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Hello. Good evening. Good day. Good afternoon. Good morning, wherever you are in the world and welcome to the Black Belt Academy Medical Skills. I'm sorry for the delay that we have had this evening. We're still having internet problems on the screen. Introduce Gabrielle, who's in uh w where are you based? Gabrielle again, Lithuania and Gabrielle, one of the producers of Metal Gabrielle reliably informs me problems globally with the internet evening. For what reason? Gabriel? Well, from what I've heard, there is a NATO summit in Europe. So apparently there's a lot of cyber attacks or something. Uh That's, that's the, the message and also we've got a rather large sun activity with the aurora predicted to be seen over northern England and northern Europe and this will be interfering with internet activity. Unfortunately, our guest speaker this evening, Professor Paul Barrack is trying now for the fourth time to log on and participate in our discussion this evening and it may well be that we'll have to record it and to stop at a later date. Apologies about that. David. I'm here. Can you hear me, David? Oh, I can hear you. Well, excellent. Oh, you made it. Uh I won't make any jokes about anesthetist surgeons over this way through technology. But yeah, and, and guess what the echo seems to disappear. So, welcome. I have a special guest this evening, Professor Paul Barrack. He's an international patient safety champion and physician executive, a practicing anesthetist, cardio thoracic anesthetist, a prolific research with more 300 publications, five books on patient safety and health policy. And he's an expert in surgical safety and human centered design and a firm believer in health information technology to improve safety and quality in surg care. He's a double boarded, an etiologic and critical care physician scientist trained at Harvard University and Massachusetts General is an elected member of the International Society of the Association of University, an slogs and he's held the position of Chief Quality Officer, associate chief medical officer for major academic medical centers, the Chair of the Patient Safety Commission for the World Society of Intravenous Anesthesia. And he founded and ran one of the first full team simulation centers in the world and developed the team training program team step. He's been really funded for his research and in $16 million in grant funding. And he holds numerous positions as honor professor at college in London, uh University of Birmingham, Queensland Australia, Sigmund Freud University in Vienna, lecturer and senior advisor to Dean Jefferson College of Population Health, visiting professor in Milan Polytechnic, visiting professor and honorary professor at the National Cancer Center in your career and visiting professor at the university in Pakistan, as well as Muhas and Tanzania. He is also the former editor of BMJ Quality and Safety Journal. And with that introduction, it appears that Paul has decided to leave the stage as we have continued to have in net issues. But while we wait for Paul to come back, I'd like to go through some of the questions that you have answered on the chat room and Gabrielle is gonna go through the questions and perhaps you can put some questions in the chat room to ask Paul when he returns. So, Gabrielle, what did we ask? That's a very good question. So we asked, um, some very interesting things. The first one was, do you always know the name of the anesthetist? And the, the majority of the people said yes, but equal number of people said no. And sometimes, um, we also asked before we move the people who answer that sometimes they go in theater and you have no idea who the anesthetist is. Is that what we gather from the questions? 50% strange. Very strange. Any thoughts on that in the chat room, please? Next question, Gabriel. OK. So the next question we asked was who is in charge in theater? And vast majority said surgeon. Um Then the second most popular answer was theater manager and only a few people said, scrub nurse or anesthetist. So again, very interesting answer. That's an interesting answer. Welcome back, Paul. We're just going through our pre discussion questions. We asked the audience who was the most important person in theater and this is predominantly surgical audience. And unfortunately, the biases come out in favor the surgeon and the most important person in the theater is the pa course and who is in charge? Well, it depends on where you are and what stage the operation because certainly in a cardiac bypass, there's the anesthetic, the incision, what the draping, the prepping the incision going on bypass, bypass, the anesthetic again. And then this so the lead for the operation is moving around theater all the time depending on the stage of the operation. The most important person in theater of course is always the patient. So the next question, Gabriel, yeah, it's funny you mentioned that because the next question was who is the most important person in theater? Um And half people answer the patient. But there's some other options were surgeon, a few of those, the whole team, everyone as a team. Um And then also a few an an I I can't pronounce that. Um But yeah, the majority said the patient but there were others there as well. The whole team is there to serve the patient, whether in theater, the privilege of being scrubbed at the table and hands on the patient. But everybody is there for the patient. And I recall raising an issue in theater about cleanliness and they sent a whole lot of managers down to theater with clipboards and they stood there and said, yes, we understand this. We'll have a meeting and had to explain to them that I had the privilege of operating on the patient and putting my hands in their chest. But that patient was their good faith, expecting the whole system, not only me but the people in theater and the theater itself to be fit for purpose. And that was their privilege. Although they did not have that most. Going back to the first question, Paul, many of the people answered that they weren't know the name of the just going into theater. And I find that so much strange because ok, certainly this day and age we should briefing an introduction and who checklists is not a checklist, the operative word in the who checklist is, who, who are you working with? Do you know them by name on the issues and who is on the table? So when I led brief in theaters, we introduced each other by first names and the first names are always written on the board. But to help with the reductions, we also are, is there anything to celebrate? And we had bar mitz weddings, divorces all as part of the celebrations. But on one occasion, I was asked, is anybody troubled by anything? And there was an answer. But an ad p followed me out of theater and said, actually, I am somewhat trouble because this afternoon and I'm at a tribunal because I've over done my sleeve because my son had asthma and had to tend to him in hospital. So he was up for disciplinary procedures that afternoon. Yet, the system expected him to be focused and on the page for a major cardiac operation, we'll run to the other questions and there are lots of questions for Paul and we're just testing his connection. Gabrielle. The next one. Yeah. So the next one links quite well to what you just said, does how you feel physically and emotionally affect your operating. Um And again, it was a nice split. So half of the people said yes and another half said no. Um interesting. We were in our question question but to be