One of the major stimuli to the change in the safety culture in the airline industry was brought about by a shift for instruction of pilots on how to fly planes to facilitating them to fly them better. Instruction is didactic – the art of instructing or teaching is a blended form of direction, command, and instruction: ‘Do not do it like that but do it like this’. Facilitation, however, infers a more intrinsic learning, an ease in performance or action with the development of a fluency with an ‘easiness in persuading’. The latter enables, in fact encourages, the learner to find their own way to get the job done. Since we are all individuals with different persona and body habitus, we will do things differently. That is not a problem if the outcomes are agreed. In a complex field like aviation and surgery the moment-to-moment decision making is very contextual and needs to rely on the expert pilot or surgeon. The airline industry realised that enquiring about how you made that decision and what you learnt from it was much better and in fact changed the culture of safety, removed blame and inculcated understanding.
Daniel Kahneman, psychologist-Nobel laureate, and guru on decision theories, said that doctors applied rules of thumb and their learning was experiential. Evidence is not the primary decision tool used by most surgeons! In that sense there is an element of truth; you need to understand the science to apply the art. Every patient is anatomically, physiologically, psychologically, and socially different - It is ‘what matters to me [the patient]’. They are only person who can determine the utility or value of their decision. The clinician should enable that decision process with a knowledge of the prospects of outcomes doing something or doing nothing. Kahneman termed this ‘prospect theory’. I believe the application of this theory is very pertinent to the discipline of surgery as the prospect of outcome is reflected on the Y axis [the expert surgeon with knowledge of the evidence of doing something or nothing] and the utility or worth of that outcome is what matters to the patient. The latter is the most important aspect and is the privilege and right of the patient. It is what matters to them! It may sound straightforward, but it is not, as both surgeon and patient bring conscious and unconscious biases to this interaction. Furthermore, the value to the patient changes over time and with context. The prospects of outcome of doing something or doing nothing depends on current research or trials – often inadequate or absent. Both parties, however, tend to be risk adverse and both parties have different perceptions of that risk.
We all pay attention to the ‘gold standard’ of class 1a research – prospective randomised multicentre trials, but also can cite many reasons why the person in front of you is the exception. Sadly, some of these trials have been questioned because of poor interpretation and application of definitions. This is a sad slur as it calls on the integrity of the profession. It is quite reasonable to say ‘I do not know’ but is it unreasonable not to find out, seek opinion or use the valuable tool of MDT discussion. We are after all fallible and since surgery carries absolute risks, it is our duty as surgeons to explain the risks and make it clear where evidence is ambiguous, contentious, or not available. It is no longer reasonable to take the stand that the doctor knows best. Simple decision trees offer a method of highlighting outcomes. Not infrequently, you will find to the right of your decision tree you are left with question marks.
The art of decision making is dependent on knowledge of the subject, evidence, and most importantly what matters to the patient. This is a facilitative process and not instructional. Teaching surgery must also move from instructional to facilitative. Instructional is the WHAT and WHEN. This is WHAT you must do e.g. ‘not like that but like this’ and WHEN you must do it. Instructional is seen in the transactional nature of ARCP’s and the ticking of the CPD, DOPS and CEX boxes. But there is much more learning to be gained in these tools with reflection. WHY and HOW explore the decision processes of the operator or pilot. This achieves more engagement, as explained by Simon Sinek, and facilitates learning. The learning is more profound and sustained as it is built on understanding of why we intervene and how best to intervene. More importantly it includes the patient. A recent visit to a fracture clinic with my son with a broken collar bone, exemplified this position as the consultant said the 99% of these will remodel without intervention; the evidence in adolescence was good. However, radiographs of fractured clavicles at orthopaedic MDT’s always generated discussion somewhat polarising adult and paediatric surgeons. The evidence for the treatment of the fractured clavicle is contentious. I particularly liked his summary as it resonated with my philosophy (of course I had done a literature search and called a friend!). He summarised that surgical intervention carried a definite risk and that is doubled as any internal fixation will need to be removed. In his twenty years of experience, he believed (and I agreed) the risk-benefit equation was not favourable.
Surgeons are those who cut, good surgeons know when to cut and the expert surgeon knows when not to cut. Knowledge of when not to intervene is most likely to be acquired from a volume of good and bad experiences (Daniel Kahneman). This is the art of surgery that needs to be taught with facilitation, humility, and an understanding that we are all fallible. We can and need to change the culture of surgical training.
About the author:
David O'Regan is the Director of the Faculty of Surgical Trainers. He has been a Consultant adult Cardiac Surgeon in Leeds since 2001.
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