Embark on a journey through the interplay of teamwork, civility, and patient safety with our esteemed guests, Matt Sherrer and Mitch Tsai from the Fresh Flow podcast, and emergency medicine savant Chris Turner. The conversation navigates the treacherous waters of workforce shortages and academic anesthesiology pressures, unearthing strategies to foster a thriving professional climate where mutual respect reigns supreme.
Feel the pulse of our professional interactions as we delve into reputation—your very own "theme tune" that echoes in the corridors of your workplace. We examine the subtle dance between the image we project and the legacy we yearn to build, from the ominous tones of Jaws to the symphony of positive influence. Uncover the critical role of psychological safety in knitting teams tightly together, as we reveal the cognitive cost of incivility's subtlest gestures and advocate for an environment enriched with courtesy and cooperation, ultimately uplifting patient care and collective morale.
Closing on a harmonious note, we contemplate the art of leadership and the quintessence of wisdom in the healthcare cosmos. We spotlight the transformative power of wise leaders who orchestrate a culture ripe for questioning and shared knowledge, instrumental in informed decision-making. Our exploration extends to the tender discussions of end-of-life care, aligning treatments with deeply held patient values. And for a final twist, we engage in a light-hearted riff on the transcendent language of music, comparing the distinctive strums of British and American guitar tones, affirming the melody of our unified pursuit: enhancing patient safety.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/202-teamwork-civility-and-the-quest-for-patient-safety-a-fresh-flow-podcast-takeover/
© 2024, The Anesthesia Patient Safety Foundation
Embark on a journey through the interplay of teamwork, civility, and patient safety with our esteemed guests, Matt Sherrer and Mitch Tsai from the Fresh Flow podcast, and emergency medicine savant Chris Turner. The conversation navigates the treacherous waters of workforce shortages and academic anesthesiology pressures, unearthing strategies to foster a thriving professional climate where mutual respect reigns supreme.
Feel the pulse of our professional interactions as we delve into reputation—your very own "theme tune" that echoes in the corridors of your workplace. We examine the subtle dance between the image we project and the legacy we yearn to build, from the ominous tones of Jaws to the symphony of positive influence. Uncover the critical role of psychological safety in knitting teams tightly together, as we reveal the cognitive cost of incivility's subtlest gestures and advocate for an environment enriched with courtesy and cooperation, ultimately uplifting patient care and collective morale.
Closing on a harmonious note, we contemplate the art of leadership and the quintessence of wisdom in the healthcare cosmos. We spotlight the transformative power of wise leaders who orchestrate a culture ripe for questioning and shared knowledge, instrumental in informed decision-making. Our exploration extends to the tender discussions of end-of-life care, aligning treatments with deeply held patient values. And for a final twist, we engage in a light-hearted riff on the transcendent language of music, comparing the distinctive strums of British and American guitar tones, affirming the melody of our unified pursuit: enhancing patient safety.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/202-teamwork-civility-and-the-quest-for-patient-safety-a-fresh-flow-podcast-takeover/
© 2024, The Anesthesia Patient Safety Foundation
You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.
Speaker 2:Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. We have an exciting show for you. Today we're doing a podcast takeover. We will be tuning in to the Fresh Flow podcast, which is a collaboration between the University of Alabama Medicine and the Association of Anesthesia Clinical Directors. The Fresh Flow podcast brings unique perspectives to the recording studio to help improve perioperative operational processes. Let's meet the hosts. Matt Scherer is an associate professor and director of faculty recruitment in the UAB Department of Anesthesiology and Perioperative Medicine, who is dedicated to education for future physician leaders and creating fulfilling work experiences for all members of the anesthesia care team. Mitch Tsai is an adjunct professor at the UAB Department of Anesthesiology and Perioperative Medicine and a professor in the Department of Anesthesiology at the University of Vermont. He is the president of the Association of Anesthesia Clinical Directors and is dedicated to operating room management.
Speaker 2:For this takeover episode, consultant in emergency medicine Chris Turner leads a discussion focusing on the importance of teamwork and civility in the field of healthcare. Teamwork and civility are vital ingredients in the recipe for keeping patients safe during anesthesia care. In fact, teamwork is one of the top 10 APSF's perioperative patient safety priorities. This is such an important conversation and we are happy to feature it here.