sharp, you have to stay sharp and it all starts with you looking after yourself, your physical mental and even spiritual state is vitally important for the job that we do. And we'll cover that and we go through our questions, Gabriel. Yeah. The next one was a statement I can operate without sleep. And we ask people to rate that between one being no and five being. Yes. So the score was two there, which means that the majority cannot operate without sleep. Well, well, that's reassuring it. Indeed. When he gets in, the fatigue comes up on the dash board saying you've been driving for 2.5 hours time for a break, I'll address that with Paul because we both work in the cardiothoracic field and our operations go on for hours and the longest I've been at the table is 19 hours and that was after a two hour break following a previous 15 hour operation on a dissection madness. I think madness. Well, Paul looks like he's here to stay and welcome Paul. We have done your introduction. Thank you. And maybe I maybe to make you feel at home, I should do this and the drapers and I look at you across the drapes and, and, and this is it, this is what separates and an the test and are the drapes at the top. So Paul has got enormous amount of experience and safety and teamwork and it's a privilege to have such an eminent anesthetist on the Black Belt Academy of Surgical skills to talk about what he has observed for his side of the table. Pull the floor is yours. And thank you very much. Indeed. What if you from your side to the table? Thank you and sorry about the technical issues. Hopefully you can hear me. Well, um you know, it's, it's interesting having uh done this for about 25 years. Um some things have changed dramatically, many things have stayed the same what's apparent to me. Um, over these years is that we've trained to perfect the individual provider in their silo as an this, as a surgeon, as a nurse, as a circulator. But still, even after all these years, we don't train together, we don't really debrief together. We don't really necessarily spend a lot of time together. And, and that fundamental difference is dramatically different than any other team. I've been part of either in the military or in sports or music, um singing choirs and, and it might be, we fundamentally violate the socialization rule of how team members learn to trust each other. spend time in which they understand each other's needs both vocalized and implicit and ultimately learn to um to really support each other in a explicit, not just implicit manner. And I, and I think that's probably the biggest challenge uh that we still have. After all these years, we've gotten much better in the technical aspects in the respective pre professions. We've got much better in the pharmaceutical tools that we can use to support the heart, the lungs, other organs of the body. Um But we, we still uh use the heroic uh measure idea that, you know, do the best you can work the hardest you can, but really rarely acknowledge the fact that our performance is highly context dependent on the people we're working with. And all the research shows that while for example, in cardiac surgery, it's very important that surgeons have a minimum number of procedures per year, per week, per career. But equally and more important is the number of procedures that the team around them have including uh in the operating room as well as in the ICU. Um And, and so the fundamental philosophy that this is a team endeavor that requires core competencies of knowledge, skills and attitudes, both as individuals and as team members is something that we still haven't really uh addressed properly. We're only doing at the margins and I think that leads to um highlights and lowlights, but most importantly, it doesn't lead to stable performance. So what have you observed from your side of the table? Uh Over this time you've described the, the tremendous technological but you don't think advanced at all from a team perspective that's coming from a cardiothoracic and just where we have 12 people in theater, usually we do. Um but it's always implicit, there's no pre training before we go into the operating theater. Um There's no regular post operating room debriefing. Um We're doing AAA major literature review and about to start a major study looking at morbidity and mortality conferences. Mm CS uh In the NHS turns out that most departments don't do them, don't do them regularly, don't invite management. Even though the Royal Colleges recommends that management come to these MM CS rarely involve nurses. And yet often the types of issues that we discuss often might have a technical side, but they also have a nontechnical side that relates to the environment, the human factors of the team, the noise, the distractions, uh the flow. Before the case, the flow after the case, where the patient's going to go, all these things that we know play a vital role in complex uh interactions between social and technical systems. And yet, we rarely explicitly make them part of the conversation. Um And so we don't really have a good learning system to learn from these uh process and outcome failures. Um Having said all that of all the surgical disciplines, the cardiothoracic ones which were really under the microscope 2025 years ago, after Bristol and Manitoba and uh events in the US and the Northern New England cardiovascular, their outcomes have gone from about an average of 25% complication rate to down to about a 1 to 2% complication rate, um which is dramatically better than any other highrisk surgical sphere. Um If you look at the uh G I surgery space, um which are not life threatening, certainly not acute. You know, the, the accepted complication rate under score, accepted quote unquote um is about 25%. Um That's where cardiothoracic surgery was about 25 years ago. So we've improved the preparation for surgery. We've improved the quality of the bypass machine. We've improved the minimally invasive, we've better understood which patients should not be go on pump. We've better understood which patients don't require a full valve replacement. They can get away with a valve repair. We've understood the coagulation science much, much better. And so we've been able to reduce significantly um complications, but still, there's still quite a bit of variation between teams and between hospitals and certainly between high and middle-income countries or middle-income and low-income countries. Um We still see sometimes 15 20% complication rate. So we've perfected in some areas but others, we've not really harvested the wisdom, integrity and engagement that comes from a fully formed team that doesn't just come together in a space like the operating theater, but comes together before during and after the case and grows like a formula one team or like Manchester City uh or like London Philharmonic and that can go on and on and on. These are different exemplars from other domains where 95% of the time they practice and 5% they perform, we typically do the opposite. We uh perform 95% of the time. And if we're lucky, maybe we practice 5% and sometimes we never practice together. So I've worked with many, many cardiothoracic teams and I've never practiced with them in the simulator or any other space. And often, uh we don't really talk outside the operating room. Um And so it's a very narrow type of communication and it rarely benefits from deep reflection. Um and the time to incorporate the wisdom from other peers um that might be nursing, they might be technicians, there might be cardiology or they might be surgery, anesthesia. You, you