Grand Rounds-What Surgeons Should Do to Effectively Manage Operating Room Team Conflict

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- Hello, ladies and gentlemen, and thank you for joining us for another session of the Dublin is upgrade Grand Rounds. Our today's guest is Dr. David Rogers. He's a professor of surgery at University of Alabama at Birmingham. He's also the senior associate Dean for faculty affairs and professional development. He's going to talk to us today about conflict management in the operating room, and specifically for surgeons. As surgeons, we're captain of the ship and this comes with a significant responsibility as an organizer and a manager in the operating room. It also comes with a real risk for conflict that is essentially unavoidable. So the topic today is extremely important, essential or functional surgeon in the operating room. And I really appreciate David for giving his time for us to talk about this important topic. David, thanks again and please go ahead.

- Oh, well, thank you, Aaron. I'm excited to be able to share some of the results of our work as a practicing surgeon. I entirely agree that we manage teams manage conflict within the teams, and I think we've produced some findings that should be of interest to anyone who works in this very challenging environment. I have no conflict of interest to disclose related to this presentation. This work was funded by a grant from the Association for Surgical Education Foundation Center for Excellence in Surgical Education and Training. I'd just like to acknowledge their support, without their support that work wouldn't have been possible. We also had a wonderful collaborative team that is listed here. Lorelei Lingard was our methodologic expert, Sherry Espin and Maggie Boehler are both nurses who do educational research. And then three surgeons were involved in this, that functioned as a part of the larger research team. The real motivation to put this presentation together was provided by one of our surgeon participants. And basically he or she commented when we were in the focus groups or basically posed a question. Will we get some kind of feedback on this? I assume that you will get some kind of publication out of this that we can see. And I think the curriculum idea just makes a lot of sense. To which we respond to, yes, you will get feedback. Yes, there were several publications and we agree that a curriculum around this makes a lot of sense. The other motivation to do this, which is related is really the beginning interest around this entire program of research was about providing some practical advice for operating room conflict management surgeons. My background in this is I had done a research in non medical teams and how they deal with conflict. And it just occurred to me that that what we do in the operating room is incredibly impactful. And we really just want it to provide some practical advice for surgeons like the audience. So these are the presentation objectives. These are the things I hope to accomplish in this presentation today. Talk a little bit about why the topic is important, both Aaron and I have endorsed that fact, but I'll try to give you some evidence for why the topic is important for us to address. Additionally, talk a little bit about our findings and how surgeons are currently managing or learning to manage conflict. Talk a little bit about the topic of the consequences of conflict mismanagement and not to belabor that point, but really as a motivation to understand how to manage it more effectively. And then finally talk about the main body of our findings and our central focus, which is what constitutes effective conflict management by surgeons. So this was really the background for this. I'd like to step through and just sort of give you some highlights about this, but basically look at the impact of operating room team conflict on patient outcomes. I think everyone would agree this is our primary focuses as surgeons is to make sure our patient outcomes are optimized. Additionally, talk a little bit about what existed in the existing literature about surgeons and how they manage conflict, address a little bit of the motivation of dealing with surgeons specifically. And then finally give us general sense of some of the background literature, which was speculative in nature, but needs to be acknowledged as it did exist. So this is a piece by Gawande and his group that looked at basically errors that had occurred in the operating room. And you see circled on the slide here that conflicts over decision-making is a major contributor to errors that occur. I'll draw your attention also up here to this idea of communication breakdown, you'll see that in our work we found that conflict mismanagement particularly can actually lead to communication breakdown. So we think that this article supports the idea that conflict is an important topic and has an impact on patient outcomes. But we think that this 50% number likely underestimates it because conflict mismanagement can lead to communication breakdowns. Most of the literature that we could find or most of the comments about how surgeons manage conflict we described as being a little bit stereotypical. Here's a quote from a work done in Scandinavia, "more conflict among surgeons than in other specialties where physicians have less see less reputation for the eruptions of temper." This is another quote that came out of the legal literature that basically says physicians tend to be very temperamental and surgeons, even more so. With a surgeon, they get upset with you and walk out. Our feeling as surgeons is that these are likely fair representations of some surgeons. In some circumstances, there are, you know, I've seen surgeons behave this way. Frankly, occasionally I've been a surgeon that's behave this way, but we think that this is a stereotypical representation. These stories are interesting. People like to talk about them. They kind of fulfill what we see in the media. And while they're true, our feeling was, is the vast majority of surgeons have likely developed some effective conflict management behaviors and none of that's commented on the literature. So we felt that there was a tremendous resource that's available on surgeons about how to manage conflict. In addition to the sort of anecdotal instances where surgeons have mismanaged conflict. One reason to focus on surgeons is you really want to affect the performance of the team unless you target surgeons. And that is this comment by Amy Edmondson, who's a researcher from Harvard who's not a physician, not a surgeon, but she based on observation and the operating rooms has commented that surgeons have tremendous, enormous organizational power. So if you're gonna change the team, you're gonna have to change the surgeon, attitude and behaviors. This was the existing work. One of them is a piece that Lorelel Lingard