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We live in a sec. Hello. Good evening. Good afternoon. Good morning. Good day. Wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a retired cardiac surgeon and the professor in the Medical Education and research Development unit at the Faculty of Medicine at the University of Malaya. As you know, with the Black Brown Academy of Surgical Skills, we don't just focus on technical skills and we have regular speakers to talk about the more important elements of surgery, which are the non operative technical skills. This evening, we have the privilege of Professor Peter Brennan. Now we have 100 registrations this evening from 33 countries and it's thanks to me that we connect across the globe and I'm sure you'll find the talk from Peter in lighting. We're going to have a conversation. Now, Peter is a colleague and friend, a consultant, oral and maxillofacial surgeon in Portsmouth, specializing in head and neck oncology. And he got a personal chair for his research and educational achievements. I have to say that it was a privilege to announce his association of surgeons in training silver scalpel ward in 2022. He has over 830 publications and 80 plus on safety and human factors. He has established unique collaborations with airline pilots, the National Air Traffic Service, the Royal Air Force acrobatic team, the Red Arrows and he improves practice across surgical and medical specialties by reducing hierarchy, enhancing teamwork and raising awareness of the many factors that lead to human error. He undertook a phd in the subject in 2019 and receives many invitations to talk about this work at national and international level and it's a great pleasure to welcome you this evening. We are, we are seven hours apart, but I think we are crossing 13 different time zones as well, which is quite incredible. So, from the background, Peter, what got you into human factors? Um Well, I had one of, one of our uh attendees actually is a private, uh has a private pilot license, so is intrinsically involved in human factors and human errors. So, what got you into human factors? Um Well, firstly, thank you. Thank you so much for the invitation. And I still remember that 2022 silver scalper when, when you announced it. And um totally surprised to be perfectly honest as you. Well know, I broke down in tears on your, on your shoulder. I was, I was overwhelmed with emotion and uh such a prestigious accolade. So um I still owe you some money for the, uh, the cleaning of your, of your dinner suit, I think. But anyway, but thank you, thank you so much for the, for the invitation. Yeah. Human factors. Um, I knew probably absolutely nothing about human factors when I was a medical student in the nineties. It was something that was never really, never really talked about, never discussed. Um, there were occasional papers, I think in the anal of the college of surgeons and so forth. But it was, it was never something that, that I thought was, was important. If I'm honest with you, I had a, a retired airline pilot as a patient who, who had a horrible, horrible cancer. And he actually spent about six months in hospital with every possible complication that you can imagine. And one of his friends was, was an airline pilot on, on the 747 the Jumbo Jet for British Airways. And he used to come and visit regularly and we used to go. So we got talking and things and he was a frustrated surgeon and said he always wanted to come into an operating theater. So I arranged that with approval of the managers, he came into theater and he, he asked if he could make some notes and I said that's fine. Um And about 4.5 hours into one of our big operations, he said, aren't, you, aren't you gonna stop for a break? And it's like, no you know, we, we work for 67 hours nonstop. And he says, well, ok, ok. Anyway, we carried on, um, and then we did stop and then, and then he said, have you, have you ever asked your team, uh, how they feel about it? You know, you might feel you can operate for that time. You ever asked your team? And I said, no, no, why, why would I do that? You know, they, they work, they work with me and it, and it was that nirvana moment, David actually of hang on a minute. There might be something in this and, and I went away and thought about it, did a bit of reading, saw that there was, there was very little in surgery on HF and that's really where the journey started to, to be honest with you, slightly skeptical, I thought to start with because, you know, surgeons we can operate, can't we? For eight hours? Non stop, we always have done? But suddenly, you know, the more, the more I started reading and learning about human factors, the more, the more I realized how much I didn't know and how wrong I was in, in my, in my surgical practice. And I guess the rest is history. Really? Yeah, that wouldn't be Trevor, would it? No, no, no, no, no. So from your point of view, this was your nirvana movement. What was the most important element of human factors that opened your eyes? To this being important. Um So I think so, I think before we go any further, we need to, we need to state what human factors is and it's an enormous science, isn't it? It, it ranges from how we behave, how we interact with each other, the psychology of it, teamwork and so on and also systems design, systems and things that are put in place ergonomics, how we interact with technology and equipment. And there are experts in human factors, who, who are experts in ergonomics and experts in systems design. And that's probably what pure human factors is. If I'm really honest with you, I think for me, the clues in the title and it, and it's that human element. It's, it's recognizing our fallibility. Yes. It, it's working with systems working with checklists, working as