mentioned formula one and I think the Ma de lai needs telling and you tell it. Well, Mark was a remarkable individual and uh may rest in peace. Mark was uh the chief surgeon at Great Ormond Street. And uh in the late nineties, right after the Bristol Royal Infirmary story was unfolding with all of its uh challenging dimensions. Mark had a rash of bad outcomes around uh tetralogy of fallot and some other complex single ventricle problems. Um And even though he was recognized as one of the lead surgeons in the world at the time, uh he realized that something wasn't right. And so from his perch, being the senior surgeon at Great Ormond Street, he chose to uh take some time off and essentially retrain if you will uh with a, with a senior peer in London and um and went to some others around the world and then he came back and he improved his best performance from prior to his break by at least 40%. And he wrote this remarkable piece called the Cartesian Logic of the cardiac surgery, the lancet and where he acknowledged the fact that he could have gone better. And the fact he had been doing it for so many years, he stopped being able to see how he could dramatically transform the system, working with psychologists, working with human factors engineers. Um they were able to push the envelope and really create the best outcomes in the world at the time in pediatric congenital heart surgery. Um and really unpack. What was it that they changed? It was nontechnical skills, it was coordination, it was handoffs. Uh lovely work that uh Ken did that was published in the journal of pediatric anesthesia where they went to formula one in Italy. And they studied the transitions of uh of uh of pits. And what they discovered was that these teams when they begin, it takes them about 30 minutes to actually change the tires, change the oil change, check the system, talk to the driver and over a period of many, many months and careful selection of participants, they're able to get the best teams in the world are able to do all that and more in about two seconds, two seconds. And so they're able to improve from 20 to 30 minutes down to two seconds. And today, when you see a formula one race, you know, usually the top 5 to 8 teams will break two seconds. Um but it's not by chance and, and it's not just people that begin, these are seasoned, people that work together for months and years and understand how to get the most out of each element of the process. What does it mean to have important technical skills but also on equal. What is the value of nontechnical skills as it relates to communication, coordination, collaboration, and threat and their management and capturing near misses and the role of simulation, simulation, simulation as a way to build trust as a way to build a culture of safety on the journey towards higher reliability performance. So how did psychologist help improve the surgical performance? You mentioned the psychologist in there and the Black Bar Academy talked about mindset. But from your perspective, yeah, that's a great question. Um So the eminent James Rees from Manchester, uh who is known for many things, but also for his work on the Swiss Cheese model. Um what James and others did or Jim and others did is that the ability to help clinicians understand patterns in a way that clinicians saw individual outcomes. Psychologists saw patterns, they saw patterns of not engagement between surgeons and anesthetists. They saw patterns in which the system created elements in which even the best surgeon was having suboptimal outcomes. They saw patterns in which a surgeon that was distracted because a patient in the itu were on the floor, which could have been handled by somebody else that call was directed into the uh into the operating room as the surgeon was operating even though it did not require their attention. It a a pattern in which complex cases were not done. The first in the morning, they were done in the afternoon after the surgeon was a little bit tired and other complexities lined up to delay the case and delay the patient arrival and all the rest. And so what it started doing was identifying, where was the process, uh these various nodes in the process what was happening in each of the steps? And how could the psychologist help us better understand what is optimal performance based on truth telling, transparency and uh and trust building, what Patrick Cini calls the fundamental building blocks of any team and certainly in a complex social technical system and the role and importance of deliberate practice. The idea that we train every day, we get feedback every day, we seek out feedback as experts. We don't need less feedback. We actually need more feedback. And that feedback helps us going from pretty good to exceptionally good and from exceptionally good to mastery. And that journey from competency to mastery is where the psychologist helped us frame an explicit language. What does it mean to move from r you know, fairly good technical skills? It might be, you know, working with cutting or working with sutures or working with bypass coordination to really refining the sequence of activities that goes in from the moment the patient uh is assumed under the responsibility of the cardiac surgical team until this patient is handed off to the it to continue the management of that performance. So the consistency of team members and having a regular anesthetist goes a long way to the performance of a surge. I think so. Although I, I think so, but I, I like to think about it. Not just as you know, there's an interesting question here about surgeons like to work with quote their anesthetist and while that's a very attractive model, that model is one difficult to manifest in a, in a, in a large system, it's technically very challenging because one, there's multiple cases going on. Two, there's people that are on sick leave or on vacation or a post call and all the other things that are part of a very complex scheduling apparatus. What is particularly clear is that a small number of surgeons working with a small number of anesthetists working with a small number of nurses working with a small number of perfusionist and they train together at the big team and regularly they pair off or, or work on more than pairs at small teams and they're regularly standardizing effective steps to work together. They're developing receptors for optimal team performance. This was the fundamental building blocks of team steps that a group of us developed about 18 years ago based on knowledge, skills and attitudes that we can all train to, we can objectively assess them. Um It came out of the um the, the US Navy research that you might recall uh an Iranian uh Airbus um jet was shot down by the US S Vicens because of poor communication and coordination between elements of the team. And based on that, a group of us looked at the best team training models in the world. What we realized that we could improve the performance of teams in general and surgical teams in particular by helping them better understand the needs of the team members by not just working the exact same people, but the people that work together have shared mental. What does it mean to listen and support? For example, the role of the Anestis is not to be a passive follower of the surgeon. The role of the Anestis is to follow and to lead the role of the Anestis and the surgeon are to work together in different phases of the procedure. As they coordinate leadership and followership, almost like a, a spouse or relationship if you will, where there's movements where the