and I where we looked at existing literature on conflict management. We looked at literature that looked at acute care teams and try to offer some suggestions. I would say we were about 70% accurate in what we predicted would constitute effective conflict management, but we were wrong in some important ways. And that's why we actually did the research. This other work by Dr. Lee and others is a nice piece about conflict resolution. And again, these are drawn from other things and they aren't grounded in any evidence, but they do exist and they certainly inform some of our thinking in this work. So the first question principally as a, surgical educator is, is there a need for a curriculum? If there's no need the surgeons are already figuring this out, then we certainly don't need to spend the time developing a curriculum. Additionally, we were actually quite uncertain as to what behaviors constituted effective conflict management. As I mentioned, most of the work that existed was somewhat stereotypical, typically negative. So there really wasn't any good understanding of what constituted effective conflict management. So just briefly this was our research process. This was a multi-institutional study done at five different centers. We selected target groups of operating room nurses and surgeons. We developed some initial questions from the conceptual work that I presented earlier, sort of the theoretical work from this, all of the conversations that occurred in the focus group were recorded and transcripts repaired. We did a preliminary analysis that occurred while we were doing it to be certain that we were asking the right questions. And then we continue this process until it up here that no new information was evolving, which is a concept called sampling saturation. We created what are called or from the transcripts, we identify what are called incident narratives. So these are when surgeons or nurses would describe an incident that entire incident is coded as an event. We then created a concept map and I'll show you a little bit of a slide of how we do that analysis. We then go through all of these narratives and reviewed this with the primary team that included Dr.Ligard, Dr. Espen, Ms. Baller and myself. And then we share these with the three surgeons at three centers and ask them just to reflect on their current work environment, but also their work experiences. And all of them are surgeons with some experience. And this was simply done to validate these themes. In other words, is what we were discovering seem authentic to these surgeons based on their experiences and observations. This is what a concept map looks like. And so it's a very rigorous process of a qualitative research. And I show this because I'm gonna give you in the remainder of the talk, some illustrative examples, and I don't want the audience to operate under the misperception that I've just, that the group has sort of picked out a little incidences that supported our biases. We really go through and analyze quite rigorously the entire transcript, but not many surgeons have done a grounded theory, qualitative research. So I just wanted to share with you what that process looks like. So we did a total of six focus groups of each type done at the five centers. They consisted a 31 circulating room nurses with the majority being women, 35 surgeon participants with the majority being men, the final sort of book, consistent of 220 pages of these transcribed narratives. So to answer the first question, was there a need? What we found was is that almost all the nurses and surgeons described that they had received no or inadequate training related to their preparation for this, for managing conflict in the operating room, that they, what they had learned, they have learned through trial and error. And then we found really good evidence that conflict mismanagement has a number of consequences. Some, I think we would have predicted from the patient safety data that I shared earlier, but some was quite novel. And so I'm gonna step through and sort of highlight some of the findings in these general areas. So this is a nice reflection from a nurse that talked about the lack of training in her quote, "and really there's a huge lack of training and understanding because they," referring to surgeons, "don't get anything in medical school and we really don't get a lot of nurses school on conflict." I would say more of the nurses than the surgeons indicated that they had received any sort of attention to this topic in their instruction. One of the nurses, however said that what she had been taught in nursing school actually was a negative feature in terms of preparing her for the real life experience. So that's an example of inadequate training or even training that interfered with effective performance. This is a, the problem that we, that our participants talked about, the problem with learning it through trial and error. And so I just wanted to comment on these briefly. One was this legacy of inadequate management skills. And another one is that the world where we work is clearly changing. So this is a reflection about the problem with learning from trial and error. And that is that the faculty sets the tone, but the faculty isn't very good at that. Then the residents take on a lot of those characteristics. To me, this is not good. So this is an example where for a generation surgeons, haven't been prepared to manage this. And so you have faculty who are not very good at managing conflict, and they're trying to teach residents. And so predictably, the residents will, you know, at the very best will take on some of these, of both fortunate and unfortunate characteristics, but certainly not a very effective way to teach people to manage conflict. And this, I think is a really strong theme that came out of the work. And I think all of us who are in practice now know that the world has changed and will be held to be accountable in ways that are very different than perhaps a way that the people that trained us. And this quote that basically says, "I think the days of I'm a surgeon and this my way, and the rest of you be damned or gone. As a new younger people come out, while you may wish it may still be that way you realize it's not." And we got from the surgeon participants sometimes this sense of a wistfulness for a back in the sort of good old days where surgeons literally were kings or queens. And what they said was the law. I think we now know from the patient safety data, that this isn't the best way to practice that having the full team engaged is much better, produces safer outcomes, better solution sets. But I think in a real way, both nurses and surgeons said that the residents that we're training now are gonna be held accountable for their behaviors in a way that's quite different. And I think we're already seeing that happen in a lot of different environments, if not all.