part of process to try to try and reduce errors and things from happening. But when you, when you start understanding it a bit more, it's actually that human element, our fallibility, how we are prone to error. Uh And so we make about 5 to 7 mistakes every single day. Um It might be something simple like leave, leaving your sandwiches in the car or um in fact, what happened to me about six months ago, I was at a conference, um, drove up in Bournemouth down on the South Coast, um parked the car, um put my keys on top of the car, someone pulled up alongside, um had a chat with them about, about factors funnily enough. And then I walked over into the conference center, um, and I left my phone, I picked my keys up and I left my phone on top of the, on top of the car. As I, where's, where's my phone? And then suddenly realizing I'd left my phone and then, then rushed back. Fortunately, it was still there. But, um, uh, you know, distraction just, just one example of, of um a simple error that that happened to me on that on that day. Um And I think I understand human factor. So, so it's our fallibility. David really, I think, I think that's probably the most important thing to take away from this, from this talk. So uh how do we start teaching people or learning how to reduce the fallibility? Where would you start? Um Yeah, that's, that's a really a really good question. I think, I think really most, most or a lot of what I talk about, a lot of what we've published about is actually a common sense application. Um That that might sound simplified. And I guess the ergonomics experts are probably going to say no, no, no, you're actually damping down human factors. And it's like, yeah, maybe I am. But you know, we are, we are clinicians, we are surgeons, we are nurses, we are people and when we come to work, we tend to leave that common sense at the front door. So I think, I think to start with it, it's just recognizing that fallibility, recognizing common sense and maybe what we do live at the door. Yes. There, there are some massive textbooks. I mean, this is, this is one I used as part of my phd Human Factors methodology and it's immensely complicated with, you know, sort of table after table and sort of things and one loses, you lose interest very, very quickly when you try to read a book like this, you know, a fantastic reference book. But you really want simple things, bite size things both in reading social media, you know, small little articles just to start learning, chatting with colleagues, chatting with friends. And then once you start getting more into it, then you start thinking about simulations, for example, and other methods to really embed that human factors. But I think most of us work in teams, don't we? And I think the joy of surgery particularly is actually working in teams bouncing ideas off of each other, having, having the whole team looking out for you. Um So you've empowered them to speak up if there, if there's any safety concerns, if they feel you operated for too long without taking a break, for example, using each other to optimize the team's performance as well as well as safety. And for me, I mean, people call me a human factors expert and I'm very glad you didn't because I'm not, I'm an enthusiast and most of what I've learned has been almost like osmosis if you like or diffusion it sort of, it has come to me over a long period of time and I'm just trying to distill some of the things I've learned to you this evening or this morning, if you're east of the UK, sorry, west of the UK. So, how do you inculcate psychological safety with your theater team? Such they do hold your back and speak up? Yeah, I mean, that's, I mean, psychological safety is, is a really important area, isn't it? And it's, it's, it's feeling safe to be able to take calculated risks. It, it's, it's disagreeing with colleagues. It's, you know, having a transparent and open type approach, you know, discussing things when things don't quite go so well as having that supportive framework around us. Um And that's really, really important because if you, if you haven't got those elements, then you, you haven't got a psychological safety in my, in my opinion. So it's, you know, it's recognizing that you're a nucleus together, you work together, you're as strong as the weakest link. And I would never say anyone is weaker anyway, I value everyone equally. But, you know, the only way you work and have that safety is that anyone can speak up, anyone can criticize, anyone can say, fantastic job and actually having that framework and then being able to talk about it, having a debrief and actually talking about things in that safe environment. Knowing that you're not, you're not going to be chastised. You're not going to be told off. You're not going to be saying you're stupid. You're not going to be saying you're valueless. Those for me are some of the key, the key words I think this is always considered in theater, isn't it? But it applies to all practice. Most definitely and everywhere else. Yeah, most definitely. So there's an interesting paper that's well worth reading. If you, if you're interested, it's written in the BMJ published in 2019. I'll see if I can put the reference in the chat in a while. Um So it's Maria Panagiotis et al who has looked at about 350,000 hospital events in like a meta analysis and they found that one in 20 hospital admissions has some form of error and of those one in 20 another one in 20. So one in 400 is a serious medical error. There's a recent paper in the New England Journal of Medicine which was published last year saying it exactly the same. In fact, the percentage may even be higher. So most errors are not only in operating theaters, they are in ICU in intensive care in the emergency department and actually prescribing mistakes