surgeon leads and there's movements where the Anestis leads and there's movements where the nurses or the perfusionist lead and they're working together by explicit communication as well as implicit recognition of communication patterns which they learn to shape and share and learn. And, and most importantly, David, they learn to give honest feedback to each other. They learn to effectively say these are the things that went really well. These are the things that we want to improve. So next time we go, we have a more smoother going on or off pump. For example, in the cardiac rooms, we have a much smoother time managing um you know, managing phases of the procedure where there's a high risk. For example, you know, putting a patient who has critical aortic stenosis to sleep is a high risk procedure in anybody's hands. That's an example where the entire team stops what they're doing. And all they do is ask the Anestis, what can I do to help you? And they stand in certain positions and they reach out with their hands and they're ready to support if that means going a crash on bypass. Or it means just a slow up ramp until the patient is ready to be intubated or something like that. So that means that the, the surgeon understands the workflow of the Anestis. And David, as you remember when you trained, and when I trained, I remember surgeons that would spend ample time in the operating theater, working as an anesthetist being tutored by a master Anestis. And as an intern, I spent time in surgery even though I wasn't going to be a surgeon. But I spent a whole year learning to understand what do surgeons need to be effective and successful. How can I help the surgeon be even more effective? We've stopped doing that by and large. That cross training, which is fundamental to effective military teams was a really important part of team steps. For example, I spent two weeks learning how to work the bypass machine, the perfusion machine, I'm not a perfusionist, but when the perfusionist needs help, I know how to give blood, I know how to clamp the lines. I know when there's air in the channels, I know where to stop and call for help. I know how to do that. Um And that's the limit of my knowledge. So I know how to support the perfusionist when they need help. They don't even have to say much. They just call my name and I immediately assume the position and I know what they need until they tell me otherwise. That's the type of effective teams that have each other's back. That doesn't mean they're nice to each other. Although niceness is nice, they learn to support each other both in times of extreme need or when things are going very smoothly, they learn to support and they're very engaging and they learned to say to the surgeon that was a great procedure or this could have been done better. David, you were tired, you're fatigued, you're distracted, you're a little bit grouchy. Let's find out next time when that happens. Let me know how I can be more effective. So I can help you get through this case because you're fatigue or because it's the fourth case of the day or simply because the pace is just a very difficult anatomy and it's gonna require our collective skills um to, to get the patient through the procedure alive, supported and to uh to an itu to continue their management as you is putting yourself in other PURs shoes and understanding what their needs are. And I too spend time learning to put a bi system together and do that, spend time in the anesthetic room as an anesthetist making it cross the blood brain barrier from your perspective and practice. What does an anesthetist look for in a certain, it's a really, really good question. Uh We have all kind of jokes related to that, but in a serious note, they look for seriousness. They look for preparation. They look for discipline. They look for listening. Are they able to listen and take information from vital members of the team? They look for planning and uh management of complications before the complications arise. One of the um challenging moments for Anestis is that when there's banter by the surgeon and then it suddenly becomes quiet. The first thing anesthetist know is that trouble is around the corner. Um Another thing they look for is how relaxed they are in their positioning. I teach my, my trainees that there's three planes in the operating theater above the table on the table and below the table and I force them to get on their knees and look beneath the table when I see a surgeon who's standing awkwardly or is standing in a pool of fluid or simply is agitated. I know this, this is not a good thing. So I'll, I'll try to facilitate and help them deal with that. Uh either because they have neck pain or back pain, you know, remarkably a little bit less in cardiac surgery. But when you look at the laparoscopic literature, David, close to 80% of G I laparoscopic surgery have occupational injuries due to standing in correctly or because the devices, the laparoscope, the robots are not designed for human limitations. And so those are the types of things that we look for. We also look for having a pleasant time. I mean, this is hard work to do well and, and going through it and being annoyed or going through and being grumpy or going through it and being nasty. We've all had those nasty comments at us. Um We're gone of the days when things would be thrown at us. I still remember things being thrown in the operating theater um where there were misogynist comments, sexist comments and um uh homophobic comments. I mean, those things are, are happily gone. Um But there was a kind of feeling in those days that what like in Vegas, what happened in the or R stayed in the or and that usually was a testament to the fact that we knew that this culture was flawed but that we were able to get away with that. Um Another element we look for is when the case is done, the surgeon is very interested in hearing input from the nurses from an this and they really wanna seek out feedback as part of their deliberate practice so they can get better. Now, it might not be in the technical skills because that's not the arena of these other people, but it could be in issues like nontechnical communication and coordination, phasing out um understanding the sequencing more effectively how to deal with imaging and, and uh the blood bank, uh more precisely and in a more timely fashion, how to make sure the equipment is set up in a way that the surgeon wants. Um But done in a way that, that they're open, say, well, maybe there might be other improved ways to set up the room in such a way that we can get better flow and get better feedback both to the team members as well as to the people outside the theater who are planning the next case later today or later tomorrow or later, next month. And so how do we improve the scheduling of the sequencing? So, surgeons that are open to feedback um and are willing and eager to grow as surgeons. Those are the type of surgeons that I really enjoy working with. How does the relationship between the anesthetist incision affect the team from your perspective? Yeah, it's a really important question. I think uh I think many look to that relationship as a barometer of what's gonna happen. And, and so those first moments of interaction, um if they're based on truthfulness, if they're based on respect, if they're based on uh effective communication, I think they set the tone for the rest of the case, particularly for ancillary staff, particularly for agency staff, more and more now we have much more agency staff. And so they're constantly looking for signals from