- Hey David, I wanted to ask you a question here. Why do you think traditionally surgeons, I mean, Harvey Cushing in neurosurgery, for example, many of the founders had such a prevental attitude and what you call the king personality. Was that a requirement for success in those times because we find this very prevalent idea of sort of overbearing temper. Can you have any, do you have any thoughts on that please?

- Yeah, I don't, this is a great question. And I think that it must've been a cultural expectation. I think that at that time, people that were in a professional model, what they would say was not questioned, that was certainly suits certainly true early in my training, that if an attending said something in the operating room that simply that was carried out. I think that, you know, what, if you study how aviation changed, that was really one of their challenges is that the pilots were not questioned that if a pilot made a determination, then the copilot simply followed instructions. The whole flight crew simply followed instructions. So I would say there must have been cultural similarities. It's an interesting question about what caused that to be true. It may have been that where surgery was in its development in that time, you needed very strong people that basically, you know, organize their teams that way. It's, I think it's true of aviation. If you look at the development, for example, a space explanation, the very first astronauts were kind of Cowboys and they were a little bit crazy. And, as the space exploration has evolved, they've gone to where people are much more team-based in training. So yeah, I expect that maybe the, I oftentimes tell my residents that, 30 years ago, even 40 years ago, surgery was kind of a near death experience. And so you needed to move along quickly. That's not really the case, the science, has evolved. So one of the things that I think is a disadvantage for us is that we train with this crisis mentality. And the truth is a really competent surgeon. The surgery should be fairly routine, even, you know, even complex pediatric surgery like I do, or neurosurgery, it ought to be fairly boring if the surgeon is capable and the team is working effectively. But it's a great question.

- Thank you.

- So with respect to the idea is conflict mismanagement consequential? I've referenced this article here. It's not really the topic of this, and I don't want to belabor it, but we found a number of instances of conflict mismanagement. Some of them are just sort of a negative sort of feature of things that I'll talk about as being a positive management, but some of them are a little bit unique, but in this work, and you're welcome to read it. We talk about these are instances of conflict mismanagement, and that all of them have consequences, and I'm gonna step through those, but you can read more about their behavior. Some of them are difficult narratives to read. So I think, but I think they're important just to acknowledge that they happen. But let me talk about just briefly some of these consequences, because some are a little surprising. These weren't terribly surprising, and that is conflict can have a mismanagement or can have consequences to the staff. What the staff described is when the surgeon becomes emotional, that they then attend, give part of their attention to that behavior on the part of the surgeon and this distraction then causes them to create increased errors. As I mentioned at the very onset of the presentation, if you strongly rebuke a staff member, then what they would describe is that they would then be less willing to communicate. Even if it was information that was potentially important for the patient care, they basically become less motivated to perform. They're part of the care task. We found evidence and there's good literature elsewhere that actually it makes their jobs fairly miserable. This can re we found in other work can lead to physical illnesses, psychological distress, and ultimately they leave and they leave in a couple of different ways. Many times we'll go to the people in charge of making the assignments and say, I refuse to work with that surgeon again. So functionally, they become a loss to you. Now, many cases, they quit their jobs altogether. And so they become a loss of that entire operating room. And so, if you have a valuable team member, one of the things I think as surgeons we have to think about is we tend to think about them when we're working with them. If they're really valuable to us, we need to think about everyone else they're working with, because all it takes is one surgeon who is practicing conflict mismanagement that can cause them to be a loss to our team. The other.. So this is an example of the doc yells at them too much. They're just fine I'm gone. I'm out of here. And so if you're these are valuable folks. So once they get trained and develop a positive working relationship, this is a lot of value that just leaves the institution. And a lot of value has to be then devoted to bringing in new people and training them. This was a little bit of a surprising theme that developed, and that is conflict mismanagement actually has consequences for the surgeon in the same way that it has distracts the staff. You can see the second bullet point here. It can distract us from patient care. It can lead to increased stress and frustration. And one of the things that I've that came up in the themes is that nurses will develop an opinion about the competence of surgeons based on a conflict, either mismanagement or management. And so I always tell graduating residents, you will very quickly form a reputation as a practicing surgeon based on how you manage conflict in the team in conflict. This is an example, a really nice example of a surgeon, reflecting on how conflict sort of affects his or her thinking. You have a delicate, complicated operation you have to do, and you have to focus all of your attention on that. If you have a tussle with somebody, it may be difficult to do that. So I think that there is a, both a cognitive and an emotional consequence of being in a conflict. And you almost have to settle yourself down to concentrate fully on the important task at hand. An area that we were interested in was direct patient outcomes. You remember from Gawande work and other work, that it has some patient outcomes and so we ask a number of questions. What we found is, is that of the conflict and conflict mismanagement likely causes the case, cases to become longer. Again, likely through this avenue that people aren't communicating effectively are less motivated. They won't, the staff would talk about they don't violate policy, but they aren't going to do anything extra to help you so many times I tell surgeons, if it feels like your room has suddenly slowed down, or the turnaround has become very long, it may have been because you mismanaged a conflict and