are a significant cause of serious error, even, even death in fact, and not just prescribe mistakes, getting, getting wrong drugs and, and that's where ergonomics comes in. So you have a drug and an ampoule that looks very similar to another drug and in the heat of the moment you just rapidly open it and that's where system design and ergonomics obviously comes in. But yeah, I think communication you mentioned never events earlier. So a never event is an event that should never happen. So, wrong site surgery, retained instrument, a nasogastric tube going into the lung and so on. Um I mean, for me, it's a, it's a bit of a misnomer because you can never prevent error, David, you know, but most never events are communication, communication related. So wherever we are in the outpatient setting on the telephone, you know, talking to colleagues walking down the corridor, you know, you can have a communication error and you can start the process of an error from happening and you can prevent it as well. Obviously, if you understand it does beg the question. Should we be calling it a never event in the first place? No, shaking your head. I don't like the term and I'm not sure what you can call it. I've been thinking for years, what could, what could we call it? But you can never prevent error. As a human, you can never 100% eliminate error. So these events are going to continue to happen despite systems and things in processes in place. And one of the reasons why they happen is because people don't engage you know, we are fallible as I keep on saying it's very, very easy to, you know, to make a mistake, a communication related mistake, as I've said, that's the commonest cause of never events. Certainly in the NHS. So 80% of never events in 2022 23 there were 600 of them. So 80% is about 400 had a serious communication related issue. I have to congratulate our audience and their honesty is 60 plus registration attendants have said they have committed a mistake. The problem is that when you say never, it always assumes blame. Yeah, 61 because me as well. 6162. So how do we mitigate that? And how do we change that? Yeah. So, so that's interesting. So, so what we need is we need something called a just culture and what a just culture is, is is asking why something has happened, you know, why never event has happened rather than who is to blame. And, and that certainly happens now in aviation and other so called high reliability organizations. Hs sadly, in healthcare, I I have been on the receiving end of an era where I was blamed and it was like, you know, you were the supervising consultant. You shouldn't have let this trainee do this, do this particular procedure. The fact of the matter is is that the trainee was almost a consultant, very experienced, wanted to do the procedure, didn't want me in the room, I was happy, a serious error happened. And yet I was the one who was actually blamed and, and it's really hard, you know, I took it really, really badly actually. So we actually need that just culture, they shouldn't have blamed. But I would have actually said, well, it's my responsibility. I am the consultant, it was my decision and you need to respect that decision and that's exactly what I did do. And in fact, when we have a mistake, what I would strongly suggest to the audience is you don't say you've, you've done that or you've cut that nerve, you say we and you immediately diffuse the situation. Yes. Yes, you might, you might want or you will want a debriefing afterwards and actually discuss why this has happened what went wrong and so forth. But it's certainly not, not a good idea in my practice or in my suggestions that you actually say in front of everyone in the operating theater, what have you done? You've cut this, you know, it's, it's, it's harmful actually, to be honest. Um Now just brought up. Yeah, I mean, just, just to make absolutely clear David, actually, that a just culture does not if you go to work wanting to cause willful harm. And, and there's a few characters around that, that have actually done that. So the UK Paterson comes to mind with a breast surgery and Shipman as the GP who was injecting opiates into his patients and killing them all. A just culture doesn't, doesn't actually protect you from will for harm or from negligence or from gross negligence. No, no, of course not. But most of us go to work and we have no intention of causing harm. We want to go and help our patients. So how do we start learning human factors and why aren't we teaching this in medical school? Um Well, some, some medical schools are being taught human factors actually. Um, there's, I mean, if you, if you look at curricula, they are, they are enormous and everyone wants their slice of the pie. So you want a bit of cardiac anatomy, cardiac surgery, you know, there, there's a, there's a huge number of things to do. Um, and I think the problem is that is that still the culture of human factors, some people see them as soft skills and they use those words, soft skills and, and they are far from soft skills. They are, they are crucial skills. So, you know, it's a little bit like aviation, you know, and I would, I would never compare the two. I don't think you can compare with aviation and health care. The two are totally diverse, but you can certainly learn lessons. I mean, even in aviation, it took many, many years to actually embed human factors effectively despite after several, several tragic tragic crashes with huge loss of life. So it's something that is slowly happening. We need a top down approach from our regulators from the Royal Colleges, from our employing trusts where we work and then we need a bottom up approach from us um who are providing the health care and you kind of equilibrate somewhere somewhere in the middle, that is the best