Achieving surgical proficiency by Harnessing nontechnical skills

Introduction

“Engine fire,” announced the first officer during the take-off roll. The captain rotated the aircraft and confirmed that the aircraft was climbing away and commanded the landing gear to be retracted. Then the flight deck was silent with no one saying anything until 400 feet above the ground when a carefully choreographed sequence was commenced, identifying the engine that was on fire and shutting it down. This is a typical simulator scenario that every airline crew around the world will practice. An observer in the simulator watching a good crew would be surprised at the unhurried performance, a notable absence of talking, and the seemingly low workload that was displayed. However, there is a huge hierarchy of skills that the pilots will draw upon to achieve this performance which is not immediately obvious to the casual observer.

Aviation is an industry where training is at the core of an airline’s Safety Management System (SMS) and every pilot undergoes regular recurrent training in the simulator up to four times per year to maintain and enhance technical and nontechnical skills. Advances in aircraft design, engineering and flight training have been responsible for the safety record that aviation enjoys today with an accident rate of 2.6 accidents per million departures. Medicine, and in particular surgery, has an interest in aviation as pilots and surgeons do share some common ground in the cognitively complex and technically and nontechnically challenging environment of the flight and deck and the operating theater. However, not everything in aviation can be seamlessly transferred as both domains have unique differences. Aviation is less variable, highly regulated and the current fourth generation of aircraft are very reliable and do not show the nuanced problems of human beings such as comorbidities or difficult anatomies. Despite these differences, some aspects of aviation are very transferable such as nontechnical behaviors and training methods, and this chapter will focus on these nontechnical skills and allied subjects that are so critical to the high performance of airline crews as there is increasing realization of the potential benefit of the transferability of these skills into surgery to improve surgical outcomes.

Humans are subject to error

Flying an aircraft is a complex and challenging task and it was often said that good pilots had a “great set of hands.” This focused on the technical aspects of flying, but in a survey conducted by the author among experienced instructors, the general opinion is that this has shifted to an emphasis on nontechnical expertise with up to 70% of skilled flying attributed to nontechnical ability. However, humans, despite being well trained, are subject to error and we are all fallible. ^, Errors are a fact of life and they can be small and inconsequential or catastrophic in high-risk industries such as aviation. In surgery, an error committed by a well-trained surgeon can have similar tragic outcomes. Human error cannot be eliminated but can be mitigated by nontechnical training.

Over many years, aviation and a number of other high-risk industries were forced to investigate a number of accidents where human error was a causal factor. During the 1970s several major accidents were very puzzling: the aircraft were serviceable and flown by well-trained crews but were involved in accidents that resulted in the loss of life. The major event was the 1977 Tenerife crash between two Boeing 747 aircraft, one operated by KLM and the other by Pan American where the aircraft collided in reduced visibility on the ground, resulting in the loss of 569 lives. The subsequent investigation revealed failures in communication, teamwork, decision making and leadership. ^, Other nonaviation accidents had similar factors present, such as the Chernobyl and Challenger disasters of 1986 and the Piper Alpha oil platform explosion of 1988.

Investigations and the findings into aviation accidents made it clear that technical skills were not enough to ensure safe flight and that nontechnical behaviors were influencing pilot’s decisions and behaviors. ^, Surgeons are similarly affected, where the mastery of technical skills is insufficient in preventing error. An estimated 50% of all surgical errors occur in the operating theater, and of these, 40% to 50% are deemed entirely preventable. In more sobering statistics, in the United States, the US Institute of Medicine estimated that each year between 44,000 and 98,000 people die as a result of medical errors—which puts doctors at 7500 times more likely to cause harm than a gun owner.