uh from the surgeon and from the this about how this is going to go. Um, can I speak up? Do I feel I have psychological safety where if I say something, it'll be received with kindness and maybe it'll be a wrong thing and they'll correct me, but it won't be abusive, it won't be dismissive. And most importantly, they'll invite me and my input into the process starting with the moment when we do our checklist in the, in the, in the theater, when we say, is this the right patient, is this the right procedure? That process of engagement sends a very clear signal. Uh an in an invitation to participate as an active team member. So how, how poor would you work through the hierarchical mentality that was in the past? And I, I think it is moving away and I certainly always insisted on first on the board. How do we get past the hierarchy? Well, I think we know from many other industries that there are many steps to uh to derisk those problems and to uh reduce the hierarchy. Now, reducing the hierarchy doesn't take away from the seniority and authority and wisdom of the surgeon or Anestis. What it does is it is it creates an effective way to communicate more fully and honestly. And so I think it begins by training together. First of all, we need to train together the way we've done in the military and music and sports. We never assume that A s uh you know, the goalie for Manchester City would train separately than the, than the uh the forward, the forwards on the team. We never assume that a conductor would train differently than the ba soonest. Why would we assume in surgery that we should have people not training together? So that's number one. Number two, I think is uh my friend um um Rob from, from Sydney who, who uh received international acclaim by having people's name on their hat. So on their covering of their hat, it would say David or Paul or Gabriella. And that measure I think goes a long way in, in introducing familiarity um and not in a disrespectful way, but in a way that uh uh assures a more effective communication. Furthermore, I think the best way to do it is by reinforcing positive behavior. So when somebody speaks up, even if it's something you don't agree with, you respond with respect, you respond with kindness and you respond with precision and you don't do it with derision, you don't do with, you know, I can tell you there are many stories, but I remember uh I was several months into my uh my fellowship. OK. After I was already uh you know, trained in this, after five years in the military as a major and all the rest. And I remember uh going to a complex Thora abdominal case and uh there was a step that the surgeon was doing a little differently and, and uh it had certain implications for the patient's uh vital signs. And so I said, the surgeon, you know, you know, you know, this is what's happening to the patient. Should we do it differently? And he said to me, young man, how many of these cases have you done? And I said, well, this is my 15th. He said, well, I've done 800 when you've done that many, you have the right to speak up so that more or less set the tone for, I wasn't gonna speak up then or any time for the future with the surgeon because it was clear he wasn't interested in my input. And even though my input was correct, as it turns out, he was not interested, he never spoke of it again. And that kind of set the tone for our relationships uh for the rest of the year. And, and what's the best scene, Paul? I, I'm, I'm pretty damned sure that wasn't the West, but no, I've seen, I've seen a range of things and I've uh learned from all of them. I've, I've, I've seen remarkable teams that talk the night before that meet weekly that uh have joint M and MS um that are keen to understand near misses and adverse events as tools for learning and improving. You know, I've seen teams that really thrive on going into the operating room and performing like, like a, like a wonderful quartets, uh you know, I've seen teams that just flow smoothly. Um But it wasn't by chance, it was deliberate, it was based on a detailed understanding and respect these team me, team members would meet outside the theater, they would hang out together socially. They would, they would go get a beer together, you know, they would um they would regularly and deliberately focus on building trust, they would regularly and deliberately tell each other truth tellings about the case. They would regularly try to improve the performance of everything and anything in the operating room before the operating room and after the operating room, they would meet and talk about these things because they really wanted to refine their skills and they really cared about the performance of the, of the uh of the procedure. And they realized that as well and as good as they might be, that would never be enough to consistently create high reliability outcomes. And so those are the teams that I really enjoy being part of. And um and I think we can get there. I think it's possible. I don't think it takes a big investment in money. Um I think it does require a deliberate practice. We have to really seek out that type of teams. Um And we have to support what the slack that's needed to create those types of teams where the system understand that it's not just about getting more cases done, but it's about building the spirit of the team. It's about supporting safety. Yeah. It, it is a slack in the system because as you were talking about the sedation and getting to know him, the days the operative days started as, you know, 7 30 finish at 7 30. The last thing you wanna do at 7 30 at night is go and have a beer with somebody after when your dog tired. Absolutely. And you're already starting at seven o'clock in the morning to bar on who's gonna get the next bad next case. So that's a really important issue. And that really connects David something we rarely talk about in safety and quality, which is the importance of scheduling and logistics. You know, how we schedule the cases, how we build in time for reflection, how we build in a few minutes to have a conversation that's not about going to see the next patient or running to the itu to see the last patient or going to the floor to, to spend a few moments with the nurse. It's really about realizing that teams have a life that's not just in the theater, it's also outside the theater and it's also in between the cases and the best teams really focus on reinforcing that interstitial between the technical aspects of the procedure. And they build on that because they realize that teams that tell the truth to each other, that respect each other that enjoy working with each other. Those are teams that create the best outcomes consistently. And when one of the team members is slacking off or is tired or distracted, the other team members don't just let them off the hook, they help them. And when it's deviant behavior, if they're drunk or if they're inappropriately inebriated or simply, they're not up to snap, they, they help find the solution. They don't just look away or, or keep their mouth shut or keep their head down because they're truly committed to the outcomes, which is a respectful and safe outcome for the patient, both before the procedure, during the procedure and after the procedure. So we've have an audience of training surgeons. What is your advice to a training surgeon as an expert in anesthetist and human factor? Yeah. Yeah. So at first I'd say is that you're in an incredible profession and embrace it because it's a magical thing uh to work in the field of, of, of acute care medicine in, in, in, in