Speaker 2:Before we dive into the episode today, we'd like to recognize Nihon Code in America, a major corporate supporter of APSF. A major corporate supporter of APSF, Nihon Code in America has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, nihon Code in America. We wouldn't be able to do all that we do without you. And now it's time to take a listen to the Fresh Flow podcast episode, civility Saves Lives, with hosts Matt Scherer, mitch Tsai and guest Chris Turner. Check out the show notes for more information about the Fresh Flow podcast and Civility Saves Lives. We hope that you will like subscribe and listen to the Fresh Flow podcast for timely and thought-provoking conversations on topics in anesthesiology and perioperative medicine. Here we go.
Speaker 3:Welcome to the Fresh Flow podcast sponsored by UAB Medicine, the UAB Department of Anesthesiology and Perioperative Medicine and the Association of Anesthesia Clinical Directors. He's Mitch, I'm Matt, and we like to talk about interesting topics in the perioperative space. Thanks for tuning in, mitch. What's going on, man? How are you buddy?
Speaker 4:I'm doing all right. I'm really excited about this podcast. We talk about workforce shortages, the financialization of healthcare on this side of the United States and how academic anesthesiologists are pulled into the operating room to cover the clinical workload. So I'm coming off my overnight shift. This one's going to be special, yeah, you took call last night, right.
Speaker 3:So you're pretty much no frontal cortex right now. So I think that means the rest of the world will probably be able to relate to you, because usually you're way above any of the rest of us. So you're down to my level, at least today by being up all night. Sounds good, looking forward to it, let's get going. Well, I'm excited about this one too.
Speaker 3:Our guest today is Chris Turner. Chris, how did we meet? Let's see, I was working on an article with a young lad named Stuart Hanmer Shout out to Stu. He said you got to meet this guy, chris Turner. We were talking about civility and healthcare. And he said have you heard of Chris? I said no, you got to go check him out. So I went to your website, civilitysaveslivescom. Watch the TED Talk. It's incredible. I recommend it to everybody who's listening today. And I said I got to talk to that guy. So you and I have chatted before and you're kind enough to come on with us today. So Chris Turner is an emergency medicine consultant consultant in the UK. His accent makes him sound much more intelligent than Mitch and I, and so, chris, thank you for being here with us today. We appreciate it.
Speaker 5:Oh, it's a massive privilege and it is lovely to see you guys and to get the chance to chat with you. I'm delighted to be here. Thank you for the invitation.
Speaker 3:Thank you. Well, so, just starting right off, you built and continue to maintain this platform called Civility Saves Lives. For you to take on a project like this, there's got to be a story behind it. So can you just help us understand what led you to embark upon this endeavor?
Speaker 5:Yeah.
Speaker 5:So I don't know if it works the same for you guys, but we have clinical governance structures, and the clinical governance structures look at things that have gone wrong and what we can do about them and how we might avoid them happening again. And I was a governance lead for a decade and in that time I tried to work out what happened to make things go wrong and lots of different issues that came up. Emergency medicine has a lot of governance because a lot of things go wrong, and as I was doing it, I noticed that the organizational response to this tended to be blame orientated. Everybody liked it when we found the bad person. We found the bad person. We all pointed the finger and said, yeah, it was them, it's not us, and we all felt better about that. And then we stepped back off it and we said, well, do a bit of education and that won't happen again. Then it happened again, and then it happened again.
Speaker 5:And the people at the end of the line, the people who we're all pointing fingers at, I also stopped and thought about them. They were good folk. These were good, hardworking, knowledgeable, frequently very kind individuals exactly the sort of people that I want to look after and I want to look after my family if we get sick. Yet somehow we were happy to point the finger at them and I started to realise we must be missing something. And I had breakfast one day with a guy called Trevor Dale. Trevor is a pilot. In fact, trevor flew Concorde just the once, but he has flown Concorde, which I think is rather cool just the once, but he has flown Concorde, which I think is rather cool. And Trev and I often talk about what's going on when things go wrong, because you know, there's a lot of pilots in that area. And we started talking about the work of Christine Porath at Georgetown and looking at her work and Amir Erez's work and we basically start saying, hang on.
Speaker 5:Second, maybe there's more to this than just people not following protocol. Maybe the protocol, the standard operating procedure, is work as imagined and the work as done looks different to that. And we are satisfied by pointing the finger at people and saying, hey, you didn't follow the protocol, it's your fault. So start thinking about what else is going on. Well, there's an environment and there's the way we treat each other.
Speaker 5:And that's how I got into it and honestly, I thought it was going to be one talk. I thought I was going to give a talk about the impact of behavior on performance. I stand there and then I do once. I might do it twice, and then I'd move on and learn about something else and give another talk on something else. And that was seven or eight years ago and what happened was the very first time we talked about it. A whole bunch of people came up and wanted to talk about it afterwards and then I got a few more invites and then I got more invites. This thing just snowballed and Joe Farmer, who started it with me, joe and I just ended up getting invited to go and talk all over the place.