way to integrate and teach human factors and to mandate it to the UK regulator. The General Medical Council says that you should know about human factors and embed them in your practice and yet and yet just not happening or it's happening very, very slowly. So I think GMC needs to be more proactive about that. And I've actually published a couple of papers now with the regulator about the importance of human factors. Um It's taken a while, Rome wasn't built in a day, David indeed, but it seems to have been going on for a long time because talked about the same back in 2008. So how do we start practicing good human factors for people who across the globe who wanting to do surgery or working with surgeons or in clinical environments? What would you invite them to start thinking about and practicing? Yeah. Um and I just love John's comment. There, there were, there were old pilots and bold pilots but no old b Yeah, that's fantastic, John, that's, that's brilliant. Um And, and there's another expression is like um would you rather be, would you rather be down here wishing you were up in the sky or up in the sky. Wishing, wishing you were down here when you, when you've taken off and you regret it. Um You know, another aviation. Um But, um, I mean, I think, I think the way to look at human factors are purely from my own perspective and that and that might not be the way that others look at it. But I look at, I look at individual performance. Um I look, I look at team performance so how we interact with the team and actually getting the best out of, out of your team if you, if you're the team leader, um and then, and then, you know, engaging with systems and things, which is really important. So engaging with those checklists really, really important. The who checklists are there for a reason and actively engaging with them as if your own life or limb depends on it. You know, many people see these things as tick box exercises that you have to do. It holds up the operation. You know, I've got to do this check this, come on, let's get on with the surgery. I was the same, I'll be honest, I was exactly the same when you actually put yourself into the patient's position or a member of your family. David. So, you know, you would, you would change your behavior. You do because you own that patient, you own that, you own that procedure very much like an airline pilot, a pilot owns that checklist. And so if they make a mistake, if they forget to set the flaps or the wrong, the wrong thrust settings or whatever, everyone dies, including them. So they, so they own it, we can walk away. And if you change your minds set and actually own that checklist, own that briefing as if it's you or a member of your family on that operating table. Um You, you will behave sort of differently. So yes. So individuals, team working systems, obviously simulation and training as well. Um And then actually debriefing at the end, going around looking at what we've learned, what we've done. Well, what we've learned and integrating that into our practice for future the you add to the fact that the checklists are thought of as kickboxing exercises. Do you think we should customize the checklist for specific specialties or use a standard checklist? Um So I think so, I think there are there are certain certain elements that, that you can use generically. So confirming the name of the patient concerning the side of the operation that you're going to be doing, concerning what operation they are doing, concerning what nerve block or whatever it is you're going to be doing. But, but then I think there are certainly specialty specific checklists. I think if I'm honest with you, II think the shorter the checklist, the better you probably won't no more than about five or six ticks ticks in the box. Um, there was, uh, an interesting, um, sort of disaster, I guess. No one was actually hurt. But in fact, in about 2015, there was a container ship that left Southampton, there were 226 ticks in the tick box. All the ticks were the same. They were done very quickly. They look identical. Basically, the ship was loaded top heavy and for various reasons, we don't, we don't have time to talk about that, but it was loaded top heavy when she sailed out of Southampton turned left top heavy over. She went, wrote off millions of pounds worth of Aston Martins and J CBS and Rolls Royces. And what have you? No one was actually injured but millions and millions of pounds worth of damage because of that 226 ticks in the box. So the shorter, the better David for me and certainly, certainly specific for, for specials. We have our, we have our own check list for Max Fac or for major head and neck cancer. For example, I've looked at the who checklist as who's on the table and who are you working with? You check in, I know you check in with your staff before you start. And I used to ask anything to celebrate any birthdays, anybody troubled by anything on one occasion. The ODP came up to me afterwards and said, actually, I'm in front of a tribunal this afternoon, I might lose my job and this person was going to be crucial element of a major cardiac operation. Oh, no, not appropriate. So, progressing on Peter, why is looking after yourself important as part of the human factors? And just, just if I may, I'm sort of, I'm sort of distracted by the, by the messages. So we've got Sarah saying, I think the timing of the debrief is the most difficult bit. Absolutely. And you know what, you don't necessarily need to have a formal session for that, you could, you could actually do it as, as you're closing, closing the patient at the end and just, just have a have a talk about what went well, the most important thing I think is actually thanking the team and actually valuing the team and talking about what we could improve on. Um