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The American Journal of Surgery xxx (2017) 1e4
Contents lists available at ScienceDirect
The American Journal of Surgery
journal homepage: www.americanjournalofsurgery.com
Thomas G. Orr Memorial Lecture: “Planning and Performance under
Stress”
Southwestern Surgical Congress. Tuesday, April 4, 2017 2:45 p.m.
S. Rob Todd
Baylor College of Medicine, One Baylor Plaza, MS: BCM390, Houston, TX, 77030, USA
a r t i c l e i n f o
Article history:
Received 29 August 2017
Accepted 18 September 2017
Good afternoon. I have nothing to disclose.
Upon completion of my Trauma and Surgical Critical Care
Fellowship at the Oregon Health and Science University, I was
fortunate enough to join Fred Moore, Christine Cocanour, and
Rosemary Kozar at the University of Texas/Memorial Hermann
Hospital in Houston, Texas. And I can tell you, from a junior faculty
perspective, you couldn't ask for better partners, mentors, or
friends. When I was first talking with Fred about professional
development and things of that nature, Fred said, “Well, you have
got to join the Southwestern Surgical Congress”. To be honest, I had
presented as a resident at the Southwestern Surgical Congress, so I
had some knowledge about the Southwestern. When I began preparing for this talk, I went to the Southwestern Surgical Congress
website to brush up on the Southwestern. Its purpose as an organization is to promote the advancement of general surgery. And
we're not just talking about general surgery for academicians, but
for community surgeons as well as rural surgeons. It's also for
medical students, residents, and fellows. The key tenets of the
Southwestern Surgical Congress are four: education, advocacy,
research, and innovation; and through all of this, we promote
excellence in patient care and professional development.
The origin of the Southwestern Surgical Congress starts with
Walter Stuck of San Antonio, Texas. It was at a meeting of the
Southeastern Surgical Congress in 1948 that he and Drs. Beasley
and Sanders dreamt up the idea for the Southwestern Surgical
Congress. Interestingly enough, at that point in time, the Southwest
United States was the only part of the country without a regional
E-mail address: srtodd@bcm.edu.
surgical society, and that's why they drafted this concept. So in my
mind, they saved the best for last, but I'm probably a little biased on
that front.
It's through the Southwestern Surgical Congress that I got to
know Clay, through this society and other societies I'm involved in. I
consider Clay a great colleague, mentor, and even better friend. So
Clay, thank you so much for asking me to deliver this lectureship.
It's truly an honor. So thank you.
The Southwestern Surgical Congress has three named lectureships at the annual meeting. The first one we heard this morning by
Christine Cocanour, the Edgar J. Poth Memorial Lectureship. It was
initiated in 1975, honoring Dr. Poth as the 15th president of the
Southwestern. The Thomas G. Orr Memorial Lectureship was
established in 1966, honoring Dr. Orr as the 2nd president of the
Southwestern. I'll speak more of him in a second. And the third
named lectureship is the Claude H. Organ Memorial Lectureship. It
was established in 1996 to honor Dr. Organ for his dedication to the
Southwestern Surgical Congress and also to general surgery, and
surgery as a whole.
Dr. Orr was born in Carrollton, Missouri in 1884. He attended the
University of Missouri for undergraduate, then Johns Hopkins
University for medical school. Upon matriculation, Dr. Orr joined
the faculty at the University of Kansas in 1910, and quickly rose
through the ranks to Professor and Chair of the Department of
Surgery by 1924; a title he held for the next 25 years until he
stepped down. He was one of the charter members of the American
Board of Surgery, and nationally also rose to the ranks of President
of the American Surgical Association; so quite an accomplished
academician and leader in the surgical community. He had over
200 peer-reviewed publications, book chapters, and several
https://doi.org/10.1016/j.amjsurg.2017.09.013
0002-9610/© 2017 Published by Elsevier Inc.
Please cite this article in press as: Todd SR, Thomas G. Orr Memorial Lecture: “Planning and Performance under Stress”, The American Journal of
Surgery (2017), https://doi.org/10.1016/j.amjsurg.2017.09.013
2
S.R. Todd / The American Journal of Surgery xxx (2017) 1e4
textbooks; this being the second edition of “Operations of General
Surgery” which he edited.