your team is having the effects that we've found in terms of related to them. We asked the question, did you, for both staff and surgeons, have they ever observed an instance where a conflict mismanagement actually led to a patient injury? The reactions to this from the field notes is quite interesting because the participants basically physically withdraw from the question. So we think this is a very threatening question to ask. There were only very few incidences that were described, and these were always at had described to other people. So we think while this isn't an empirical study, that this is it's likely that everybody steps up and behave professionally, but there are clearly occasional incidences where conflict is mismanaged so poorly that actually patient negative outcomes do occur. So then moving on to what constitutes effective conflict management and just to review the, basically what we shelved at this point in the work is that very few of us are prepared to manage conflict the preparation we get, probably isn't very effective. We learn it through trial and error, which is certainly not effective. And there is a compelling need in our current environment, both to train ourselves, but also to train our residents because they're gonna be in a very different environment. So then let me give you sort of what I think we discovered would constitute effective conflict management, which can be then the focus of your teaching in the operating room should be the focus of a curriculum that will be designed to teach conflict management. And these are really the behaviors. And I'm gonna speculate a little bit about how you might teach them. We've not done that yet, but I think in terms of the conversation, one of the reasons to present this work is with the hope that other people will develop curriculum at their sites related specifically to this topic so that the behaviors are to maintain a calm, to inventing, engage yourself in a two-stage problem solving activity, to engage in a type of enhanced communication, and then to be prepared, to confront others and be confronted by them. So let me expand these drawing from the data that we generated in our work. This is a nice example or a nice reflection from a nurse. And again, this is just an illustrative example. There are lots of narratives that talk about this, but basically the quote is, "they are calmer." And they is referring to the surgeons. "Are calmer and they're able to prioritize and rationalize important things instead of just flying off the handle." You remember, I talked about this reputational consequences for surgeons, and basically the way that it fits together is if you're calm in a period of conflict, then the nurses basically feel that you're doing that because you know how to manage yourself and to do what to do. And so they attach a higher estimate of competence when you're calm in conflict than when you become more emotional. One of the thing about that I would comment about that is that you're not really maintaining calm. We know from work done at the Imperial college and elsewhere that in a time of conflict or crisis, we know that our physiology is affected we know our heart rate goes up. We know that we're stressed. And so you're really practicing, maintaining the appearance of calm. So these are the consequences of maintaining the appearance of calm. The staff then has more cognitive resources available to do their work. And as I mentioned, they have an increase estimate of surgeon competence. Strategically then this means that you may be more likely and recruiting the staff that you want to your room. If they feel that you're more capable and perhaps more predictable in a time of conflict. Drawing from other research, this idea of keeping your calm actually comes up in other work. And this is one where they asked medical students to talk about what they regarded as exemplary behavior. And you could see a lot of the same vocabulary, appropriate handling of a difficult situation, calm under fire, kept cool, maintain composure, stayed calm. And this makes sense if you take the staff or the medical unit perspective, if you're a medical student in an operating room and things get really heated, either in a conflict or in a crisis, if the surgeon becomes somewhat hysterical or emotional, that must be very unsettling to the medical student and staff, because in many situations, the surgeon is the one person that can make things, right. So if that person becomes emotional, it must be very unsettling if you're in the room and you can't make it right. So how might we teach to stay calm? I think the first thing is you have to, develop it as a target to do it. In other words, you have to be convinced that it's important to do it. And one of the conversations that we had in one of the focus groups, the nurses talked about that the surgeon got very agitated in a conflict with anesthesia. So frustrated that he or she left the room and they heard the sound of something pounding on the outside wall of the operating room. And they didn't know if it was the surgeon pounding his or her head against the wall or kicking it. But the surgeon came back after a few minutes, had collected themselves and was calm. And the nurses really endorsed that stepping out of the room for a minute and just getting control of yourself as a, certainly a reasonable way to do it. But you have to have that target in mind. And then I think for those of us who train residents, we have to role model doing it. We all have lapses. We all have moments where we become emotional. And I think you can take advantage of those and perhaps in the debrief period or the surgeon's lounge to say, I really lost my cool when this conflict developed, or I made this personal with the anesthesiologist and that's not an effective way and I've made that mistake. That's one of the nice things about being an academic surgeon is you can take your mistakes and use them as positive teaching material. And then this, I mentioned this strategy of stepping out of the room that, you know, is something probably our ancestors couldn't adopt, but now with alcohol prep is pretty easy just to step out for a minute. If you need to sit down on the stool for a minute, whatever you need to do to let your sort of physiology come back to the normal state. So this is the stage one of the two-stage problem solving. And that is you really want to put aside all of the larger concerns and focused on the immediate task. I was at an institution where a surgeon actually happened to be a neurosurgeon, was looking for a piece of equipment that he really needed to deal with a trauma. And in our conversation, which wasn't really a part of the study, he was frustrated with the lack of equipment. And then he began to talk about, well, this is supposed to be a level one trauma center, and this is ridiculous that we can't have what we need to take care of this