the surgical domain. Be it anesthesia or surgery? It's a privilege and a and a true life honor to be able to be in that, in that unique crucible. But it also comes with a series of obligations and that obligations means that above and beyond learning your technical elements of your craft, you have to learn how to be an effective team member. You have to learn about the science of teaming and there is a science there and I highly recommend as a start is Amy Edmondson's book, um a Harvard professor who has spent all her career focusing on building effective teams and high reliability teams. The second thing is that you have to study the science of human factors. This is the science that focuses on what are the factors around you that bring out the best in you and your team to create optimal conditions for success. So that might be quiet, it might be avoiding distractions, it might be well rested, it might be having a good plan before you get into a, a uh a pickle. Uh It might mean how do you deal with command and control issues? These are all aspects that we call the science of human factors. Um And there's a whole range of them and I don't have enough time to go through them, but that's a science that's worthwhile learning from taking a course, reading some key books, um understanding how to ask better questions around these types of issues, which is the performance shaping factors. What are the conditions? And perhaps with time also starting to take note, do you work better in the morning, afternoon or evening? Do you work better with this team member or that team member? Um What is it? What are the conditions about your own performance the night before procedures? Big procedures. How do you rehearse before the procedure in the shower, in the car, in the train in the metro wherever it might be? What are those conditions and being very, very explicit about what it takes to be exceptional in your career. The third thing is to appreciate the science of improvement. How do you actually improve your performance as a surgeon and as a member of a surgical team? And there's a science there, there are tools that you have to learn. There are courses you can take, there's an environment to be part of that, ask this question. What can we do from every case that you do? What can you do to make it better and having an open mind for the fact that even when the outcome is good, there are many things that could be improved and sometimes when the outcome is not so good, but still you follow the pattern. Perhaps there are other elements that you haven't asked or haven't inquired deeply enough. Um And finally, is the science of implementation. So this is the science about how do you change the behavior of yourself first and foremost and how do you change the members around you? The nurses, the anesthetist, the management. How do you learn to be an effective change agent? Which is something that is not just about your technical and nontechnical skills, but it's about how do you become an effective citizen in the community that you work in, in the operating room, in the department of surgery in the hospital? And as part of your membership and your fraternity of colleagues and, and that itself is something that is hard to learn and it is difficult, but, but it is really quite important. And again, there are many tools that you can learn about things that you can implement in your surgical practice on your journey to become a lifelong learner. Using what Anders Erickson calls deliberate practice. This idea that to become an exceptional surgeon, you have to commit yourself every day in every way, not just when you're in the operating room, but as you're thinking about procedures, as you're planning your energy, as you understand the, the course of disease and you understand your own joy and satisfaction as well as how to protect yourself. And I think that's the maybe the last thing which is how do you protect your body, your mind and your soul. Um Do you work out regularly? Do you eat well? Do you have a place to talk about what you're not happy with? Do you have a place to reinforce your mental health in these days where more and more an assist in surgeons are quitting early and retiring because they're not res resilient enough in that way, they feel broken in spirit, they feel broken in body and ultimately, they've lost hope and trust in the system around them. How do you fortify yourself early on to build the, the wherewithal and the tools to deal with these stressful settings, to deal with the environment that's challenging and not by damaging yourself through alcohol and drugs and other modalities. But how do you learn to become a more effective agent of change that identifies these signs in yourself when you're depressed, when you're burnt out, when your peers around you, that, you know, are not quite performing up to the level that you expect them? How do you help them with a kind word with a supportive gesture perhaps with helping them take time off by reinforcing their ability to support you and your abilities, you become a a AAA master in your domain. And so those five steps that like a bicycle, some of them are easier to learn to take a lifetime to master. These are the types of things I think that will help you become um a lifelong effective surgeon that people will, will clamor to work with you and, and you will be joyful in this practice, this magical practice of being able to have the, the rare honor and, and, and the opportunity um to, to take care of patients in their most critical and vulnerable periods and beautifully po po and mentoring play an important role there as well, don't they a huge role? I I highly recommend you read a toe's book on this aspect of coaching in other domains, any other domain you look at just because you finish your formal training. That's not when your training stops. That really is the beginning of your career. Um Seek out coaches, seek out mentors, seek out people that will give you feedback in some countries like Canada. After the Manitoba cardiac surgical debacle that led 12 Children with suboptimal outcomes or death. The Canadians require that cardiac surgeons that finish their training for the first two years must regularly engage with master surgeons as part of their growth and development. Seek out people that will give you feedback, invite them into the operating theater. Share, your data, learn to realize is through transparency and vulnerability that you can become a better surgeon. Um And that means uh keeping a log of that, not just logging what you did in the case, but what did you learn? And what did you miss and how could you make it even better and better? Just like if you were a, a master athlete and you were learning to uh get better in swimming or running or in pole vaulting every time you jump, every procedure you do is an opportunity to get better, seek out video feedback. You know, I I'm a big fan of, of uh of videotaping in the operating room. We've done several studies showing how these videotapes can be used to improve performance. Um You know, read a little bit about the black box uh um project and the, the company led by a surgeon who's trying to push the idea of regular feedback in a safe way, key that this feedback is delivered in a safe manner. Um You know, my, my 12 year old plays football, um, soccer to those, the rest of the world. And uh, every week he gets a short reel of his highlights from his game. You know, if a 12 year old gets a reels from his performance, why doesn't every surgeon get video feedback of their performance? Uh, imagine if you could