I am a nurse anesthetist (CRNA) who has worked in Paducah, Kentucky for many years. A few weeks ago, I had spontaneous, a heart-to-heart conversation with Dr. Poston. He seemed interested in what I had to say and (surprisingly) he wanted me to write down my thoughts about our team.
I first met Dr. Poston when attending a dinner that he arranged for the whole CRNA team at Cynthia’s Restaurant soon after he arrived in the fall of 2022. The purpose was to introduce himself, his management style, and his interests in debriefing. It would have been a nice evening, but for all the crazy debriefing stuff he talked about. Each advantage that he gave for having these debriefs made me increasingly resistant to the idea.
First, I hate meetings, particularly when they are mandatory. Second, we don’t need them. I’ve done cardiac surgery cases long enough to be able to see success as simple. Its about selecting a straightforward case for surgery. When a surgeon does that, everyone on our team does fine. We don’t have to talk with each other, we just let our years of experience kick in and be left alone to do our thing. If our CRNAs do that, the patient’s outcome is excellent. Overthinking our job screws up our rhythm and makes routine decisions harder. I’ve heard that called “analysis paralysis.” When I recall cases done over the past several years that didn’t go well, it’s almost always due to selecting a bad case. Unfortunately for us, CRNAs don’t have any control over this one thing that matters the most.
A third reason I was resistant: these heart surgery cases are tough on an anesthetist. I don’t know if Poston realizes how taxing these cases can be, compared to other surgical rooms. When I’m assigned to the cardiac room, I have to be “all in” and 100% committed. I know for a fact that every one of my colleagues is as well. We are constantly be vigilant, knowing things can go badly at any moment. What this means is that even when things go perfectly under the best circumstances, these cases drain you physically and emotionally.
So, why would a new surgeon strive to make it even tougher on us unnecessarily? The other cardiac surgeon has built an outstanding reputation over decades as the most gifted surgeon in town, in part by just letting crazy high-risk cardiac cases go to Nashville. Poston arrives on the scene and tells us he not only wants to keep those cases here, but from what others tell me, he makes us sit in front of the class with a dunce cap and get chastised for doing a bad job. Life is just too short to be humiliated while forced to do the impossible. I’ve never had complaints about my performance before. That gives me the credibility to say we need to keep things the way they were.
In addition, there is a much more pressing issue affecting patient care than these debriefs: we don’t have enough CRNAs. Over the past two years, several CRNAs have left, at least in part because of the increased stress of doing cases with Poston. Every time someone leaves, it becomes harder on those who remain. Most of us are now working longer hours than we ever have in the past. I didn’t even use all my vacation time last year. It just isn’t sustainable.
Two things are true and related: the other cardiac surgeon has always appreciated the way we do our jobs and recruitment has never been a problem in the past. Maybe it would be a smarter recruitment strategy to go back to his old ways: select more realistic cases and respect our expertise. Nobody wants to join a program where a new surgeon adds stress by nitpicking and throwing salt on open wounds. Believe me, if any of my CRNA colleagues don’t do a good job, they will be their own worst critic. We care a lot about our performance and don’t need our flaws thrown in our faces. I used to show up to work in a good mood—that doesn’t happen much anymore. Becoming demoralized doesn’t help make our jobs easier or job openings more attractive.
Even though my instincts told me not to, I was eventually badgered enough to attend one of Poston’s cardiac team meetings. I showed up at 6:30 am sharp to find a room full of OR staff already there, mostly just sitting still and staring at their hands. Poston was seated at the head of the table, seemingly oblivious to the tension building. Everyone sat quiet for almost an hour as Poston did all the talking.
Scanning the room reminded me of high school algebra: half of us staring ahead, trying to understand what was said, the other half too stressed to care. Nothing discussed was negative about me. It was mainly just technical stuff about surgery and not how I could perform my job better. He never even looked my way or noticed I was there. Boring, anticlimactic, and not at all what I was expecting. Talk about someone who can’t read the room. After that deflating experience, I stopped going.
My final concern about these meetings is philosophical. Paducah is a small town. Everyone knows what everyone’s doing; people get involved in your business. When a patient dies, we certainly feel horrible for the patient, but even more so for their families. I know most of them personally and routinely run into them at the grocery store and at church. The only way everyone on our team can remain at peace after a patient death is if we followed surgical methods that are tried and true, using methods we’ve done at our hospital many times in the past.