trauma. All those things were true. But when I find my in my own self, that this begins to happen, it doesn't ever settle you down. You just get more and more angry, more and more frustrated. So what our participants suggested is what you really want to do is focus on completing the immediate tasks, put aside those systems level concerns until you can get through the immediate moment. And I actually do this sometimes if I become very frustrated in a conflict, I actually sort of do a mental process where I remind them myself to solve the problem. And don't think about these other things and then demonstrate flexibility in solution, generation and implementation. So take a moment, you know, it's okay to stop in surgery for a minute and even talk about with the team. If you have trainees like I do, or with a scrub tech, say, what do you think are other ways we could solve this, a major source of frustration, that's about equipment, and you can say, okay, what other equipment do you have that I can solve this immediate problem? And this, again, relates to a positive reputation for surgeons. Nurses observed that when the surgeon has a, what I call a tool box that is they can solve a problem in multiple ways. They feel like that we're more capable or competent than surgeons who only know how to solve one problem one way. And any of us who were trained through residency and fellowship, one of the advantages, you got to see attending solve problems in different ways. So you really should have a tool kit, not basically one person running around with one tool trying to solve every problem. But that's not to say that we should satisfy, we should be satisfied with inferior equipment. And I'll address that in the second stage of problem solving, because there's clearly as a place for the surgeon to engage himself, to make sure that this particular problem doesn't occur again. So this is nice, a nice example from a surgeon. Okay. I really used, can I really use something different or am I going to stand there and tap my foot on the Mayo stand? Okay, give me something that does work and we'll go from there. So there's an example of a surgeon saying I'm capable and I'm gonna be flexible, and I'm gonna figure out how to make this work. So a nice model suggestion. And again, this isn't validated, basically I was taught by one of my attendings at a time, when you needed to make critical decisions, just to take 30 seconds to a minute and say, okay, what are my options? And this would be a nice thing to do in a point of conflict when the equipment is not available, particularly to say, okay, what are other things that I can do related to this? And then finally we have to commit to a plan. That's one of the unique things I think about being a surgeon. I really think that as surgeons, many times we sell ourselves short because we talk so much about the technical part of what we do and that's important. But to me, the hallmark of a really outstanding surgeon is one that can stand in a moment of crisis, keep their wits about them, and then generate a plan that we have to actualize. That's different than some of our non-surgical colleagues. They can console somebody. Now, certainly I've called partners to the operating room and that's things we, that we have to do from time to time and need to do and should do. But many times as surgeons, we are the ones that will have to actualize a plan. And this is a model just to think about as you teach your residents. So we sort of talked about kind of having a, real brief period and that relates to enhance communication. And I'll mention that in the second. There is a second stage of problem solving. This is an unexpected area. I just wanna comment that I am gonna come back to that, but I want go ahead and finish talking about the behavior set occurred in the operating room, because that was the main focus of our work. This is an example of a surgeon, reflecting on a, what I call an enhanced form of communication. And that is basically in a conflict what he or she is saying is if you slow things down and say, this is what you need to do, and this is what is happening. And this is what I want to do. Sometimes this helps. One of the things that's been interesting to me as we've gone to the briefing model in surgery is many times the team doesn't brief. So this audience is primarily neurosurgeons. I suspect that's more true for you than it is for me. And pediatric surgery is just, my cases are fairly short, but I certainly have had instances where the scrub tech, our scrub nurse has changed. And I look up and it's a completely different person. And I don't many times hear them doing sort of a, a handover to let each other know what's happening. And I think this is sometimes where we get in trouble as we look up and it's a whole different person than we started with either the shift has changed or they've taken a break. And so this reflection that one of the things to consider is, hey, I've got to kind of get this person up to speed on what I'm doing. They don't even know what the case is or where we are in it. And so we've introduced this concept of our re brief. That is, I think either when you're getting ready to enter into a difficult part of a case with potentially a new team member, but it's basically just stopping and saying, okay, you know, stop, I'm hearing this conflict beginning to develop. This is what I'm anticipating doing. This is the equipment I'm going to be needing. What's what needs to be available. Basically taking a time out in the midst of the case to re brief the team, particularly when conflict occurs. You were.. Aaron asking about our surgical forebears. And we think that this is related to this idea of a changing environment because in the people that trained me, they would never have an operating room staff member come and confront them about anybody certainly in my presence is hard with some of my attendings, as I think about some of the older ones, that's just unimaginable that anyone would ever go to them and say, you can't do this. If you think about the operating if you think about crew resource management and Team steps actually were teaching the staff to confront us. And again, reflecting on your question, this is what aviation learned. They began to hold the pilots accountable that when a team member said, I have a concern, the pilots were now held accountable to attend to the concern. And clearly we're teaching operating room staff to behave this way. I don't think what we've really done is teach the surgeons what do you do when someone does confront you? So here's an interesting reflection from a nurse about this saying, well, I've confronted them before he looked at me and said, in other words, you want me to be quiet and just do my job. And I said, you've got it. And so this is a nurse reflecting as she confronted, or he confronted the surgeon and they you know, reacted pretty positively to