Speaker 5:And it turns out that this idea that behavior matters in a material way is actually something that resonates with lots of folk, and I think what's happened to an awful lot of people is when we go into the workplace and somebody treats us in a way that feels disrespectful not necessarily screaming and shouting at us, just leaving us feeling disrespected that when we walk away from it we look inside ourselves and we say, hey, I should be better than that, I should be able to deal with that, I should be tougher than that and I should be able to cope with that sort of thing and it's a personal failing. And once you start to look at the research, you realize it's not a personal failing. It's human beings. It's who we are, and when we treat each other negatively, people perform less well and share less information, and that is a toxic combination.
Speaker 4:I mean it's obvious that across your journey, or through your journey, you've dug a lot into this research. In her most recent book, annie Duke, who's a faculty member at Wharton, points out that there's a difference between pedestals and monkeys. Right, and I think a lot of what we've done in patient safety is we just keep trying to build a better pedestal, right. I think there was a recent study by, I believe, etheridge JAMA Surgery about how do you re-implement the surgical checklist right, but one of the comments that they made was the surgical checklist doesn't ensure patient safety, it doesn't ensure civility, right. And so, going back to Duke, we can build the pedestals or we can actually do the harder part, which is training the monkey right. So how does civility allow us to build a better healthcare system?
Speaker 5:Hey, Mitch, tell me you didn't just refer to the surgeons as monkeys.
Speaker 4:Oh no, that would be Matt Scherer at the University of Alabama. Fantastic.
Speaker 5:All right. So here's the deal you want people to behave better towards each other. It's got to be meaningful. There is no point in somebody coming and telling me hey, chris, be nice to the guys in your trauma team if I don't think that's going to result in better outcomes. I think an awful lot of people of my vintage and I'm older than you guys, I am 55, a lot of people of my vintage grew up in a medical setting where treating each other like crap was just normalized. I was educated through humiliation. I used to be terrified to go onto some wards because some of those consultants, those senior doctors, had such negative reputations that I really didn't feel able to perform well. Now, none of them were doing that to deliberately hurt me. They weren't doing that. The guys who are hostile in theatre, the guys who are hostile in theater, the guys who are hostile in the trauma, call at cardiac arrest. They're not doing that to hurt other people. They're doing it because they think that gets results.
Speaker 5:And in my experience and this is what the evidence says is if you can start to talk to people about why this stuff matters, a huge number of people simply choose to change if they believe it, if they think it resonates with them. So the starting place is not actually hey, you guys need to be nicer to each other. It's not even you guys need to start to implement the WHO checklist, it's actually. This is why it matters. This is the impact that doing this thing either implementing the WHO checklist and we're talking about change management here or thinking about how we interact with each other this matters because and what comes after the because is not what matters to Mitch, not what matters to Matt and not what matters to Chris. It's what matters to the person that we're talking to. We change in response, to change our own values, not each other's values, and sometimes a little bit towards organizational values, but as doctors this is a comment about doctors here.
Speaker 5:For a second, doctors are broadly autonomous, have an awful lot of agency and we tend to want to do what we want to do because we believe it's the right thing for the patients and for the people around us. So if we want people to move from one position to another, to choose to move from one position to another, to choose to move from one position to another, we have to find out what matters to them and then to wrap up the conversation in that information, not in what matters to us. So just to elaborate on that a wee bit if I'm talking to an executive board, the sort of stuff that I talk to with them tends to be about reputation, financial performance and the impact that how, how well their team can perform at an at a board level. If I'm doing this with surgeons or any frontline clinicians, doctors and nurses and allied health care professionals, if I'm doing it with those guys, I tend to talk about our performance at an individual and team level and how we can get better outcomes for patients and actually also for staff if we choose to behave in certain ways, particularly as leaders, and that resonates more with people, and many of us have basically damascene conversions as we walk along. When I discovered the way that I'd been behaving as a senior member of staff was possibly creating harm for the people around me and for patients, I had to have a long, hard look at myself in the mirror and then think how do I want to be, who do I want to be to other people and how do I need to behave in order for people to see me that way? And I think that's a journey that many of us go on as we begin to understand that this stuff is important.
