Working on Communication Skills in the Simulator

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CHAPTER 4 Working on Communication Skills in the Simulator

“Speech finely framed delighteth the ears.”

2 Maccabees II:39

Picture yourself sitting in front of a person with a doctorate in education (EdD) from Harvard. This professor now holds joint appointments at MIT and Harvard.

The professor is not the Marquis de Sade or the Grand Inquisitor peppering you with rapid fire, trip-you-up, “where were you on the night of the 15th”? questions. This professor does not have you on the rack, is not holding a cat o’nine tails. No light is shining in your eyes. This professor is not standing over you, does not have you in a shorter chair, has not deprived you of sleep. This professor has not made you take a blood oath of allegiance to the Boston Red Sox. This professor has done nothing whatsoever to intimidate you; on the contrary, this professor has shown nothing but kindness to you.

You ask a question about the behavioral aspects of Simulation training.

“You know, I’ve studied all about the clinical end for years, the heart attacks and codes and stuff. But this behavioral business, how do I go about learning that?”

“Well”, the professor with ties to MIT and Harvard says, “you have to read.”

And the professor looks at you.

“Oh,” you say, “yeah.” And you squeak out a forced/embarrassed/moronic giggle. “Yeah, I guess, to learn something, it does, sort of, make sense that, you know, you, or me, that is, I would be, um, well advised to, uh, actually open a book and look at the words written in the book, which is what constitutes the act of, well, reading.”

“Yes,” the person with a doctorate in learning from the most hallowed institutions of learning in the world says, “reading in order to learn has a long track record.”

Who are we to argue with that?

You can’t just instantly know how to teach the behavioral part—or you could call it the “communication” part—of the Simulation experience. You need to study it, to read about it, just like you had to read about cardiac physiology or the autonomic nervous system.

An initial reaction might be, “Ah, to hell with that psycho-babble. I’m training people in the clinical arena! Codes! Shock! STAT! That’s the ticket. The Simulator was never meant to be a marijuana-laced, Haight-Ashbury-esque, harmonic convergence love fest. Nor is the Simulator meant to teach us how to talk ‘administrative-ese’ like a bunch of CPAs. So let’s skip the ‘getting in touch with our feelings’ and the ‘prioritization of goal-oriented intermediary assessment protocols.’ That’s all sissy stuff.”

BOX 4-1 How to Learn About Behavior

• Read

You think to yourself, “Why should I read about this fluff at all? Real clinicians don’t give a *#! about that hooey anyway. Skip the ‘talk’ books, let’s put that Simulator into V-fib and freak out some students. Now that’s REAL learning!”

And, truth to tell, when you start to drift into this behavioral sea, you do hit some suspiciously “administrato-speak” sounding icebergs.

CRISIS RESOURCE MANAGEMENT

What’s this? Crisis and management in the same phrase? “Crisis,” which evokes images of the Hindenburg bursting into flames, bodies falling from the sky, people, still smoking, staggering out of the wreckage. “Oh the humanity!” And you couple that with “management”?

Management. Double entry ledgers. Setting minimum the wage. Breaking up the gang around the water cooler with a gruff, “Time is money.”

Crisis is a can of Coke that you shake up, then pop open all at once.

Management is a can of Coke you left sitting open in the fridge for 3 days.

Conceptualizing

Six syllables, in one word?

Spare me.

But the kicker in this is—this behavioral stuff really does matter. These phrases, although they come across as bloodless and limp, make a big difference in the crunch. And the more you read about behavioral psychology, negotiating under stress, working in teams, the more you realize we do need to know this stuff. When you see it all unfold in the Simulator, you become a true believer.

The Professor was right: “You have to read.”

Hmm. Where to now? Here are the questions:

• What should I read?

• How do I make this reading “meaty”? How do I turn “flat cans of Coke” into “exploding cans of Coke”?

Here is the answer to the first question: What should I read?

• The 7 Habits of Highly Effective People. Steven R. Covey. [I listened to the audio tape in my car.]

• Getting to Yes: Negotiating Agreement without Giving In. Roger Fisher, William Ury, Bruce Patton

• Difficult Conversations. Douglas Stone, Bruce Patton, Sheila Heen

• Notes from the Center for Medical Simulation’s “Teach the Teacher” meeting

• Learning from Accidents. Trevor Kletz

• Innovative Simulations for Assessing Professional Competence. Ara Tekian, Christine H. McGuire, William C. McGaghie

• Simulators in Anesthesiology Education. Edited by Lindsey C. Henson and Andrew C. Lee

• Anger and Other Emotions in Adverse Event and Error Disclosure [two-DVD set]. Robert Buckman [can order by telephone 1-800 488-8234; e-mail: cinemedic@bellnet.ca; web site: www.cinemedic.com]

• Boulet J, Murray D, Kras J, Woodhouse J, McAllister J, Ziv A. Reliability and validity of a simulation-based acute care skills assessment for medical students and residents. Anesthesiology 2003;99:1270–1280 [great bibliography; gets you up to date on all the latest “Simulato-think”]

• Gordon JA [one of the teachers at the “Teach the Teacher” course], Oriol NE, Cooper JB. Bringing good teaching cases “to life”: a simulator-based medical education service. Acad Med 2004;79(1): 23–27 [Dr. Gordon is major cool, and this article reflects it.]

