICU debriefs where we discuss cases and learn from mistakes. At one of these meetings, we agreed that CT surgery patients will be routinely provided a consultation with the palliative care service when they are at increased risk for a longer recovery so their goals of care can be clarified. They have been invaluable in getting patients to articulate how willing they are to be rescued from a difficult postoperative course before they ever embark on a potentially hazardous operation. Finally, I frequently engage in bedside teaching moments that occasionally attracts nurses and nursing students taking care of other patients.
Teamwork is not just “give”, but also some “take”. If I truly want to optimize our team, I cannot shy away from efforts to resolve any conflicts about the topic of high risk cases. I acknowledge the difficulties these cases put on nurses. Case selection is challenging – more of an art than a science. Effective conflict resolution also requires me to be assertive and advocate for my own views on this issue. Our ICU nurses to respect the power of the surgeon-patient consent. This sacred contract creates too many obligations of a surgeon to restate here but also grants inherent rights. Most importantly, surgeons have the moral authority to judge what is in their patient’s best medical interest. If I’m doing that job right, I will incorporate the collective wisdom of all those involved. But critical moments can happen quickly in an ICU where someone has to be the one to “break a tie”. It is the consent that grants that to the surgeon. I bring this up to help me become more approachable and a better teammate in the future.
Practice does not make perfect. Only perfect practice makes perfect. What this means is that I can spend 10,000 hours on a golf course and never become a master golfer. It is not just practice, but engaging in the right kind of practice and the right kind of feedback that makes one better. Mistakes aren’t the problem. The problem is not taking the time to articulate the specifics of the mistake, the cause of the mistake, and the potential solutions, so you can avoid making that same mistake over and over. If that mistake is choosing the wrong patient to operate on, we will be honest and learn from that mistake. If showing that kind of candor makes me more approachable, it will help all the other cases we agree to take on.
robpostonblog 