Speaker 5:How we behave has therapeutic validity. I mean, I don't know if you guys have ever spent time talking about or reading Compassionomics reading Compassionomics but Compassionomics is a phenomenal book about the impact of compassion on the efficacy of the treatments that we give to patients and it's mind-blowing. We just don't have a good scientific basis to explain it through. But the empirical evidence says that we treat people compassionately. They get better quicker, they have less pain and that seems like a big deal and I think that can drive a bit of behavior. But it's always about what matters to the people that we're talking to. So huge long answer, apologies, but if we want to move people, then find out what matters to them. And the Robert Cialdini work out of Arizona State from a few years ago about what things help people to be persuaded to move to a different state really useful around that. It's lovely videos of his work on YouTube.
Speaker 4:One of the business professors that I had a chance to learn under would be Warren Bennis, and one of the things that he always talked to us about was that there's a difference between being and doing right, and most of us just do things to supposedly be something. But the other piece is that you know, once you figure out what you want to be, then you know what to do right, and I think those are two different frameworks that absolutely apply to what you're talking about here.
Speaker 5:One of the bits of work that we end up doing with people when we're workshopping this is we talk about reputation. Everybody listening to this podcast and all three of us we are interpreted through our reputation. If we have a positive reputation, if people see us as being good folk, when we do things, people tend to believe those are good things that we have done, and if we do something bad, people go. He couldn't have meant it and they might even come and check if we're okay. And our reputation. And this is doubly true when we're sending somebody an email, because when you read an email, you're interpreting some words on the page through the mood you're in at the time and the reputation of the sender. And reputation is massively important. And a way that I think is lovely to think about this is your reputation.
Speaker 5:Is your theme tune? What music plays in other people's heads when Mitch walks in the door? And it's not what plays in your head, it's what plays in their heads. And actually, what music would you like to play in their head?
Speaker 5:And if you decide what music you want to play in their head, what you want your theme tune to be when you walk through the door, how do you have to behave in order for them to hear that music? And then working on that and working on ourselves. We're all working on ourselves all the time, but working on your theme tune, thinking about what you want it to be, and then working on it so that other people might hear that. And it doesn't matter what you want. You might want the theme tune to jaws, which I would argue is probably a little bit negative, but if you want that, then behave in the way that terrifies people when you walk through the door. You might want something positive where people feel able to tell you information, where they're not scared of you. Well, choose your tune and decide how you need to behave in order for people to hear that.
Speaker 4:I just watched Indiana Jones and the Dial of Destiny with my youngest son, so I'm going to go with the theme song from Raiders of the Lost Ark.
Speaker 3:I love that. I have a buddy of mine that we talk about what our walk-up song would be If we were. You know, in baseball in America you walk up. You get to choose your song. This is going to change my perception of it. Maybe not the coolest, heaviest riff, but what do I want people to think of? I remember when we had Alex Macario on and as accomplished as he is in anesthesiology in the United States, we said what do you want to be remembered by? And he said I want people to think that I was kind. That stuck with me. That was an incredibly impactful statement. All right, chris.
Speaker 3:So you know you've talked a lot about getting people on board and getting people to see the value, and you've talked about the data. I know this stuff is kind of ingrained in your mind. You go out and talk about it all the time. I love your infographics page here on the civilitysaveslivescom website and there's infographics that anybody's free to come and take and post in your workspace. Of course, my favorite is leading through. Incivility is like breaking wind in a lift you may feel better, but everyone else feels, and performs worse, so just a reflection of who's driving this website.
Speaker 3:That's a great one man.
Speaker 1:I want it in all of our operating rooms at UAB.
Speaker 3:But there's lots of data and I've said for a while hey, you know, we all want to be evidence-based physicians, but it's hard to admit that healthcare is not a team sport and so if we're going to understand and be evidence-based physicians, then we all have to understand the evidence behind teamwork and incivility, et cetera. So you know a lot of that data. It's kind of near and dear to your heart. So just briefly, can you tell us what does incivility do to us?