that. Again, this is part of our new challenge and the way we work, I can't even imagine some of my attendings having these sort of conversations. So I think drawing from the feedback literature, the best way to teach this is anytime we're confronted to simply say, thank you for the feedback. Amy Edmondson talks about in her work, this idea of flattening the hierarchy. And one of the ways that I've tried to do that is if I've had a nurse say to me, for example, in the brief that I have the wrong side, or I'm mistaken, what I say to them is thank you so much for pointing that out to me. If we really want those staff to confront us when things are unsafe, or even when they have suggestions then we're gonna have to encourage that, because we still have a ways to go in our culture to get people to confront us when they think we're getting ready to make a mistake, or when we just, they see a way that we could maybe do things better. So this is completely unexpected part of our work. And as a nice consequence of doing what's called a merging theory work. And that is, we identified that there were major systems that contributed to conflict. We were really focusing on the operating room. And so this really came up from our participants, but there was so much of it that we felt like we needed to take a separate look at it. So basically what they described were systems that contributed, and they also talked about our role where surgeons have been affected effective in modifying these systems changes. And these are the things that contributed to, the team conflict in the operating room. Team features was one in particularly new staff. It's pretty clear from our work that nobody wants to have new staff assigned to their room. Surgeons would complain that they would have to train these people and that they didn't know whether they would slow things down, even other staff. And that doesn't really welcome having new people in their room. One of the areas where endangers conflict is that staff, particularly in evenings, in emergencies, many times are pulled out of their usual type of work. So orthopedist, for example, we talk about, they would have the neurosurgical team down to do an IM rod, and that they wouldn't know, they wouldn't have been prepared for that role. Equipment management systems. So for example, one case here was at the leadership of the operating room, decided for inventory control reasons that they would take all of the equipment out of the rooms and move it to a central area and barcode it. And this made a lot of sense in terms of efficiency of stocking and capturing the cost. But what happened is that the nurses then had to become, start running 25 to 50 yards to get the equipment. And so the surgeons, all of a sudden noticed, hey, that I'm having to wait. And this equipment is not available because nothing had been communicated to them. And then finally, administrative leadership and the really important administrative leader in the operating room is typically the head nurse or charge nurse that is there to run the daily activity and effective administrative leadership involves these leaders that are willing to engage. Surgeons would comment negatively if the, if these administrative leaders just simply avoided dealing with these systems. So our suggestions is in terms of the surgical role is to become sophisticated about determining which conflicts are caused by systems and which ones are caused by factors in the room. So if it's a person in the room, then that doesn't have anything to do with the system. I think recognize that surgeons can play a positive role, that we do have power in the operating room, which is a whole nother, interesting topic about why do we have it, but we clearly do have it. Everyone acknowledges that. And we can use that influence in a constructive way. And then finally, that the strategy that really seems to work is educating the administrative leaders about possible patient outcomes. And we're uniquely qualified to do that through our training, but also because of our role in the operating room and the fact that we are there, and as surgeons observed powerfully the impact of a systems on our patients. So here's an example where the nurses endorsed us going to administrative leadership because they commented that it was frustrating to the staff because issues that are beyond their control. So I think that the biggest thing would be to direct their frustration to the area of the person who can handle the problem. The analogy I like to use here is think of the operating room as a lifeboat. And you have the room, the people in the room are in, are the people in your lifeboat with you strategically, you don't want to just sort of be tossing people out of your room. You want to, you know, try to protect those people as best you can. And in many cases, they're as stuck as we are in a system level change that was in may without any kind of involvement from people that actually take care of patients. So I think being discerning about that, the fact that the conflict may have occurred because of a system level change and that we're all sort of in the boat together. The staff are pretty sophisticated about understanding when a surgeon was acting on behalf of the team and the patients and those surgeons who were simply acting to advance their own self-interest. They're quite positive when we act on behalf of patients on behalf of the whole team, but they're not so positive when they feel like surgeons are just trying to advance their own interests in a competitive way. So just a cautionary note, you need to reflect on your own interests, but that's not to say that many times, those things aren't aligned many times what's of interest to us is also interested in patients, but just be aware that this is a, a powerful behavior that that can have some mixed outcomes. Additionally, surgeons who routinely go and have staff removed from their team can develop a reputation and staff are gonna be less hesitant to wanna work with a surgeon if you develop a reputation of being intolerant and simply having people removed from your team, it does have a bit of a reputational consequences for the staff. If they get bounced around from time to time. One of the things that our work was a little bit surprising is we found listening to be very only mentioned very rarely. Nurses mentioned it a couple of times of instances where certain and said, listen, even in it's a fairly indirect piece, surgeons never mentioned listening. So this is five centers I gave you the numbers of surgeons, a large group of surgeons, no surgeon could ever say, hey, I really stopped and listened to people, and that was effective way to do it. So I can't recommend it based on what our data showed, because we just didn't find surgeons ever mentioned any. What I can say is that there a fairly large of literature about effective conflict communication practices that