That’s not happening now: robotic surgery on high-risk cases, a team full of interpersonal tension, and debriefs with unclear motives. If you don’t do anything the way he thinks you should, it might end up being discussed in this blog. The Netflix show “Stranger Things” would call this Upside-Down world; it’s your same neighborhood but nothing resembles the past. It’s hard for any of us to comprehend such a horrific alternate dimension, and even harder to look our neighbors in the eye when a surgery patient has a bad outcome there.
Dr. Poston means well. Robotic surgery, debriefs, blogs: all very innovative. Some of the criticism against him might be unfair, but some is spot on. The root cause is cultural. He is now in a small town. This not the place where people go to rapidly innovate; their citizens don’t choose to live here because they want change. In fact, a scientific study has proven that people walk slower in small towns compared to big cities (3.5 vs. 5.8 km/hr). We walk that way because we want to say “hi” with those we know, not rush past them. Tight connections with neighbors are a good thing; it also prevents fads from catching on. Before trying something new, people raised in Paducah think of how others will respond. We always want our neighbors’ approval. When we don’t have a clear conscience after a bad outcome, it is hard to face grieving families
I looked at Dr. Poston’s CV and one thing stuck out like a sore thumb. He has never lived in small towns. He was born in Dallas and spent his career in big cities, usually in the north: New York, Chicago, Baltimore, Trenton, etc. I imagine big cities have their unique quirks just like Paducah. They are where you go to innovate; their sheer size makes it easier for people to develop and share ideas. It’s hard to do that in less-dense areas. I imagine people in big cities are excited to see someone like Poston and foresee how he might contribute to their intellectual projects. His passion is self-reinforcing. It attracts other educated, highly skilled, entrepreneurial and creative individuals. It may seem like a generalization to judge a city’s culture based simply on its size. But many of these factors are true.
Those raised in a small town like going to big cities, but we eventually come home. This happens for a reason. The things small towns stand for—goodwill, neighborliness, fair play, patience—are elemental traits at the roots of human civilization. And the conservatism of Paducah makes it easier to transmit these traits from one generation to the next.
Most people in the United States live in small towns. Now more than ever we understand the theory behind ‘six degrees of separation‘, any two people on earth are connected through a maximum of six acquaintances. The virtues of Paducah spread throughout our nation. If small-town culture is eroded by half-baked ideas, it could not only harm patients, but also the fabric of our nation. This is why we say that being a member of a small community makes us feel part of something bigger than ourselves. Thus, we protect our neighbors.
Dr Poston responds to the (fictitious) complaint letter.
I admit it. The preceding letter is complete fiction. I wrote it myself, without any specific CRNA in mind. It was based on an aggregate of all the anesthetists’ concerns making their way through the grapevine over the past two years. Telling a story through their eyes proved surprisingly painful, particularly when having to write bad things about myself (try it yourself sometime). Taking this perspective forced me to modify how I viewed my contribution to the problem and got me to recognize the folly of seeing anyone as a hero, villain, or victim. If nothing else, I hope this shows our anesthetists that I care enough to listen. I also hope we can honestly reflect on what has transpired over the last two years and negotiate its meaning. Sometimes, writing down concerns transforms situations. It is a reflective process that reveals flaws in our underlying reasoning; ones that might not appear if we keep everything bottled up inside our heads.
Similarly, storytelling is a promising way to make sense of debriefs. Stories such as that told by our fictional anesthetist draw the reader in and reveal patterns that have different meanings for each of us, based on our unique past experiences. Since the debriefs have been more controversial than intended, I would like to ask our OR team to deeply reflect on the concerns articulated in this letter. Does everyone agree that the points raised reflect our team’s main concerns? Is anything missing? Moreover, are these legitimate concerns? Getting a team to make sense of a conflict is a critical role of a leader. This process requires trust, consensus, and wisdom among the team and a sense of self-efficacy for each individual. These resources get stronger each time we use them. We make headway by simply acknowledging the elephant in the room (the OR): the substance of these complaints.
The complaints of the letter seem to express a mindset that says: ‘These meetings are disrespectful.’ First and foremost, the fact that I have a different opinion does not mean I am disrespectful of your expertise. Far from it. Debriefs provide a forum for us to discuss our differences, based on respect for divergent opinions that evolve as we struggle to get through difficult cases. We seek everyone’s perspective, even though this process may cause conflict; complaints about each other might also surface. The alternative is to avoid tense interactions altogether. That maintains short-term peace, but it doesn’t eliminate underlying conflicts. It just pushes them underground, creating resentment when nothing improves. Latent problems inevitably emerge, which create situations that might harm our patients. I realize that debriefs represent a form of culture shock for Paducah. However, humans have striven to achieve better communication and teamwork since the beginning of history.