Speaker 5:So, before I say what incivility does to us, I'm going to tell you something different. It's about what is the single most important factor determining the quality of decisions that teams make, and it's information sharing. It's not how smart Mitch is, Matt is or Chris is, and I'll tell you why. It's not how smart we are. It's because in every team that we work in, there are people in that team who know things that we do not know, and unless we know about it, unless they share it with us, we cannot take it into account. We can't let our wonderful leadership brains take it into account when we're making the next decision. So the key factor here is what's helping a team to share information? And what does help people to share information is feeling valued and respected. When the people around us feel valued and respected, we turn on the flow of information. We share information. If we don't feel valued and respected and this is psychological safety, it's all in there If we don't feel valued and respected, we turn off our flow of information, we don't share information. And when somebody doesn't share information with me in a trauma call, there's every chance I won't know what's in their head and then I make my next decision and it might be a really poor one, because I've starved myself of the oxygen of wisdom which is information. So what happens when we treat each other in an uncivil fashion? And when I'm talking about incivility here, I am not talking about the screaming and shouting. I'm talking about the mild to moderate incivility the eye rolling when you speak, the tutting when you speak, the people who correct your English halfway through the sentence or finish your sentence off for you when they couldn't possibly know what you're about to say. And the evidence on this is that in the moment it squeezes our bandwidth, it stops us thinking so well, and there's about a 61 percent reduction in our cognitive ability when somebody treats us in a negative way. Now that lasts for a varying length of time. For some people it's just a few seconds, but for many of us it's a lot longer with a tail, and if you witness incivility between other people not directly at you, there's about a 20 reduction in your cognitive ability just being around it, and I suspect that the mechanism that's going on here is that incivility is the very thin end of the threat wedge. Now threat can come at an overt level, where somebody's standing in front of you and they're pulling their fist back and they're about to hit you and it's pretty clear that you're in trouble. So we have a fairly extreme physiological response to that. But at the other end of threat is the stuff that we don't know if it's meant to be offensive, but it makes us uncomfortable and we think, well, if they're okay with treating me like that, how else are they going to be okay with treating me? And I think that's what we're measuring with a mild to moderate incivility is the thin end of the wedge of threat. And that means that a couple of things happen If I treat the guys in my team in a negative way.
Speaker 5:The first thing is I make them less smart. They're not wonderful smart human beings. I squeeze their brains down and make them a shadow of themselves. So that's the first thing. But the second thing is that they are now less likely to share information. So I've got a double whammy on my hands Less likely to talk, and even if you do talk, you're not going to be as bright as you were before, and that is a disaster for my decision-making. And that's the mechanism that I think is going on when this happens, and that's from pulling together lots of different sources.
Speaker 5:There's tons of other data.
Speaker 5:I mean, you mentioned a few minutes ago and I've forgotten the chap's name, but you said he wanted to be remembered for being kind.
Speaker 5:Yeah, alex mercurio. So I I think that is a wonderful thing to want to be remembered for, but witnessing incivility literally makes us less kind. If you witness incivility not directly at you, just witnessing it, you get up and you go around the corner and somebody asks you for help, you're a full 50% less likely to help that person. It makes us less kind, it primes us in the negative and that just seems like a really bad idea in my head, because most of the time at work I'm relying on people being kind to me, helping me, because I am constantly as I'm sure you guys are constantly in workaround mode, trying to make things happen in a system that feels like it's fighting against us sometimes, where we're trying to put a patient first and it doesn't always feel like the system wants to do that as well. So we work with other people, we have work, but they rely upon other people being willing to help us To be kind.
Speaker 4:Thanks, chris. You know, matt and I we've had the opportunity to toss around a few ideas with JD Pendant, who was on our podcast earlier, and he's at the NHS as well. He's the editor-in-chief for Anesthesia and Algesia. But you know, matt is definitely a proponent of team-based care, right, and that's important for how we deliver care here in the United States. The interesting thing for us is, as residents, very few programs train you to learn how to work with a team, right, and our residents here are taught how to run a team. And what I teach the residents is that communication's up and down and down and up, and what you want is you want to have a team of people that surround you that at two o'clock in the morning, when you're on overnight call that somebody's going to feel comfortable enough to tell you that hey, did you think about this? Right? And to have that communication open is going to save a patient one day, and I think that's really, really important.
Speaker 5:This guy called Michael West and I suspect you've not come across Michael West, but can I commend him to you with my whole heart. Michael West is the professor of leadership at Lancaster University in the UK and at the King's Fund in the UK and he talks about the evidence base behind highly performing individual teams and organizations in the system I work in in the NHS but most of this won't be any different to you guys and he can show how highly performing teams share certain characteristics. There's not usually more than eight or nine people. Once you get beyond eight or nine people, it's actually hard for everybody to be heard when you're in these mega teams. Only some voices get heard and we have to work hard to give people voices in those settings. He can also show that the best teams have away days. Every three to six months they go away and they talk about what it means to work here and the strategizing of where we're going and how we want to be treating each other. He talks about other stuff as well, and one of the things he talks about is this If you cannot do the whole thing on your own, if you can't go into theatre and do the operation, be the scrub assistant do the anaest.