includes listening. So you may want to just try the experiment of listening, and you don't have to listen for long periods of time, but just listen carefully to what people having to say. My prediction is, if you did this, that you would be in the top 10% of surgeons with respect to conflict management, just because I don't think it's commonly done in our culture. And again, I don't think this is because we're bad people. I think we're, we, train up in this crisis time pressure mentality. And the truth is that we can spare a few seconds to mention it or to listen. And this is from our conceptual framework of the 2006 article, but basically listening allows for an optimal solution set. I have a incidence myself where I was struggling to do a minimal access case and a scrub tech at one time said, you know, the, one of the other surgeons here has this kind of special instrument where that really makes what you're trying to do much simpler, which was fabulous, that she felt comfortable enough to suggest that we weren't in a conflict, but she just was proactive. This is an example of creating a room where people feel comfortable and trusting then allows them to make those suggestions and additional basically from other settings we know that if you exhibit listening, that nurses appreciate this, but also believe that you're more competent because you engage in this, in a communication style that includes listen. So the big lesson that I've really learned is that I think of many situ... Assuming many frameworks for thinking about leadership include conflict management. But I really think that conflict surgeons, maintaining leadership behaviors through conflict is really the true test of their leadership. And if you think about what we've shown, we shown that maintaining your calm, engaging in superior problem solving and effective communication, and then going out ` system level surgeons, all that's just leadership. So I don't know that I would even teach a course on conflict management. What I would do is teach a course for effective leadership for surgeons in the operating room. And then basically argue that all of those things that we do in conflict are really fundamental leadership things. And if you don't do them in conflict, then you aren't really doing them capably. So I've tried to outline some of the existing literature about why the topic is important. I think that concentrating on it with our trainees is gonna increase their probability of success is gonna make our teams happier and work more effectively. And I believe that it'll actually improve our patient outcomes. I think what we've shown is what we've been doing isn't very effective. And so I think through this presentation and through concentrating in this on every day is how we're gonna change our culture and change how we do things. We've given, I've given you a reference there clearly consequences of conflict, mismanagement, profound conflict, consequences to the surgeons, to the nurses and to the patients. And so I think that it's even in our own self-interest, to think about how to manage it effectively. And then finally, I've tried to give you some behaviors that are effective, a conflict, that represented effective conflict management that I hope you'll think about in your own practice. That concludes my remarks. And I'd be happy to answer any questions, Aaron, if you have any.

- Yeah, I mean, this was extremely useful. I mean, there's no doubt this is something so important, but we don't pay attention to it. And going back to that discussion of why our fathers or forefathers in surgery had such strong personalities? I think it was very well answered by you, is that the environment at the time was that for example, Harvey Cushing, or William Halstadt and Johns Hopkins, they were really trying to do things that people significant question. There were things that they were under severe critic system, and they were just doing things that they were in themselves sure, it would 100% work. And under these circumstances, insecurities develop. And when you have insecurities, you have to battle it with that severe reactions for anybody who questions your behavior. That's just how we are as humans. The other question which you know, is very important is I have found out that conflicts really develop not just as a one single incidents. In other words, you have people who work in your room. There are little incidences where you sort of let it go, but you develop that tense relationship. And then one day when you're having a bad day and one other conflict develops then necessarily other days would have not placed you in a difficult situation because of the emotional mindset you have. And because how you're entangled emotionally with that day, you really erupt and you make it a vicious cycle. In other words, you say, well, this pitch, look what they did. And you start telling them how rude and ineffective they are to you and how they're not doing their job. And when you're hearing yourself, your emotions become even stronger. As if like, look, there is another person telling me it's actually just yourself, that this person is back and that gets your emotion even higher. It's almost becomes a self-sustaining and you erupt so badly at the end of it, and then feel that that was your right. And actually you did the right thing. It, it's very interesting at the end of the day, that no matter who you are, if you have a bad conflict, you feel bad about it after it's over. And what it shows is that you really responded to the emotion. You're not really responding to the event itself. You're discharging your sort of emotional response. And what I have learned from people like yourself who are so good at it is the critical us, two words are emotional intelligence. And I highly highly recommend to people to read about emotional intelligence, just surgical intelligence is important and makes us great surgeon emotional intelligence is absolutely undermined and not well-respected in surgery. And the most important factor in emotional intelligence, which you very well mention is active listening is not just listening. It's active listening. So if somebody comes to you and it feel concerned about something, you don't necessarily answer it in a way that, well, you really long about answer asking that question. You answered you. In other words, ask another question you say, well, I think that behavioral had really made me made you feel uncomfortable. Could you tell me a little bit more about that? And sometimes just people having a chance to tell you why it made them comfortable is all you need to do. And it really puts you so much higher than other people, and they will do anything for you. So I think at the end of the day, complaint management comes down to emotional stability and active listening, which is such an extremely important part of emotional intelligence in general. What are your thoughts there?