Dr. Orr is held with extreme regard at the University of Kansas,
or KU, where they established the Orr Academic Society, this being
the logo. It's a play on a lot of things. There's a scalpel. Notice the
caduceus, with an oar being the winged staff. Also, note the blue
“O” for Orr, and the sunflower and Jayhawk representing the University of Kansas and the State of Kansas.
In reviewing the list of Orr lecturers, it's impressive, with quite a
few whom I consider friends and several in attendance here today.
And so I asked Clay, “What would you like for me to speak about?”;
Clay's response “Anything you want!” Thanks a lot Clay, that's the
worst situation to be in, because it provides no direction. These
represent the past several years of Orr Lectures. You can see the
topics are quite broad, ranging from privileging to C Difficile associated diarrhea, and anyone who has gone through credentialing
recently might consider these one and the same. So I have chosen to
discuss “Planning and Performance under Stress”, which I hope to
highlight over the next 30 minutes or so.
As surgeons, we face a multitude of stressors, be they in the
operating room or elsewhere. The operating room can be a very
stressful situation, and it certainly doesn't help to have Dr. Mattox
peering over ones shoulder while completing a popliteal artery
injury repair.
But that's only one such stressor we face as surgeons. On the job,
there are others -environmental stressors and issues. As surgeons,
we live in a very complex and dynamic environment, and it's
changing all the time; be that in the trauma bay, in the operating
room, on the ward, or in the intensive care unit (ICU). We often deal
with imperfect, ambiguous information. And this might be due to
the poor historian in our patient, the radiographic imaging not
providing us the details we desire … So we must ascertain how best
to assimilate the data we have, and how to get the most out of our
team to bring about a successful outcome. Additionally, there are
time constraints on top of all of this e resident duty hours, staff and
employee work hours … This simply adds to our stress level.
From a personal perspective, we must manage task saturation: a
successful surgeon must be a taskmaster. There is also performance
pressure, and it comes in many facets: academic productivity,
clinical productivity … Fatigue often sets in, and how do we
manage that? We deal with innumerable interpersonal relationships, and as we all know, there are variable personalities out there.
All of this aforementioned is fairly routine for us as surgeons, and
that is when things are functioning smoothly. We deal with such
stressors on a daily basis.
But think of more stressful situations: the trauma bay with mass
casualties; the ICU with multiple critically ill patients … It's in these
situations where we are truly tested, where we are put under significant stressors, and so how do we perform in these situations?
It's not all about the technical skills in these scenarios. More
importantly it is the non-technical skills of surgery (NOTSS). Many
of you may have heard of NOTSS, but I suspect many have not.
The NOTSS System was developed by surgeons, sociologists,
psychologists and anaesthetists from the Royal College of Surgeons
of Edinburgh and the National Health Service (NHS) Education for
Scotland. It describes the non-technical skills associated with good
surgical practice. And so you might say, why now? We've been
training surgeons for decades. There are several reasons:
A shifting education paradigm: i.e. the 80-h work week,
increased specialization, integrated training programs …
Competency-based training: it's not all about time, but
competency
An increased focus on skills to maximize the safe and effective
management of patients
Additionally, there are increasing data to support that many
adverse event in surgery originate from the non-technical aspects
of performance. Technical skills alone may not be sufficient.
Moreover, tradition training teaches knowledge, clinical expertise,
and technical skills. It does not teach us the non-technical skills.
Historically, these were learned in an informal, tacit manner. This
does not suffice in the 21st century.
The NOTSS System is composed of four categories: Situational
Awareness; Decision Making; Communication and Teamwork; and
Leadership. Each of these broad categories possesses three elements, for a total of twelve non-technical skills. These elements are:
Situational Awareness
Gathering information
Understanding information
Projecting and anticipating future states
Decision Making
Considering options
Selecting and communicating options
Implementing and reviewing decisions
Communication and Teamwork
Exchanging information
Establishing a shared understanding
Coordinating team activities
Leadership
Setting and maintaining standards
Supporting others
Coping with pressure
While the NOTSS System was primarily developed for the
operating room (OR), it is applicable throughout the clinical realm.