And I agree with you John about chief executives actually who visit departments. Absolutely. Absolutely. Um I was picked up and reminded on one occasion after a death on the table, it was important to have a debrief after a death on the table. And even though it's rare and hard, uh you want to go back to your office and think about it, but to stand in theater and discuss it with the team, there's a lot more learning to be had. Yeah. Yeah. And it, and it enables closure in some respects and you should never forget that emotional element as well. Which, you know, a lot of, a lot of, a lot of people think our surgeons, they've got rhino heart and, you know, and they don't care. Well, actually, I mean, some of us, most of us are actually very, very sensitive about, about it. You know, the slightest little mistake or error or complication, we really care and we worry about that patient. You be, you bear the cross. I had a little pile, fortunately a little pile of cards of the patients who, who unfortunately did not survive. And that was almost a memorial on my desk. You have to remind me of what we do. Yeah, it's as important as, as you mentioned here, the timing of your debrief. Hm, immediately after the operation at the end of the day or both. Um, well, some, well, sometimes we actually debrief at lunch time if we have a morning and an afternoon list or we've had a, we've had a big case in the morning and a separate one in the afternoon, then we will, we will have a, a sort of mini debrief then, uh and actually talk, talk about how, how's everyone feeling? How do you think it's gone? And actually I always ask people, how has the procedure gone? How do you think it's gone rather than saying? Well, I think that went really well because then you're introducing potential bias. So, asking your team how they feel it went. What could I have done more of what could I have done less of how could I have uh thing asking your trainees about, about their experience and things. And of course, that, that plugs into the silver scalpel award that you mentioned earlier, you know, valuing trainees as every single case for me is an opportunity, a training opportunity. Um making sure that they have the very best experience um not getting cognitive overload, for example. So, so I remember being a trainee, you're trying to do some surgery, you're learning a new task, you're being asked all the anatomy of the region, all these lots of complex questions and you actually reach, you reach that bandwidth, you reach saturation and therefore you, you can't answer the question and then b your surgical skills start suffering. So actually just understanding that and, you know, recognizing that trainees reach that overload point much, much faster than you're going to. So maybe keep the questions for later, you know, for example. Um but I think, I think sometimes, you know, just if the list has gone well, everyone is happy, you know, you necessarily, or you don't necessarily need that formal formal brief, you know, debriefing, you don't necessarily need it just a, just a one minute. How did everyone feel? Yeah. Thank you so much for the day. Really enjoyed it and so on. I mean, when something hasn't gone quite so well, um sometimes a bit of reflection is needed and so you might have an initial debrief and then you might need to speak to colleagues or they might need to speak to you afterwards and whether that's later that day or the next day or a few days later. Yeah. So I don't think we should be prescriptive about that. Have you ever asked a direct question about your communication in theater? Um, yeah. And I, and I do regularly and actually that was one of the things that Dave Dave Smith who was, it was a 747 captain picked me up on. He said, oh, you know, I couldn't really understand what you were saying. You were, you know, you were, your question was a bit vague. You weren't clear, it's like, right? Ok. Um So, so that's how, that's another reason how my HF journey started. So yeah, communication really, really important and um you know, and getting and getting that repeat back or feedback when you want to convey a safety critical message. I think word for word repeat back is a bit anal. I mean, that happens in aviation. Yes, because it, because it is essential. So it's to send to flight level 1 1510 left to heading 27 or whatever it is. And so you have, you have to, you have to be prescriptive about that. But if you're giving an instruction to the NIE this or you're telling the NIE this, you're around the carotid. Um then I want some, some sort of response back to say, yes, Peter, you're working around the carotid now or, or the BP may fall or what have you um really important and we set that up at the briefing stage as well. So we actually discuss what points are going to be, are going to be going to need a bit of communication. Um What points we want, we want um some sort of feedback from the, from the team as well. Um Nothing should come as a surprise. So, could we elaborate a bit further because we have a lot of trainees aboard about this cognitive overload? How do you manage that for your trainees? Um Well, um I mean, you, you have, you have a bandwidth, don't you of, of what you can, what you can learn and um a number of things plug into that. So, so you're trying to, you're trying to learn the task, um You're a bit intimidated or maybe you're a bit intimidated boss. Uh You know, you've, you've, you've got other things going on in your life, you've got exams coming, you've got, you've got all sorts of things. So, so you reach that saturation point much, much, much quicker. And I've, I've got a diagram that I use in the HF talks with basically a head and neck and it's sort of low red, medium high and then saturated. So, so just so just limiting keeping to the task in