Speaker 5:It is not the individual. And boy did I not like that. When I first heard it, every bit of me pushed against this, because our entire education in healthcare tends to be about personal mastery. It's about me how good am I, what do I know? How can I work out things? And we do it all in exams on our own. So it's all about personal mastery. But when it comes to us functioning in teams, if we have people who aren't able to perform well within that team, you actually can't really compensate for some of those jobs. So the minimum unit of performance becomes the team, and that means how we treat each other really matters, because that has an impact on performance at an individual level.
Speaker 3:I've kind of maintained for a while we do a great job in this country of turning out outstanding clinical anesthesiologists who then the very next day when they take their job, are doing something completely and totally different because they're managing teams right. And so that brings me to another topic that's near and dear to your heart and you mentioned this last time we chatted and we haven't gotten to go into it and that's that one of your passions is teaching wisdom. Can you expound a little bit more upon that, because I think that's part of this. We're saying hey again. When you go out there, there's one way to do thing in your mind. There's lots of other ways to do things that people might want to try. How do you handle that? And that kind of comes more down to wisdom. So explain what that means to you.
Speaker 5:Just for a start, I would say what you've just described about what happens to anesthesiologists in the States is exactly what happens to emergency medicine consultants in the UK. You're seeing patients, you're in the front line one day and the next day you're running a department and organizing people, and that's a wildly different way of functioning. Anyhow, back to wisdom. Wisdom's fascinating, so that's what I research um research, the development of wisdom in doctors and it's properly esoteric. You try and hold it and it slips through your fingers and everyone says what's wisdom, what does that mean? And all the sort of hard academics are uncomfortable with it because it's hard to pin down. The thing is, what do we want to do as clinicians, as doctors, as nurses, allied health care professionals and as administrators? What do we want to do? We want to do, we want to make wise decisions. And okay, so I am about to say something incredibly grandiose, and it's this I think pretty much everybody who researches wisdom has got it wrong, and I'll tell you why. Pretty much everybody who researches wisdom looks at the decision-making process that goes on between our ears when we're making a decision, and I can describe this to you in terms of aristotelian virtue ethics and the nicomachean ethics and the primacy of phrenesis over the other ethical decision-making processes and, if I'm honest, I think it's a wee bit of nonsense. I think we like it and we spent the equivalent of about one and a half million dollars researching this and this is why I think it's a bit of nonsense. I don't think it's all rubbish. I think it's useful to be able to deconstruct thinking, but I think most people will make good decisions when, given the right information. And here's the gig. You ask people at an undergraduate level what's a, what does a wise doctor do? We're talking about doctors here for a second or two. What's the wise doctor? Well, they say well, the wise doctor makes a great decision. And what they then do is they assume that they make that great decision because they've got all this wonderful information inside them and they then do is they assume that they make that great decision because they've got all this wonderful information inside them and they use it and they come off and get the great decision. But that's not what's happening in my opinion, and actually this is what the evidence says that people who become great leaders and make wise decisions, they don't just have the answer. It isn't just there in their head. What they do is they behave differently.
Speaker 5:Now, when we move into leadership positions and this is true for many, many of us we move into leadership positions we have a little bit of imposter syndrome. We thought we knew how to do the job. We move up a level and go holy crap there's quite a lot of stuff up here that nobody appears to have told me about and then we start learning about it. We have imposter syndrome. Our natural reaction to that is to move into command and control mode, where we try and get grip of the situation and we feel a bit more comfortable when we've got some control. And then we start micromanaging people because we're in our comfort zone. When we're micromanaging people who are doing something, we know how to do and what we know and this is actually back to Michael West stuff what we know is that people who behave that way don't get good outcomes. They don't make what are retrospectively regarded as being wise decisions.
Speaker 5:But people who do make wise decisions from leadership positions move into what Edgar Schein, who died just a few months ago Edgar Schein would call asking, not telling. They move into a different leadership mode Instead of command and control. It's asking, not telling. And what they do is people who make wise decisions start asking people around them what they think, and you see this in cardiac arrest, you see this in things that go horribly wrong in theatre, you see it in trauma calls that often for the first few moments it's very command and control, but only for the first few moments, and then it becomes collegiate. You get a bunch of people who are talking to each other, who are sharing information, and they're working together towards a shared goal, which is usually resuscitation in these settings, but they're doing it by sharing information, and that asking, not telling, is a really interesting way of changing the dynamic so that we are effectively giving ourselves more and more information, so that our wonderful brains can make better decisions.