Although technical errors do occur in surgery, there has perhaps been an overemphasis in the past on the teaching of technical skills in surgery, despite the most influential contributions to error being a lack of application or the poor use of nontechnical skills. The nontechnical skills taught in aviation apply equally to surgery, as in both of these domains the work requires high levels of interpersonal collaboration, communication, and coordination, and teamwork is essential. ^,

Nontechnical skills

Nontechnical skills are the cognitive and social skills that complement a worker’s technical skills and are defined in this chapter as “the cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance.” These are not new or mysterious and are in essence what the best performing surgeons or pilots do every day. The “surgeon’s surgeon” will display these every day with skill, diligence, judgment and demeanor all contributing to positive patient care. ^,

There are five main nontechnical skills that are taught and assessed that will be discussed in this chapter:

• Situation awareness (SA)

• Decision making

• Communication

• Teamwork

• Leadership

It should be noted that nontechnical behaviors are usually displayed concurrently and not necessarily as discrete units of behavior. At times, however, more emphasis and importance will be needed on individual skills depending on the task’s demands.

Situation awareness

According to the US Air Force, SA is the most important factor in improving mission effectiveness but, despite this importance, the definition of SA is not commonly accepted. Mica Endsley, a researcher into SA and flight deck automation, defines SA as “the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future.” Basically, SA is knowing where you are and where you are going to be and is the crucial first step to decision making and one of the most challenging portions of many people’s jobs. ^{, ,} In 175 aviation accidents, poor SA was found to be the leading causal factor ( Box 7.1 ).

The human brain functions as an information-processing machine, but the brain is limited in the amount of information it can process at any one time and therefore attends to the environment selectively. Humans will select environmental cues and information in the memory, and it is this selective attention process that forms the basis of SA. Memory is very important in SA. There are three linked memory systems: sensory, working, and long-term memory. Sensory memory holds information for a very short time and is of less importance to SA than working memory and long-term memory.

Working memory is the contemporary label for short-term memory and contains conscious awareness. It is of limited capacity, fragile and subject to distractions and interference. When the capacity of an individual is reaching the limit, reducing the attention on extraneous information such as background music or asking team members for silence is a technique to preserve working memory. To assist in maintaining SA, pilots will often verbalize what they are seeing, and their understanding, to the other crew members and use a “mini summary” of an event or a task.

The main memory store is the long-term memory store. This memory store is a huge warehouse of masses of information which increases with experience and can be drawn out and transferred to working memory. SA involves a cyclic interplay of information, with perception interacting with working memory and knowledge being drawn from long-term memory, and involves three stages—gathering information and perception, understanding, and projection. ^, Accurate mental models are critical to accurate SA.

Mental models

Humans are very skilled at pattern matching. Streams of information can be categorized and recognized quickly, especially by an expert, with little conscious effort. This process of categorization and comprehension is facilitated by “mental models,” sometimes called “schema,” that are stored in the memory. These are combinations of cues and meaning. An aviation example is a complex taxiway procedure used by a pilot or a sequence of surgical activities—for example, the initial insertion of robotic ports and docking of a robot, where novel cues may result in subtle intraoperative modification of a very standardized procedure. Experts have a vast store of mental models in comparison to a novice who has to spend more time and mental effort trying to comprehend patterns using a more systematic analysis. The mental model does not need to be an exact match to the current situation but does need sufficient similarities to be able to categorize.

Mental models provide direction to critical cues, an expectation of the future state helping to project forward, and a link between the situation and appropriate actions. Experience forms the creation of mental models, but briefings are a very effective way of mental model creation. This is particularly helpful in team environments so that all team members have a shared understanding of a task, their role and any risks that may be involved. However, if the briefing is not accurate, then the wrong mental model may be created, facilitating the risk of poor decision making. This heightens the risk of bias influencing the decision, such as confirmation bias, discussed further in the chapter, where facts are “bent” to fit the model.

Three stages of situation awareness

Gathering information can come from an array of sources such as visual, auditory, or other team members to build up the picture of the environment. The second stage is the cue interpretation or understanding phase, using long-term stored knowledge and recognizing patterns. An expert will do this quickly with limited use of the working memory; a novice however, will find this stage more cognitively challenging. The final stage is projecting the information forward to a future state and anticipating what might happen at a later stage. SA is an essential first step in the next nontechnical skill of decision making.