- No, I think you've summarized it nice, nicely. You know, it does attach to the emotional intelligence work it also your comment about what you do every day sort of sets it up. So this idea about climate, that how you behave every day, you know, likely, and is very powerful when a true crisis or conflict developments. One of the things that we didn't see many instances of is the idea of apologizing and what we found more is surgeons that were sort of ineffective in apologizing. So obviously if you're a person that goes along pretty well, but you know, you just have a lapse and you write someone or you're frustrated. And, you know, I think you can rehabilitate that a lot of times by apologizing. And that basically is, you know, I've made a mistake. This is the behavior that I did, and this is my commitment that I'm gonna try to diminish that, what we saw in the transcripts is the nurses really understand that what we do is high pressure, stressful work, and they get it that we occasionally are frustrated. And that sometimes that gets expressed they're actually, they seem to be quite forgiving. But I had an instance in the operating room where I was, I had a trainee as a scrub tech and next to her was a very experienced scrub technician. And then I had a resident who was doing something that, I was getting very frustrated and the scrub tech was doing fine for a trainee, but then she did something wrong. And I snapped at her, I mean, I, you know, I said, you need to, to get with it. Or I made some comment. And I realized what I had done was I was taking my frustration with the resident out on the scrub technician. And i trying to draw from my own work. I said, stop, you know, I apologize, you're doing fine. And I'm really frustrated with this resident. And I, you know, directed that at you. And I won't do that again. And, you know, she was fine, but what impressed me as a very experienced scrub nurse who had been in the operating room for probably 40 years, said in my entire career, a surgeon has never apologized to me for that kind of behavior. And to me, that's somewhat distressing that we all have difficult days. You know, what I find is that the nurses that they really want to be just respected in the team, they're supportive of what we do. And they'll actually forgive you. If you take the time to say, look, you know, this was a difficult day and I made this comment and I regret it and I'm gonna work on that. I think if they know that we're trying to get better, they'll actually be quite respectful and even impressed with it.

- I agree. And you know, we, that doesn't mean we don't have to be firm as surgeons. We have to be firm, we're leaders. We have to be definitive. And there are people, there are occasional situations where an individual is just not the right fit for your personality in the operating room. And those occasional situations have to be addressed because it will place the whole OR at risk. And as a surgeon, you say, this individual is just not the right fit, but that doesn't mean you have to go and make them miserable to leave. That has to be handled at a higher level, where you go professional and sit in the office of the managers and tell them, this is just not gonna work. I really want another person in my room. We appreciate if you do that in a very nice way. And most of the time, it's best for you to go, to be very professional, nice to them in order to be able to sort of get them out of your room without necessarily a hurt feeling that would bounce back and hurt you in the future. I think at the end of the day, we all are going to feel frustrated. We're all gonna get emotional. We're all gonna get fired up. And we get up in the morning and you know, that life in the family at home could be sometimes challenging at times. And it happens to all of us. And when you come to work, you carry that with you. And what is really important is to remember that you have to stop. You have to think about it very carefully, and you have to again, go back saying that an intelligent emotional person is not gonna react immediately based on emotion, rather than have to put it in perspective. Step out of the room for a second and just sort of take a breather and just relax for a second, come back and answer, you know, handle it, not emotionally, but based on intelligence. And you will be gratifying yourself. You are gonna be making yourself feel so much better because you're gonna make yourself be superior. And at the end of the day, I think the absolute most important factor is surgical technical competency and emotional intelligence are directly related. In other words, the more insecure and technically incompetent you are, the more angry and conflict provoking person you are. It's just no question about that. So anytime you wanna raise a conflict, go ahead and think about it. You're just proving that you're technically insecure, and you're unable to handle a situation and therefore you're handling it through alternative ways that that's just common knowledge. And nobody has to necessarily say that even though you have to say to yourself when you're in a difficult situation. Well, with that in mind, David, I wanna really thank you for a very important topic is something great you have done for just surgeons in general and neurosurgeons in specific, and we would love to hear more about your great work in the future.

- Great. Thank you.

- Thank you, sir.

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