Speaker 5:And I think that wise decision making is a function of getting the best information from the people around us, which is a function of our behavior, so that we can then process that information. And if you really want to make your decision wise, you can do something else afterwards, once you've made your decision tell the people who you're working with what your decision is and why you made that decision, because you instantly provide yourself with a feedback loop. If they feel able to say things, they go yeah, but did you realize that there's another knife sticking in his back, or something like that, so that you can then take that piece of information into account? And when we describe our decision-making processes, what happens is that other people are let into our thought process and they sometimes feel able to contribute more to help us to make an even better decision. So there you go. That's one and a half million dollars and seven years of work wrapped up in me telling you I think we missed the point and actually this is probably better.
Speaker 3:I got to use the term a wee bit of nonsense more in my daily vernacular. I'm incorporating that one in a wee bit of nonsense doesn't sound as good when I say it as when you say it.
Speaker 4:Chris, I just wanted to add that I'm going to have to call Kenneth Sharp and Barry Schwartz, who wrote Practical Wisdom on this side, and then there's a section in there Medicine and Healthcare that their book is bonk. I don't have any problems doing that, Don't?
Speaker 5:do that. Barry Schwartz is a god.
Speaker 3:Mitchell Tsai at UVMorg. I know Kenneth Sharp.
Speaker 4:He's a good guy, you know. What you've said is that one of the things that Steve Sample, who was the president at USC for the longest, for a while he passed away a couple of years ago, but he wrote a book and it's called the Contrarian's Guide to Leadership right, and one of the chapters or one of the themes is to think gray, not black and white, right, and the longer you can stay in the gray, the better decision that you're going to make, because you're always taking in information and just in terms of wisdom. You know, in my travels as an anesthesiologist who's still trying to figure out what he wants to do with the rest of his life, I still think that leadership, education, entrepreneurship, design, thinking all have that same common theme of your job is to get there and get as much information as you possibly can, as quickly as possible. I love that get as much information as you possibly can as quickly as possible.
Speaker 5:I love that. I think, gray, a thing I see panning out regularly in hospital is I have a sick patient in resus. I have a sick patient Now. This patient might go surgically or they might go medically, and I invite the medical doctor and the surgical doctor who may be taking this patient to come down and see the patient and for the first few seconds they have a conversation about the patient. Then pretty quickly the patient is pushed out of it and I have the the medical guy and the surgical guy and they're basically going toe to toe. They're going toe to toe and the purpose of this conversation for them is to be right and we mistake being right for doing the right thing.
Speaker 5:Being right is black and white. It's dichotomous. I win, you lose. It's about my ego. Doing the right thing sits somewhere in the middle and I think a lot of the time for people that I see at work who get into a lot of conflict, that it's really important to them to be right and stepping away from that and, instead of being right, saying, well, what's the right thing here is something that wise senior decision makers frequently do. You see them coming in, these senior guys, these doctors, these nurses, these senior people. They come in and they talk about the patient and they pull the patient back into the conversation and they discuss what the right thing to do is, and it's always somewhere in the middle and it always involves the team that doesn't take them onto the world, committing to consulting with the patient on a regular basis rather than going. That's your problem, not my problem, and I think we mistake being right for doing the right thing, and they are absolutely different in most complicated and complex situations.
Speaker 3:I hope that husbands are listening to this too. Right? That's a marriage counseling one-on-one right there. How important is you to be right. We have taken this podcast to an entirely new discipline now, so thank you for that, Chris.
Speaker 4:Man, I was actually going to argue that it's sort of the continuation of crew resource management and civility within the cockpit. Right, and if you look at checklists in the aviation industry, all of them at the bottom, they all say fly the plane. Ultimately, our job is to take care of the patient, so I love that. You're the second individual we've had on the podcast from across the pond and given the recent resident strikes in the NHS, we can all agree that trying to figure out what to do with the healthcare systems on either side of the country and it's interesting that both the NHS and sort of the United States healthcare system evolved after World War II very different circumstances in England than it were, in America. But the healthcare system trying to figure out what to do, it's a wicked problem. From where you sit, how would you approach making the system better?