• LaCombe DM, Gordon DL, Issenberg SB, Vega AI. The use of standardized simulated patients in teaching and evaluating prehospital care providers. Am J Anesthesiol 2000;4:201–204 [how paramedics work into a Simulator program]

• Issenberg SB, et al. Simulation technology for health care professional skills training and asssessment. JAMA 1999;282:861–866 [This article sort of “lays out the debate” in the general way that JAMA articles do.]

• Issenberg SB [can you tell he’s a Kahuna?], et al. Effectiveness of a cardiology review course for internal medicine residents using simulation technology and deliberate practice. Teaching Learn Med 2002;14:223–228 (Simulators are groovy for all specialties!)

• Gordon MS, Issenberg SB [who else?] Mayer JW, Felner JM. Developments in the use of simulators and multimedia computer systems in medical education. Med Teacher 1999;21:32–36

Here is an answer to the second question, “How do I make this reading ‘meaty’?”

Make the administrato-speak (crisis resource management, conceptualization) more vibrant. Put pure learning theory into something you can hold, bite, rend, dismember, eviscerate. Toward that lofty goal, here goes with a “Primer on Behavioral Stuff Writ Gritty for Medical Folk.”

Apologies to many and sundry great educators. Lifetimes of learning and entire careers went into all this cerebration. I bastardize, warp, distill, and distort all their fine work into a few punchy lessons. Their brilliant discourse morphs into so many sound bites.

FIGURE 4-1 Educational theory and, for that matter, education in general, can drift into an endless blah-blah-blah of lectures, recitations, and stultifying boredom. The simulator, actually doing something, can put some teeth into the educational experience—can give it a real bite.

Filet mignon covered in ketchup and served as a happy meal.

COMMUNICATION AND BEHAVIORAL STUFF WRIT GRITTY FOR MEDICAL FOLK

Learning

John Dewey, a great educator in the early 20th century, looked at the importance of experience in learning. A good way to learn is “trying to do something and having the thing perceptibly do something in return.” That is the siren song of the Simulator! You give epinephrine to the Simulator, and the Simulator responds with a jump in blood pressure and heart rate. John Dewey would love this stuff.

BOX 4-2 John Dewey Paraphrased

“To learn, do something and have something happen back.”

“The first stage of contact with any new material … must inevitably be of the trial and error sort.”

—Vintage John Dewey

Bingo! Go into the Simulator, try to intubate a swollen airway, change the head position, try a different blade…. No go? Eventually you “trial and error” your way all the way to a surgical airway, placing a catheter into the Simulator’s cricothyroid membrane and starting jet ventilation.

FIGURE 4-2 In simulation scenarios, you have to play your cards right. You’re given a certain hand—say, a patient with a bad airway—and you have to learn to “play the hand you’re given.” In the case of the bad airway, for example, you may opt for an awake intubation. This is the same “deal” that you get in real life.

Dewey said, “What is [needed is] an actual empirical situation as the initiating phase of thought.”

You want an empirical situation? How about a mannequin, generating breath sounds on his right side, no breath sounds on his left side, and, through a speaker, gasping and saying, “I can’t take a deep … breath … it’s … so hard to … I … just … can’t.” And up on the wall is a chest X-ray showing a pneumothorax and across the room is a computer-generated chart detailing the “patient’s” car wreck and rib fractures.

That’s a 4+ empirical situation for learning.

Again, Dewey: “No one has ever explained why children are so full of questions outside of the school … and the conspicuous absence of display of curiosity about the subject matter of school lessons.”

Link to the Simulator? Listen to people chattering away as they walk down the hall after a Simulator scenario.

“Oh man! I’m thinking vagal, then V tach!”

“Did you catch the temp rising?”

“How come you got the tube in—his mouth was like a rock!”

Compare that with your average “regular” lesson, a lecture.

“Any questions?”, the lecturer asks, looking around at a sea of glazed eyes and partially obstructed airways. “No? Sure? Anyone?”