have that and that was connected to the case records. And every time you went back to the last time you did a AVR or the last time you did a G I procedure or the last time you did any type of procedure. Imagine if you could quickly go to that level of procedure and see how long it took and how well it went, how much blood loss you had and how well did the patient, do we have those technical skill sets? The only reason we don't do it is because of weak leadership, weak accreditation and weak oversight. There's no other reason why we need to get better as professionals. And that's up for us to do so in a safe way, in a respectful way, but determined to achieve reliable outcomes. Every time we enter the operating theater, as you mentioned, the B blocks and videos, what about you didn't mention litigation because people be worried about committing it to tape and litigation. But you didn't, I didn't, you know, it's an important question and uh you know, and, and people tend to assume that you know, particularly in the US that litigation drives a lot of uh perverse behavior. When you look at the literature about that litigation is a problem, but it perhaps contributes to 5% of the problems. It's a minority issue and it's certainly a minor issue in other countries which have tribunals and other aspects in most countries. Physicians are very well represented by uh by various entities and they're very well protected unless they deliberately harm patients happily. That's a very, very rare thing, you know, surgeons that come to the operating room drunk and, and, and unfortunately harm happens. That's a very different entity. I've not seen that in at least 15 years now. Um And so uh what we're talking about are unintended consequences of surgeons that try to do good but bad things happen. We know from the literature that if we tell patients the truth, if we disclose to them when an adverse event happens, they're much more like less likely to sue us. And even if they sue us, we're much more, less likely to lose the case. And even if we lose the case, the payouts are going to be much, much smaller. And so truth telling to the patient, acknowledging that a problem happened, offering an apology, offering restitution so that we help the patient become whole again. That's what the evidence from the literature shows. Um the that the need to tell the truth to the patient and other staff members this is what happened. This is why it happened. Here's how we're gonna make sure it doesn't happen. Again. Those things make sure that while litigation can be very challenging and difficult, um is a relatively small part of a broad system, which includes, um you know, learning to talk about events, capturing near misses, using simulation training teams, regular human factors audits, um helping teams understand how their performance can be improved. Sure, there, there is a challenge around litigation, but it's a very, very small challenge. And I'll just uh end my response around that. Anesthesia as you know, both in NHS and the UK and the US used to be one of the highest litigation liabilities spaces in medicine today. They're about number nine or 10, they're after like family medicine, primary practice. And we've done that through deliberately focusing on safety of the patient safety of the team member, safety of systems, human factors and audits and simulation. And with that, over the years, we've become as a field anesthesia, one of the safest domains. In spite of the very highrisk nature of our work, the highrisk nature of our drugs, the highrisk nature of the patients. In spite of that anesthesia has become a really uh uh from a litigation perspective, a very, very rarely litigated space because we've gone out of our way to make it safe to do the right thing. And when bad things happen, we have this of support, we can show that we train for safety, we train for human factors, we train with simulation. All these things help make sure that when a barrister tries to sue an Anestis unless it's been egregious behavior, the bar will usually say there's no case here because an Anestis are so well trained, they're so focused on safety of the endeavor that it's very difficult to find fault with their care and management. Even when they've made a mistake, the mistake is made in, in, in good, in, in, in good intentions and those cases are rarely or found in fault of the Anestis. Indeed, we have covered a lot on our conversation and to end on a light note to cover what's being discussed in social media. Recently, it's humor in theater. You and I will both agree that the dark humor in theater, what is appropriate humor, inappropriate humor in theater and, and that comes back to, you know, what in theater stays in theater and the sensitivity is about, I have a question. Yeah. Any thoughts on that. Well, I was gonna answer by way of a story. And so, um, there is some interesting research that shows that rostered helicopter crews that fly together often, uh, will make dark humor and often will banter and often might even break a few rules, but they tend to be much more effective in achieving their goals than teams that don't know each other and don't trust each other and every time anybody says anything, they're immediately shut down. And so between these two extremes, there's clearly a space where humor helps to lubricate difficult social situations and different cultures and different countries and different spaces I think have different social norms. But I think there's a great danger in trying to police, uh, humor in medicine. There's a danger in trying to codify and tie down things that, uh, are impromptu and bring joy that from grim situations. And uh you know, we're dealing with very difficult environments um with very awkward situations. And I think humor helps to relax people. It helps to allow people to get beyond the awkwardness of getting to know each other. So I'm a big advocate for, for humor. Uh As long as it doesn't insult people, as long as it doesn't disrespect them, as long as it isn't uh damaging and as long as it doesn't shut down conversation, so maybe we should teach uh surgical team members how to do, I don't wanna say correct humor because that really brings in George Orwellian thing. But, but at least what's inappropriate and maybe let people figure out the rest. But I think we need to talk about this because clearly in the past, we didn't and a lot of people, particularly surgeons got in trouble because of that and we need to be respectful. Uh I should note not just for staff members, but we also in the past would make unprofessional comments about the patient. And sometimes that was revealed through uh intraoperative awareness where the patient could actually verbatim. Say this is what the surgeon said about my behind. I mean, that kind of stuff really, there's no room for that. There never was room for that. That's not humor, that's just a disrespectful language. And, and uh we need to make sure that we don't tolerate that. Um And we make sure that we role model particularly for, you know, the older season surgeons an this and nurses, we need to role model these behaviors. So that means having good humor. That means having social banter is, is OK, is good. But knowing when it crosses a boundary, knowing where it is steered away from that in a way that helps the team get through the difficult cases after a long day. Um but doesn't cross a line that arguably needs to be discussed and it's keep it, it continuously moves. Uh But obviously, clearly things that don't violate people's rights and, and don't disrespect