hand, not trying to distract the trainee by asking them complexities of anatomy or complexes of complications of the operation in that, in that time when they are trying to learn it and, and you're getting the feedback from them as well and actually asking them, are you OK? Do you want to take a break? Would you like me to take over? Um Are you, are you happy doing the procedure still? Um you know, getting that feedback, which again, we set up at the briefing stage as well and we say we say to trainees, look, I will be asking you during the operation. Are you OK? Are you doing this? It's not, it's not a criticism. I'm not, I'm not finding faults obviously, but so they, so they know really important David. Yeah. Yeah. Uh How do you, how do you involve your trainee as an assistant when you're doing a complex operation? Um Well, I mean, like anything there will be times when, when the consultant has to operate to maintain their skills. Um I guess and so I do operate. Um but at the same time, there will be elements of the operation that I can, I can let the trainee do. Um and um and even some of the complex element like come round see the anatomy from the, from the other side of the table because because that's the side you're going to be doing it on when you, when you see um come on around, sit with me or whatever, then I have another assistant. And in fact, we actually do that a lot of the time. So we, we often get the scrub nurse round holding their tractor, then the trie comes round and so they can see exactly what they're supposed to be seeing. Um And actually I was thinking more of inviting them to make a critique of, of your skills and observation as the second pair of eyes, I often the the assistant is a second pair of eyes and looking at things certainly within the chest at 90 degrees to what you're looking at. And, and it is therefore important to invite comment if they see anything wrong and that. Yeah. Um So I'm doing some work at the moment with um eye tracking with these glasses that actually track your your eye movements. And it's actually quite interesting as a as a consultant, assisting a trainee, um consultants don't maybe look at the operation site perhaps as much as they should they start gazing around and, and that may be good that may be a reflection of the confidence in the trainee, but some interesting work, I don't have all the results yet, but let's speak in six months and, and I'll tell you a bit more really is that not providing the situational awareness for a trainee so they can focus on the job on hand. Certainly, I find myself in a cardiac theater looking at the monitors and listening and watching to anything else. And I think the trainee, as you say, with the cognitive load of the anatomy and the focusing on training perhaps doesn't have the situation awareness or capacity to think beyond what's in front of them and bring it perhaps you around to do that, um Bring it back to basic, bring it back to common sense. David, when you, when you learn to drive, you know, you pass your test, you get out onto the road and maybe you haven't got that, that essay in the, in the same way. And you know, as an experienced driver, you're actively thinking ahead, it's part of threat and error management team. So you're actively thinking ahead about, about the next stage. So, so you're on a motorway, you've got a slip road, cars are joining, so a really good driver will be, will be looking in the mirror in the mirror and actually moving out into the next lane to enable those drivers to enter the motorway. That's really good essay. So that's equally applicable in surgery. As you, as you, as you've highlighted you, you can practice it driving to work. Can you not? Absolutely. Yeah, absolutely. Do you think A I is going to help in this field? Um A IA I, what do we all think about A I? Um, I think it has some, some advantages. Most definitely, it can help, help you write that essay. Uh It can help, it can help you to a job, all sorts of things. Um, obviously with diagnostics and things with, looking at mammograms and all those things. It, it's got some great advantages. I think it comes with a few disadvantages as well. You potentially take away that emotional element of patients. I'm certainly worried about it where it's going, you know, what's it going to do? I don't really understand it. If I'm honest with you, I don't use it as part of part of my paper writing. I'm old fashioned. I do it all. So I'm concerned about the future. So I think it's got advantages and disadvantages. It comes back to what you said about human factors being a communication, exercise and skill. I mean, no computers fail the turing test. Absolutely. Yeah. So if you were starting again and reinventing the surgical field, where would you start with human factors and introducing situation awareness, what would you think would be the key element that we need to address? I would actually, I would start this type of thing in schools, um, for school Children, civility, learning, learning things, bullying, for example, it happens, doesn't it? You know, and continues to happen? Um, so I guess, I guess the earlier that you can, you can get into HF however, however you dress it up and I think bullying probably isn't human factors. Is it, it's, it's, you know, it's a behavior but the earlier the better and certainly at medical school um, certainly talking about it often, often and frequently and just little, little bite size bits really. And we, I mean, we talk about it all the time and trainees come to me and, oh, I read this paper or, um, I did this and it's like, wow, I didn't know that. So, um, just maintaining dialogue, maintaining interest, um, um, having the team looking out for those things as well as you, um, setting up, setting up boot camps, setting up talks, setting