By doing our best to improve patient safety, we are strengthening our communities. However, like surgical cases, not all debriefs go as planned. Despite everyone’s best intentions, some debriefs produce more confusion than clarity. For example, I’ve said things that did not come across as smoothly as I had hoped. Unfortunately, some remarks provoked strong emotional reactions from members of my team, including shouting and hurt feelings. Apparently, other comments seemed more like interrogations instead of a genuine effort to build consensus and improve communication within our team. These unexpected misperceptions incited defensiveness rather than learning.
I have a viable explanation for this defensiveness: having difficult conversations about high-risk cases in a group setting, under a time crunch, is often traumatic—even for competent medical professionals, particularly if they are uninitiated with debriefs. Any critique not handled well, by either the sender or receiver, can threaten one’s sense of identity as a good person. Sadly, it is all too easy to gossip about the traumatic parts, and forget when meetings have made us stronger both as individuals, and as a team. As a result—without even realizing it—these biased memories generate a false impression of debriefs.
I like the quote “Anything worth doing is worth doing badly.” Something worth doing, like a debrief, requires persistence. We need time to learn the necessary but rare skills and unlearn the “black-and-white thinking” that misinterprets the objectives of a debrief. These weekly meetings allow us to share pertinent information regarding patient safety, with the intention of making our future cases run smoothly, eliminating unnecessary, potentially deadly errors. As members of a skillful surgical team, regarding debriefs as a threat to our identity proves counterproductive. I understand it takes time to get comfortable with the uncomfortable. Nevertheless, avoiding tough conversations never makes it easier, just like ignoring a problem never makes it go away. The flexibility of “doing badly” grants us the benefit of the doubt whenever things don’t go as expected, despite our best efforts.
The fictitious letter also lists concerns unrelated to debriefs: not having enough CRNA to appropriately staff all cases, overworked anesthetists not using their vacation time, and worries about relationships outside the hospital and in the community. These matters undoubtedly add stress to an already difficult job. They deserve a solution, yet this is beyond the scope of debriefs. Navy SEALS also have concerns about their personal lives (feeling overworked, underpaid, etc.) but to perform their job mandates enforcing strict boundaries. For example, when on a hazardous mission, they compartmentalize all thoughts not relevant to the task, completely shutting them out. Lack of mental discipline could get them killed and put their teammates in jeopardy. Likewise, when someone on our team is distracted by concerns not directly related to cardiac surgery, patients could die.
I realize that CRNAs want to be left alone to do their job and avoid overthinking; they might be wary of “analysis paralysis.” This attitude reflects a traditional expectation that a cardiac surgery team should work independently, each expert taking decisive action to solve problems on their own. This situation might be true during the easy times in an OR; however, one of the advantages of a debrief is that it fosters a far different mindset that helps us tackle the tough times. We learn to listen to each other, ask lots of follow-up questions, and reflect on the knowledge we have gained together in the past. We seek, not shun, dissent. Working through these issues allows us to build our collective wisdom to identify and solve problems as a team.
What about case selection and the needless stress of high-risk cases? I value feedback about topics such as these. We have several forums to talk about case selection: the Heart Team conference, team briefings before each case, and debriefs afterwards. Each forum gives everyone a chance to explain why they might disagree. As the moderator of these meetings, I listen and sometimes change course, based on these comments. When I do not modify my stance, it is important to understand that I will need everyone’s full commitment to the team. Our patient’s life could hang in the balance. Jeff Bezos, the CEO of Amazon, calls this process “disagree and commit.” Once again, we must practice mental discipline to put aside our dissenting opinions and focus on the task at hand.
One of the more disturbing aspects of this letter is that it reveals signs of a dysfunctional team. Concerns from the CRNAs that team meetings are “throwing salt on wounds” stem from an underlying lack of trust. Using gossip to discuss concerns instead of directly challenging their origin at a meeting comes from a fear of—or deep-seated aversion to—conflict. Complaining about case selection without taking advantage of the available forums shows a lack of commitment. Likewise, overemphasizing personal concerns reflects a certain level of disregard for our team’s results in the operating room.
This final point is where I realized my fundamental mistake. I tried to build a highly functional team based on reasoned arguments, yet I ignored the social aspects that also form an integral part of an effective team. This initial error was the spark that set our anesthetists’ complaints in motion. But it is not too late. By interpreting the state of our cardiac surgery program through their eyes, I now realize that my efforts to change the team ended up changing me. The stage is now set for a heart-to-heart team meeting (pardon the pun) that will build a new and successful path forward.
robpostonblog 