For each element, there are defined “Good Behaviours” and “Bad
Behaviours”. These are utilized in obtaining the NOTSS System
rating which ranges from 4 e being good to 1 e being poor for each
element. So how do we apply the NOTSS System to our practice?
In 2015, Hull et al. examined the “Advances in Teaching and
Assessing Nontechnical Skills”. The authors determined that such
training requires a blended approach, with a distinct curriculum,
utilizing an existing, well-tested nontechnical skills framework,
and with significant faculty development. I'm guessing most of the
faculty in this room have had zero training in NOTSS.
So you might ask, “Why is this important?” There are innumerable data to answer this question. The VA Health System
identified that a NOTSS System delivered: a significant reduction of
18% in mortalities; a reduction of 0.5 deaths per 1000 (p ¼ 0.001)
after each additional NOTSS reinforcement session; and a decrease
of 15% in morbidity rates for intervention hospitals versus 10% for
control hospitals (p ¼ 0.001) after surgical-risk adjustment.
That being said, implementing a NOTSS System is not without
its' barriers and challenges. These include:
A lack of the awareness of the importance of nontechnical and
team-based skills
A lack of resources
Costs
A lack of faculty/surgical educators with the necessary expertise
In 2016, Wood et al. studied the “Training Tools for Nontechnical
Skills for Surgeons e A Systematic Review”. The authors identified
the NOTSS System and the Oxford NOTECHS II System to be the two
gold standards for individual- and team-based nontechnical skills
training. So if one is to implement such a system, who should it
focus on: medical students, residents, fellows … ? This is a very
interesting question.
Gostlow et al. studied “Non-technical Skills for Surgical Trainees
Please cite this article in press as: Todd SR, Thomas G. Orr Memorial Lecture: “Planning and Performance under Stress”, The American Journal of
Surgery (2017), https://doi.org/10.1016/j.amjsurg.2017.09.013
S.R. Todd / The American Journal of Surgery xxx (2017) 1e4
and Experienced Surgeons” in 2017. The investigators compared
junior trainees, senior trainees (including fellows), surgeons with
<20 years of practice, and surgeons with >20 years of practice to
one another. The results were eye-opening. Surgeons with >20
years of practice performed more poorly in comparison to the
trainees in all twelve elements. Furthermore, their performance
worsened over time in all twelve elements. Six of the elements had
a statistically significant difference, those being:
Considering options
Implementing and reviewing decisions
Establishing shared understanding
Setting and maintaining standards
Supporting others
Coping with pressure
The authors found this drop in the NOTSS score to be unexpected, and noted that even experienced surgeons are not immune
to deficiencies in NOTSS. The authors advocated for professional
development programs regardless of experience. To this end, Hull
et al. developed national guidelines for “Training Faculty in
Nontechnical Skills Assessment”. The methodology required was
broad, encompassing seven points.
As you can see, there is extensive work being done on NOTSS
and this has great cross-pollination with leadership development
in the OR. Parker et al. examined this (“Towards a Model of Surgeon's Leadership in the Operating Room”). The authors identified
seven categories of intraoperative leadership behaviors including:
Maintaining standards; Managing tasks; Making decisions; Managing resources; Directing and enabling; Guiding and supporting;
and Communicating and coordinating. This was subsequently
expanded to the Surgeons' Leadership Inventory (SLI) in 2013. Eight
intraoperative leadership elements were identified:
Maintaining standards
Making decisions
Managing resources
Directing
Training
Supporting others
Communicating
Coping with pressure
The SLI has since been validated, and enumerable studies have
examined these leadership profiles in the OR. As a whole, we surgeons don't always perform to the best of our abilities, especially in
times of significant stress. So once again, why does this matter? The
March 2017 American College of Surgeons Bulletin examined
“Evolving Insights for Preventing Surgeon Errors: Balancing Professionalism and Cognition with Knowledge and Skill”. This article
in conjunction with the 2006 Claims Study document that poor
outcomes are often based partly on behavioral failures. The authors
conclude that “deficiencies in professional behavior and cognition
are frequent, avoidable causes of errors”.