people. Obviously, it is, is a cornerstone for any type of respectful team uh performance. Do you have music in theater, Paul? So I'm glad you asked that because that's always an interesting contentious issue. The answer is yes. Um The literature is very equivocal about this, about the fact that does it change performance or not? What's very interesting to me when I talk to surgeons who love music is that when they get into a pickle. The first thing that gets off is the music. And to me that's indirect evidence that clearly the music does have some cognitive load on the surgeon, which is why they uh asked to turn the music off. So there's the rub. So what type of music? Um, I like music, like any other person. I like a lot of music. But I guess the question is, um, in high performance systems, is music a distractor or not? It's clear that music can get in the way having said that um where is the right measure? What type of music who controls the music? Is there? Closing music, you know, there's a lot to be discussed there. Um I think that the evidence suggests that high performing teams don't have music and so in cockpits or in formula ones that we talked about there is no music. And so, um you know, if we wanna borrow from these teams, we have to understand that music can be a distractor sometimes positive, but often for some members of the team, it can be more than that. So maybe if we have a process of engaging the team around, that might be a way of going forward around that and being very um thoughtful about the volume of the music and the appropriateness of the music and how to think about that as it relates to the complexity of the case and the sequence of the epoch and, and where the music is introduced because it's clear that in difficult situations where we know there are most amount of adverse events, for example, in cardiac surgery going on, pump, going off, pump during intubation, during extubation, those types of events certainly there should be no music, other parts, a little bit more steady, more, uh, common patients very stable. I, I think that, uh, a little bit of music is fine but I think we have to have a more explicit discussion about boundaries there. And if a team member says I need you to turn it off. Now, the only correct answer is yes, turn it off immediately. And so I think within those boundaries, I'd say uh we should have music, but I think we should be more explicit about any type of human factor, shaping factor like distractions like noise or music. We should be very clear about what is the value, what is the benefit and what is the potential detriment? I think through that we can become more evidence driven if not based on how to make decisions about things like that. Paul, it's been a privilege talking to you evening and you sharing all your wisdom with us and have you got any questions for me or Gabrielle? You know, I guess uh the thing I always ask uh surgeons and now more than ever given the growing data of, of burnout and happiness is how can we best serve and support a surgeon in their journey to uh to, to thrive as a, as a surgeon, as a human being, as a lifelong uh provider. How do we think more deeply about this growing concern of surgeons, retiring early leaving medicine, um remarkably hardworking, talented individuals that clearly we weren't able to keep them within the fold, uh particularly as it relates to uh you know, active uh surgery. How do we better support surgeons in that difficult and challenging but rewarding journey, I'm sure we could talk a long time about that. But the person that comes to mind is CEO of Barry way and the operative word is care. I think everybody needs some TLC and everybody needs to be filled then and everybody needs to be feel cared for. And I am concerned in the current environment, certainly in the UK that the operative pressures of getting through such numbers and the system is ignoring a fundamental need that everybody has to be changed, valued and cat for. And I think our professional bodies, we go a long way in corporate those values into their views and visions because as you say, it's a privileged pro profession and you can't do it alone and you do need to be supported and recognize you need supported in that regard. You know, and with that, you know, I'm uh excited about a new collaboration that I've started with the, the uh European Association of Endoscopic Surgeons who have reached out and asked to think about these things, David and I would love to work with the equivalent bodies in the UK. Um The professional colleges who really wanna think deliberately about the care and nurturing of the surgical spirit, not just the technical skills, but how do we protect that ambition, that joy, the satisfaction that comes from achieving good outcome. How do we make sure to be more deliberate earlier on and consistently in a way that these young men and women want to continue and thrive. We need them in this profession. We need them to understand the challenges that go along with it. And how do we equip them with better tools um to enjoy a full and and prosperous career. Indeed, the Institute of Health and improved, talked about the joy of work and I think that is at risk of being lost unless we support each other and put it firmly back on the table. Yeah, very much so and, and it, it, it is of concern. Yeah. And I think just to reinforce your earlier question, we need the role of social scientists to help us, sociologist, psychologist. Um we need educators to help us think differently about the length and the training and what happens during the training and the sequencing. And most importantly, we need lifelong coaches for surgeons. Um and they can be in different modalities and different frequencies and that's to be determined later. But the concept that one needs a coach like you would to improve your golf game or your tennis game. That is something that we must embrace as physicians in general, but particularly in high stress, high risk, high gain environments in the operating theater. We need to embrace coaching for all it, for all it's worth indeed, Paul, thank you very much. Indeed. For your time. I look forward to continuing conversations. Like to thank our audience for your participation and questions. And this evening is also reinforced the concept of mastery and why I like the Black Academy assess skills because it's a journey of mastery and it's a mastery of everything and a restless discontent for the status quo insofar as it only good as yesterday. And today is a new day and you start again on your improvement and there's curiosity and the desire to get better every day. Gabrielle. Thank you very much indeed for helping us with the connection. The and we understand these solar flares have interrupted internet connections. And also there are a lot of attacks on the NATO meeting in Europe which making internet difficult. But I hope this has been useful. Emotion, lightning and Paul, you've answered all my questions without me asking. I'd say that's a fa surgeon, anesthetist working. I, I, I'd love, I'd love to uh act on it. We removed the barrier, but well, maybe and maybe is my final comment. I will tell you that I was part of a team that helped design a transparent barrier, David that was plastic and see through as a metaphor for the need to uh while we need a barrier for sterility, how do we make sure that we can penetrate the opacity of the traditional barriers as a metaphor for lifelong joy and uh collaboration with uh with my fellow surgeon. So, thank you so much for that wonderful uh conversation. Thank you Paula and thank you.