Surgeons and anesthesiologists: Need to communicate?

One man never made a team. Think of Pele, Maradona, and now, Lionel Messi – “the game changers, the super heroes, the Gods of soccer.” But imagine a match where there were no passes, no gesticulation, or no verbal or non-verbal communication with the teammates. Even the most worthy of teams needs the oldest winning recipe – communication and teamwork. Communication is an essential component of training in soccer. It is the glue that holds the team together and is the source of motivation for all (www.socceressentials.com).

Surgeon and anesthesiologist are the key players in the operating room (OR), aiming for a common goal – safety and good outcome for patient. Behind the mask, they often cannot read each other's minds. Within the four walls of the theater, they may also forget the basic rules of the game and fail to achieve the goal. And in this game, winning or losing may prove to be unacceptably expensive, translating into an increase in morbidity and mortality. Quality communication is perhaps the key for everyone to remain focused on the goal.

After a series of confidential interviews with surgeons, Gawande et al. found 43% adverse events as a result of communication failure.[1] Lingard et al. found 30% such events among the various errors reported over a 3-month study period in OR personnel, indicating a lack of standardization and team integration.[2]

In this issue, Kumar et al. have analyzed a questionnaire-based study which revealed that 95.5% anesthesiologists felt that good communication between surgeons and anesthesiologists is a must for quality patient care in the perioperative setting.[3] Eighty-six percent respondents thought that a failure in adequate communication causes stress to them and 52.2% faced some situations where it affected patient outcome. Eighty-two percent were of the opinion that formal training is necessary for all medical personnel and 77.6% were interested in participating in it.

The OR scenario has been shown to parallel that of aviation, and several authors have analyzed the safety checks used in the latter. Effective communication and teamwork has worked well in aviation and has also shown promise in improving patient care in the field of medicine.[4,5,6]

Awad et al. implemented medical team training for surgeons, anesthesiologists, and nurses of the OR using crew resource management principles of aviation for a 2-month time period and concluded that it can improve communication, ensuring a safer environment that leads to decreased adverse events.[7]

Cooper et al. showed examples of how to effectively communicate in certain situations that might arise during a surgical procedure.[8] They spoke about communication gaps and how to possibly bridge them at the 2012 ASA meeting at Washington DC. Some of the reasons mentioned for not communicating were natural reluctance to interrupt, fear of embarrassment or outright retribution, concern about being misjudged, or simply not knowing what to say or how to say it. The challenge is to overcome the inertia and move over the barriers of speaking up. Two different ways to achieve this were suggested – advocacy/inquiry and the two-challenge rule. The former is a deliberate practice to express your concerns without being defensive and show curiosity to understand the others’ point of view. The “two-challenge rule” is practiced in aviation where you raise your concern without being offensive. If it is not heard, repeat more forcefully and take the issue to a more effective superior.[9]

Verbal and non-verbal communications are the two ways to get one's point across effectively. The three verbal skills that must be mastered are honesty in thought and speech, consistency in expression, and clarity in delivering the message. Facial expressions, body language, and the ability to listen to others are the cornerstones of non-verbal communication skills. Without an obvious overdo, they should represent enthusiasm, class, and character. These are conventional soccer tips and would be very apt in the OR scenario as well.

Whether it is a soccer field or an air travel or a surgical suite, teamwork works. There is no substitute to good and effective communication and we know there are many ways to implement it. It is suggested that some deliberate and structured education on communication skills be included in post-graduate training, both in surgery and anesthesiology. Reinforcement of the concept of good communication at regular intervals for all OR personnel would help in improving overall patient care and alleviate the stress in the theater environment.