BOX 4-3 Simulation Dilemmas

• Clinical

• Behavioral

• Ethical

“A difficulty is an indispensable stimulus to thinking,” Dewey wrote in 1916. Each Simulation scenario has just that—a diagnostic dilemma (is this asthma or CHF?), a treatment headache (do we go right to dantrolene, or do we see if malignant hyperthermia is really happening?), or an ethical problem (his saturation is dropping but he’s refusing intubation). And Simulator centers crank out difficulties by the boatload. The Harvard people describe 200 different scenarios. Duke’s Simulation center has a ton. Stanford, Houston, Tampa—all across the fruited plain—Simulation centers tap their evil genius to come up with new puzzlers for their students. And these Simulation centers share their wicked twists on their web sites, so Simulator learning metastasizes like a well vascularized malignancy.

You want difficulties?

We got difficulties.

FIGURE 4-3 The famous educator John Dewey said you need an “actual situation” to do your best learning. That is what the simulator gives you, an actual situation to work through. No tennis player learns to play tennis by reading a book. You need that “actual situation”—a real tennis court, real tennis balls, real racquets, a real opponent—to learn the craft. Here our intrepid instructor learns that perhaps it is time to take up golf.

“When an activity is continued into the undergoing of consequences, when the change made by an action is reflected back into the change in us, the mere flux is loaded with significance. We learn something.”

Democracy and Education: An Introduction to the Philosophy of Education (Macmillan, New York, 1916, p. 163)

—John Dewey

Simulato-people dig their scenarios and jazz them up big time. They want to make Dewey’s “flux” memorable. And they don’t just ham it up, they breathe life into those scenarios.

“What the hell’s going on around here”, the medical attending bellows, “I didn’t want this guy intubated!”

“My head hurts so bad,” the voice from the Simulator says, “this is the worst headache in my life. Am I going to die, doctor? Is this a stroke?”

The more you read Dewey, the more you love the Simulator.

Another angle on learning: Draw an “emotional circle,” with low level emotions below—hanging out at Borders on a Saturday afternoon—and high level emotions above—hanging out at Hillary’s Step, (a steep rock incline about a thousand feet from Mount Everest’s summit) with your oxygen running low and a blizzard blowing in.

Most education is attained via reading and lectures. Plowing through a book or somnambulating through a lecture creates the “Borders” emotional state.

When you go into the Simulator, you get your dander up. You get pumped. Your emotions amp. Red zone. Hillary’s Step.

You remember your “Hillary’s Step” lessons. You tend to forget your “Borders” lessons.

How About Medical Education?

“Hang around long enough, and you’ll see what you need to see,” goes the traditional thinking.

• Keep the surgeon in the hospital 95 hours per week for 5 years, and he or she will take care of the requisite number of appendectomies, bowel obstructions, and tumors.

• Sure, malignant hyperthermia is a 1/35,000 event; but if you do enough anesthesia, you’ll see it.

• Didn’t see Cushing’s triad of increased intracranial pressure, hypertension, and bradycardia? Well, do another year of fellowship. It’ll pop up. Maybe.

Scripture addressed this aspect of education long ago: “Time and chance happeneth to them all.” That is, medical education has traditionally been a crap shoot. Maybe you’ll see epiglottitis; but then again if you happen to be on vacation when the one case comes in, well, you won’t. Maybe you’ll see an inferior MI with bradycardia, but then, maybe not.

Enter the Simulator

The Simulator slays time and chance. The Simulator can make sure you see the rare things and can make sure you get practice with, well, whatever your teachers want you to know.

An internal medicine professor wants to make sure all his residents see status asthmaticus progress all the way to respiratory failure. Shazam, the Simulator makes it happen.

An anesthesiology instructor wants to walk his residents through the much-dreaded “can’t intubate, can’t ventilate” sequence. Voila! Done.

An ER team wants to go through a terrorist attack drill with multiple codes happening at once. No problem.

And best of all, the Simulator can go through these scenarios at no risk to any patient. No one had to “allow” asthma to progress to respiratory failure. No one had to “fake” a lost airway and put an anesthetized patient at risk. And no zealous instructor had to go shoot up a crowd to get his mass casualties.

You kill the Simulator? Press the reset button, and Lazarus comes right back at you none the worse for wear.

BOX 4-4 Traditional Education

• Chance not a problem

• Maybe not a problem

And when you look at it from another angle, it makes sense that we practice on un-killable Simulators. With a Simulator, we are doing our first learning on a pretend person. We are doing our first drive in a pretend car, our first flight in a pretend plane.

As medical folk, sooner or later we have to learn by practicing. And because our job involves working on people, it means that, gulp, we learn by practicing on real people.

That’s a tough sell to the public.

The public doesn’t mind that you learn by practicing on real people. So long as it’s other real people. Not me real people. And no matter how you look at it, everyone is me people. So it makes sense that we practice on the only non-me people out there—the Simulator.