Speaker 5:I mean, given everything that we've talked about today, I think we do a lot of harm to a lot of people because we don't have some conversations, and the conversation that we don't have most often is what do you want us to do towards the end of your life? And there's massive cultural component to this, so I'm going to use a really broad brush on it. My wife is Bangladeshi. My wife is Muslim I am the only non-Muslim in my family, which is a fascinating place to be and her family are great. They're just lovely people, but nobody in her family dies without being on intensive care with a tube coming out of every single orifice and machines pinging all around them. Now, I am a Scottish Presbyterian by birth and in my family it's not a good death if you die with machines on you. In my family, good death happens quietly, with your family around you, either at home or in a hospital, but not hooked up to everything. And that's because there's a cultural expectation around that, and that's a cultural expectation around that, and that's the cultural part of this. What we don't do is we don't have conversations with patients and their relatives about what somebody would want at the end of their life, and instead we get trapped in this. We want to keep people alive forever, often causing them more pain and distress at the end of their life than I personally feel comfortable with. So I think there's a conversation about what do we do, what's the kindest thing that we can do, and that might be on a machine with all the stuff going on around you, but it might be quietly in a side room with your family around you. And if we don't have the conversation and we don't think about how to have the conversation, what we will keep doing is expending huge amounts of health care resources on people in the last few weeks of their lives at tremendous opportunity cost to the patient who is unconscious in intensive care, when actually we might be able to find more valuable time for them to have with the people that they love now. It's hugely, hugely messy and it's individual and it's about individuals and what they would want, what families would want. But I think for me, the starting place, weirdly, is the end of life and talking about what the right thing to do for people at the end of life is.
Speaker 5:Within the UK we have a form called a respect form and it evolved from a do not resuscitate form and it is a much more sophisticated beast than do not resuscitate form. It has elements of advanced planning. It talks about what people value, what they most want, what they most want to avoid, and it includes a narrative around this human being and what's important to them. So for me, I'm straight into the difficult stuff. Let's start to think about how we have difficult conversations about what we do with people towards the end of their life.
Speaker 5:On a meta level, I'm all about socialised healthcare and I realise how many people will just be turned off by that in that state. But I am all about socialised healthcare. I want to know that when I have my cardinal infarction I'm a 55-year-old Scottish man, let's face it, guys. I mean the clock is ticking. When I have it I want to know that I can pitch up at the hospital and it doesn't matter which hospital I pitch up at that nobody is going to ask me for insurance, nobody's going to have a discussion with me about whether or not it's okay for me to do this, and nobody's going to be bankrupted by it, and that's how it works in the UK.
Speaker 5:So I was thinking about this earlier today. I love that. I work in that system. The system just asked me to do my best and deal with the patient in front of you and there's no phone calls to insurance companies. There's nothing like that happens. But of course the system has to be resourced and that's another political football. So for me the end of life stuff becomes incredibly important. Thinking about how we can be most effective as individuals and teams is important. And then there's the political stuff, where I don't think anybody should lose their house because they had to have a kidney transplant forever, mitch.
Speaker 3:I told you it's going to be fun. We could go hours and keep on going. I'm going to actually let the listener in here, as we kind of close up so the listeners can't see what's going on here, but I have this keen ability to see both of the guys I'm talking to on the screen, and there's this tension that you guys can't see, right? So Chris is drinking out of an ACDC mug, right? I know, mitch, though Parker has a Fender guitar and a Fender amp, right? So let's settle this once and for all British guitar tone versus American guitar tone. I will point out and I'm saying this as an American when Nigel Tufnel points to the amp and says this thing goes to 11, what's he pointing to? He's pointing to a Marshall amp. Right, it's a British guitar tone. So, chris, you're here, you have the opportunity.
Speaker 5:Do we settle this once and for all? Do we strike some sort of balance? Where do you want to go with this? It's all in the gray mitch told us that earlier. It's all in the gray man. What a what an answer, as long as it goes up to 11. Once it gets to 11, I'm pretty certain that our middle ear and our inner ear can't really tell the difference, and for me it's Marshall. But anything that sounds like Jay Maskis rocks my world. So there you go. For people who know who Jay Maskis is, awesome.
Speaker 3:Chris man, thank you so much. This has been a blast and I'm sure you'll be getting hit up by both Mitch and me later on to continue discussions, but thank you so much for doing this. This is the first time we've ventured outside of the perioperative space, although I will say that civility certainly pertinent to the perioperative space. But this is the first time we've had a non-anesthesiologist on and I think you've given us a tremendous perspective. So thank you so much for being here, man. This has been awesome.
Speaker 5:Thanks guys.
Speaker 3:Thanks, Chris. Thanks for tuning in to the Fresh Flow podcast. We hope you found it interesting and hope you'll tune in next time.
Speaker 2:Thank you for joining us on the Anesthesia Patient Safety podcast for this special podcast takeover and a huge thank you to the team at the Fresh Flow podcast for sharing your show and this important and engaging conversation with us. Teamwork and civility are necessary in the perioperative environment to ensure patient safety and there are some really good ideas that you may be able to use on your healthcare team going forward. If you have any questions or comments from today's show, please email us at podcast at APSForg. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSForg for detailed information and check out the show notes for links to all the topics we discussed today. Until next time, stay vigilant so that no one shall be harmed by anesthesia care. Thank you.