Saturday, January 20, 2007

What Works -- Part 5 -- Team Training

We have all heard stories of cockpit behavior in an airplane that causes a crash. The navigator or first mate says to the pilot, "Watch out for that mountain." The pilot ignores the advice, and the aircraft ends up in flames. This kind of thing can happen in a hierarchical environment.

The same kind of thing can happen in an operating room, where the surgeon is the "pilot" and the nurses and anaesthesiologists are the support crew. Doctors, like pilots, are trained to be in charge and to make split-second decisions.

A few years ago, a series of errors and bad communication in our obstetrics department resulted in the loss of a baby and almost resulted in the death of the mother. For a department that had always prided itself on providing extraordinary care, the event was a shock and caused an intense self-evaluation.

Using the experience of the military -- indeed from those cockpit situations --the Department proceeded on a full-fledged series of courses in team training.

This was not a simple seminar or two. It was a process that took many months. After all, it had to break down barriers and behaviors that had taken years to develop. Nurses had to feel comfortable offering suggestions to doctors, and doctors had to learn how to hear the nurses' comments.

Here's an article that describes the whole thing. I urge you to take the time to read it. Our OB staff would tell you that it has changed their view of practicing medicine. They would also tell you that it has created unusual bonds of collaboration and friendship in their department, even for a group that had always had a strong group ethic. Most important, the program has actually had a measurable difference in clinical results. Our folks now participate in programs across the country to spread the word.

I wish I could tell you that we have taken this experience and have infused it throughout our own hospital. We have not, at least to the extent I would like. Not that we are not trying, but it turns out that the culture of each department and each division is a bit different, even within the same hospital. So it takes longer than you might expect. What might work in OB needs to be modified to work in surgery or orthopaedics. Even within surgery, what might work for the pancreatic surgery group -- see the November 27 discussion below on Whipple procedures (What Works -- Part 2) -- might not be quite right for the transplantation group. Like other medical centers, we are still feeling our way through this issue of the diffusion of practice improvements.


Anonymous said...

In the operating room the anesthesiologist is the pilot.
The anesthsiologist keeps the patient ALIVE. The surgeon is the "GOD" he gets the credit for saving the patient and the nurse is the maid and doesn't know anything about surgery. There have been many times i have saved the surgeon from diaster and never been thanked. I did it for the patient. I love my patients.The anesthesiologist on the other hand totally respects the nurse and there is great communication between the nurse and the anesthesiologist. the anesthsiologist and the nurse work
together. The anesthesiologist always thanks the nurse for her help. I know for i have been an OR nurse for 40 years

Paul Levy said...

Thank you so much. If I ever wanted a better description of why team training is needed, I couldn't ask for it. Consider how this comment presents the stereotype of each group and the relationships among them.

If you were talk to our OB folks after their training, you would be highly unlikely to find these kinds of characterizations. You would, instead, find a close-knit group, with mutual respect for each person's role, and with a total focus by all on the welfare of the patient (and the new baby.)

Anonymous said...

I am sorry this culture persists. Until we learn to work together as a team in the operating room patients will be harmed.
I strongly encourage our nurses to speak-up; you are the backbone of medical care. We also need to find a way for our residents to feel free to bring issues to the attention of attendings
Ben Sachs