up sessions, training afternoons. I mean, we do, we do that regularly. I get invited all over the hospital all over the country actually to, to or could you come on this afternoon? Can you come then? It's like, you know, I'd love to, but I have to do my job as well. So I go as often as I can but, you know, just, just, um I think that's fantastic that people are so interested and they want to know more about HF so the ear the earliest time and it's never too late to start David either, you know, I mean, look at me, I was, I was a consultant for seven or eight years before before I even even knew anything about HF and still learning even now, why is it important to look after yourself as a surgeon? You've talked about sleep previously? Um Yeah, so, so we published quite a lot on this, uh you know, we published on sleep and fatigue and hydration and nutrition and, um, you know, emotional status and goodness knows what else. Um, I mean, I think, I think if we, if we just take one, if we just take two of those, if we just take hydration and nutrition, for example, so in the summer, you know, we perspire and I guess it must be really, really hot, hot in Malaysia for you. Um, and let me ask the audience, do you drink 1 to 2 L of fluid every single day? And do you go home at the end of the day with a headache? Um And the answer is um most people don't drink the recommended fluid and a lot of people do go home with a headache. Now, if I then start telling you some facts that if you, if you lose 1 to 2 kg of body weight through perspiration, your analysis and decision making. And there's, there's been lots of really, really carefully, carefully designed studies on this, your analysis and decision making falls by about 20%. So how you process information, how you make those decisions. It just slowly deteriorates and you don't even know it's happening because it's a very, very gradual, gradual process. So, so that's one example, David, um eating really important how many people in the audience don't have breakfast in the morning. Um Because because that's what they've always done or they don't or they don't think it's important. Um If you don't have breakfast effectively. You, you're in a fasting state, aren't you? You, you know, you're burning fat or generating ketones. Um, your brain doesn't really like that to be perfectly honest. Um, and there's been a, a study of 100,000 school Children in the States in the USA, 50,000 had their breakfast. 50,000 didn't. Which ones performed better at school? Obvious how many of us miss our lunch. You know, because we're operating and so we're operating for five hours, it gets to three o'clock. We're getting a bit hypo. Our performance is deteriorating. Exactly the same. You're entering that fasting state. Um, and your performance just isn't what you think it is even if you think it is and if it's ok for you to operate for six hours, um, have you ever asked your team if they've, you know, if they, how they feel and what I always say is, would you drive from, from London to Edinburgh? You know, it's about 400 miles. Would you drive from London to Edinburgh? Non stop without taking a break? And everyone says no, of course not. I'd stop, I'd stop at leeds or I'd stop wherever, at about three or four hours and yet it's safe to operate or it's safe to do a clinic for 78 hours or ward around nonstop. Uh, I just need you to think about that. Well, the system, the system doesn't sometimes provide the luxury of the break does it well, no, no, no, I disagree with you. I think, I think, I think short little breaks, um, you know, even, even a 10 or 15 minute break and you actually catch that time up and we've published on this, you know, with long complex operations, you just stop you down tools, you go away for 15 minutes, have something to eat and drink. You actually come back, you've optimized your performance, you've regained your, your, your strength or what have you. Um And you catch that time up. So, um, it's, it's, um, you know, people, people blame the trust and blame the things. But actually, um, you know, I think you can make a little bit of time for yourself, really important, really important. I indeed, I concur with that, having spent the longest time I spent at a table was 19 hours. I must say I didn't feel very well after that. Did the patient survive dissection? Yes, the patient did survive and get back to itu unfortunately, but the dissection had complications later and therefore did not survive but survived the operation. I survived the operation. Hm Not quite sure. Sure. So as we wrap up this evening, Peter, any closing comments to our audience about human factors and the importance of this in surgery. Um When I come back to, to the thing that we started with David about fallibility, you know, just, just recognizing that we regularly make mistakes. So, error is normal. It's actually a normal part of being human. And we, we shouldn't feel bad when we, when we make a mistake, we are made to feel bad because of the system and because of, because of pressure on things, but, you know, errors are inevitable. So I think that's certainly take a message. Number one, I think, take a measure. Number two is your performance slowly fades over time. So we would say, uh if you, if you're operating probably 34 hours tops, uh before, before you need a short, a short little break. Um, um I was talking to, to cardiologists in the UK, so I was invited a couple of years ago actually before the pandemic to, to a large cardiology conference. And I gave an hour talk about human factors and someone stood up and said, well, I do a 67 hour ward round non stop. And I said, well, have you thought about taking a break halfway around? And he emailed me about two weeks later and said, well, you're a genius. It's like, you know, we