The NOTSS System is intended to positively affect all of these
variances. Another key component is coaching, and how we
incorporate that into the shock room, the OR, the intensive care unit
… The data on coaching continues to evolve, but is already quite
robust. Yule et al. assessed “Coaching Non-Technical Skills Improves
Surgical Residents' Performance in a Simulated Operating Room”.
In comparing residents who received NOTSS coaching between
cases (five laparoscopic cholecystectomies) to those who did not,
they experienced a significant improvement in their non-technical
skills.
So if leadership coaching is so effective, why is it not better
3
incorporated into our culture as surgeons? Mutabdzic et al.
examined “Coaching Surgeons: Is Culture Limiting Our Ability to
Improve”. The authors identified the following in regards to
coaching surgeons:
There is a “predominant resistance toward coaching in surgery”
There is an “ambivalence toward coaching”
“Coaching faces unique challenges in the context of a powerful
surgical culture that values the portrayal of competency and
instills the value of surgical autonomy”
“Coaches should be sensitive to a surgeon's need to be in
control”
That being said, leadership coaching in surgery has come to
prominence at several institutions. Caprice Greenberg and the
University of Wisconsin have developed the “Wisconsin Surgical
Coaching Program”. It is a robust program with a distinct coaching
paradigm. Three key components they identified to building successful peer-coaching relationships include:
Aligning Role and Process Expectations
Establishing Rapport
Cultivating Mutual Trust
Achieving these results in much more fruitful coaching relationships …
Lastly, an article on coaching in The New Yorker by Atul Gawande
e “Personal Best: Top athletes and singers have coaches. Should
you?” Gawande states “No matter how well trained people are, few
can sustain their best performance on their own. That's where
coaching comes in.”
At the Baylor College of Medicine Michael E. DeBakey Department of Surgery, we have ventured into the arena of NOTSS, leadership coaching … Aviation Applications in SuRgery (AAiR) was
developed with the goal of establishing an open, engaged culture
and to enhance the situational awareness, self-awareness, and
leadership skills among the faculty, clinical staff, and trainees
within the department leading to optimal performance, and ultimately improved patient outcomes. The program is composed of
three elements:
Voluntary Reporting of Errors and Safety Issues: An anonymous, on-line reporting system to enable voluntary reporting of
errors and safety issues, including near misses. The format enables rapid data entry, with only ten primary fields to complete.
Aggregated, de-identified data are reviewed to identify
departmental and institutional opportunities for improvement.
Jump Seat Program: A program to assess the NOTSS skills in the
OR for the faculty of the Michael E. DeBakey Department of
Surgery. The Jump Seat “Observers” will be Baylor College of
Medicine medical students who are trained in this observational
skillset. These evaluations will aggregated to determine opportunities for improvement including coaching.
Coaching the Surgical Leaders of Today and Tomorrow Program: A compelling, professionally executed leader development experience for the faculty and trainees of the Michael E.
DeBakey Department of Surgery. Phases 1 and 2 of the program
will develop the individual leadership skills of “coaching
champions”. These individuals will then serve as force multipliers, supporting not only leadership development but also
organizational culture across the >100 member department.
Anticipated outcomes include enhanced productivity for professional outcomes (scholarship, overall citizenship, grants, and
publications), increased self-awareness, increased morale and
job satisfaction, and increased faculty retention. All of the
Please cite this article in press as: Todd SR, Thomas G. Orr Memorial Lecture: “Planning and Performance under Stress”, The American Journal of
Surgery (2017), https://doi.org/10.1016/j.amjsurg.2017.09.013
4
S.R. Todd / The American Journal of Surgery xxx (2017) 1e4
aforementioned leading to improved patient care secondary to
more efficient teamwork, more effective shared leadership …
So in conclusion, personal and environmental stressors affect
our daily lives as surgeons. In these and other encounters, it is often
not the technical skills that lead to good clinical outcomes and
practice, but the NOTSS. This paradigm should include life-long
learning, promoting advanced behavioral skills, ultimately translating into improved patient outcomes. Coaching is integral to this
overall process.
Once again, Clay, thank you for this opportunity. And thank you
all for indulging me.
Please cite this article in press as: Todd SR, Thomas G. Orr Memorial Lecture: “Planning and Performance under Stress”, The American Journal of
Surgery (2017), https://doi.org/10.1016/j.amjsurg.2017.09.013
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