stopped, we finished the ward round actually faster than what we would have done. It's like that's just common sense, you know. Um So, um, fallibility, common sense valuing everyone in the team equally, um, you know, creating that safe space for, for everyone, you know, not being civil. Um And I think we, we haven't mentioned about limbic hijacking, have we? But we probably should as well in the, in the closing. Yeah. So we're, the brain is amazing. And in fact, when I spoke at the society of British neurosurgeons last year and there were 400 neurosurgeons there. And I was slightly anxious about talking about neuroanatomy. But, but the limbic system is 500 million years old and it's the reptilian brain and it's the fight, fight and flight. Your higher brain functions are as old as Homo sapiens. So what 150,000 years maximum? So you can get something called limbic hijacking. So when you are in that stressful situation, um you know, maybe the operation is not going as well as it should, maybe you're feeling a bit tired a bit hungry. Maybe someone says something to you, which you don't like a so called Sentinel event that's called your limbic system hijacks and overtakes your higher functions. And so you suddenly shout out and, and I've done it, I think most of us would have done that. And then, you know, you shout, you instantly lose the respect of the team. People think what on earth is going on. Of course, they've got no idea of the stress that you're under 80% of actually, it's probably higher. It's probably 90% of people that do shout out at colleagues subsequently regret their actions. But of course, the damage is done. Respect is lost and what have you? So we would say that will be the third thing to remember. So one is, one is fallibility. Two is performance three is limbic hijacking. If it's safe to do so, just stop what you're doing. Think. Let your brain catch up and then you almost certainly, probably won't shout out and won't say something that you may subsequently regret. Um I heard a neuroscientist talk about this on a TED talk the other day and you literally do need to stop and take a deep breath through your nose slowly. And when you think your lungs are full sniff in another deep another breath, hold it for a moment and then breathe out slowly. Yeah, and that apparently takes away that limbic excitement. And it literally is when somebody says, take a deep breath, that's really neurological and neurophysiological reasoning behind that Peter, it's been a pleasure talking to you. Thank you very much indeed. And I want to give the audience a chance to ask more questions. We haven't had many questions from the audience. Uh Somebody's picked up on driving a car and as an excellent example of situational awareness, we sign out a debrief. They say two separate entities. Uh I think sign out refers to that of the individual patient where debrief is for the whole list. And of course, with the sign out is also the handover, particularly in cardiac surgery, going to itu or handover to the recovery nurses. And this is the handover where communication has to be clear and explicit. OK. The other elements we, we refer to pilots all the time. But as you quite rightly say, this is somewhat more complex than flying a plane. Uh Peter's kindly put a reference in the chat room. So, and um, preventable harm. And I'm very pleased that the audience was so honest and forthright about putting their hand up. I've made a mistake. The important thing is if you make a mistake is what you learn from it and how you can prevent it again. And it's the second order problem solving. I've just, there's just a link, there's just, there's just a really short article that we published in the Annals recently about, about just a, just a brief overview really, which is, which is, which is free, free to download. I've just put that in the chat as well, but most a lot of our papers are open access. Um In fact, if I think, I think my, I think my proudest one, David is the, is the Christmas the Christmas BMJ 2020 when we, when we talked about Santa Claus Christmas and, and how we use this, it's empowering the reindeer, taking a sleep over the oceans, effective communication with the ho ho ho that Santa uses. Well, that's got two different meanings, believe it or not. It's just so human factors affect us all. Exactly. Yeah, Peter. Thank you very much. Indeed. An absolute pleasure. And thank you to the audience for participating. I'm pleased that you find this useful and I hope it stimulates your thinking in this area. It's important in every aspect of our lives and in surgery, whether it be in theater, our patients war rounds, wherever it's all communication, communication, communication. We look forward to seeing you again next week on the Black Belt Academy of Surgical Skills. And we're gonna start our cycle of stitching with the anatomy of the needle and how to hold a needle. I confess that I started with a new Sensei with Ido at the Japan Club in Kuala Lumpur and felt like a total beginner as he adjusted my sword few degrees and picked me up and a lot of errors. And I thought to myself, we don't teach surgery this way, but the Black Academy intends to so join us for the forthcoming series. And thank you very much to me and Gabriel for the production. I wish you well and look forward to seeing you again and Peter. Thank you. No, no, thank you very much David and like I put in the chat for, for giving up your time this evening, this afternoon, this morning, late into the night. Uh I mean, it's, um, you know, I'm absolutely flattered and hope hopefully you'll, you'll have one or two things to take away from it and improve your, your own performance and of course, care, care of your patients. So, thanks for the opportunity very much and that's what it's about our, our patience. Yeah.