Errors

To prevent screw-ups, you have to study screw-ups. And don’t just limit yourself to medical ones. Study all sorts of cool stuff. You can always draw some thin thread of relevance to the field of medical education and Simulation.

(Or better yet, just sit back and enjoy. These stories rock!)

So put on your “medical education” cap and follow along. The questions you ask yourself are:

• How did this error “evolve”?

• How could such an “error evolution” occur in medicine?

• How could a Simulator fit in here and “save the day”?

If you’re not in the learning mode but are just in this for voyeuristic thrills, ask yourself:

Just how cool is this?

Oh man, isn’t it great this didn’t happen to me?

When are they going to show this stuff on The Learning Channel?

BOX 4-6 Errors

• Evolve

• Several events coincide

• System fails

Show Me the Money

A psychologist named Lia DiBello, working with the National Science Foundation, took the idea of “business simulation” to three floundering companies: a biotech firm, a foundry, and a nuclear fuel producer. First, DiBello pegged what was going on—she nailed the “error.”

At the biotech firm, half the people thought the company was a research firm, and the other half thought it was a commercial enterprise. The left hand didn’t know what the right hand was doing.

The foundry had inefficient molds and generated too much scrap. Bosses in the office didn’t know what was going on the “floor” of the factory. Floor workers didn’t realize the impact of these inefficiencies on the company’s profits. The left hand didn’t care what the right hand was doing.

In the nuclear fuel company (God Almighty, I hope they get it right!), managers from various departments feuded and sniped at each other. The left hand was beating the hell out of the right hand.

Now go to the three questions.

1. How did the error evolve? Over time all the companies “pulled apart,” and no one was working together.

2. How could such an error evolve in medicine? Think of the departments at your hospital. Do they work together, or do they set up separate bailiwicks, each looking after its own interest? Think of the subdivisions in your departments. Just how much do they talk with each other?

3. How could a Simulator “save the day”? Psychologist DiBello went to work. (her company, in San Diego, is called Workforce Transformation Research and Innovation—www.wtri.com; e-mail: contactWTRI@wtri.com; telephone: 619-232-8054.) She set up intense business simulations where everyone had to work together. Like it or not, the right hand and the left hand had to cooperate.

The biotech firm had to do a Simulation exercise designed by the fine people of WTRI. Research and development had to pay attention to financial realities and design something that would actually sell. Then they had to get the goods out on time, assess whether the product was selling, and dump the unprofitable junk. Now everyone, even the research people, were working toward a profit. Guess what? After the exercise, the company started making a real, not a simulated, profit.

At the foundry, the floor workers had to do a Simulation where they designed more efficient molds. Voila! They generated less scrap, saved money, and took this lesson back to the factory. And now the foundry is in the black. Uh, as in black ink, not black soot.

In nuclear-ville, DiBello’s Simulation forced the various managers to work together. They had to, well, perform the managerial equivalent of a fusion reaction. No explosion occurred, thank goodness, and the company went on to enjoy financial success.

Well hot diggity dog, the Simulator did come to the rescue!

Could a Medical Simulator work similar magic?

Hell yes! Medical Simulators are the greatest thing since pizza delivery. Medical Simulators walk on water, and the water doesn’t have to be frozen when they do it.

Well, perhaps I’m given over to a modicum of hyperbole, but a medical Simulator could certainly help.

• Mass casualty exercise where surgeons, anesthesiologists, intensivists, and nursing staff work together.

• End of life exercise where a dying patient is in severe respiratory distress. Ethicists, clergy, and doctors could work out this difficult scenario together.

• Radiologists, radiology techs, engineers, and anesthesiologists could work together on the problem of the anesthetized patient in a new radiology device.

Workforce Transformation Research and Innovation has identified and solved big, expensive problems in industry. By getting disparate elements to work together in a Simulation, they have succeeded in the prime dictum of business: “Take care of the bottom line.”

Time for us to take the hint. We should use the Simulator to make our disparate medical elements work together. That way we can succeed in the prime dictum of medicine: “Take care of the patient.”

A Samovar with Attitude

The Soviet take on nuclear safety should raise an eyebrow or two. One manager of a nuclear reactor said, “A nuclear reactor is just a samovar.” (An ornate kind of teapot used in Russia.)

On April 26, 1986, the samovar at Chernobyl served up a nasty brew. The managers decided to do a safety test that day (note the irony). During the safety test, a series of glitches occurred. The engineers:

• Cut off power to the water-cooling system.

• Didn’t insert enough of the radioactive rods into a graphite “absorber.”

• Disconnected a safety switch that would have dropped the radioactive rods into the graphite “absorber.”

And the design of the reactor itself had a basic design flaw: As the reactor overheated, the nuclear reaction sped up. That is, there was no feedback loop to stop a runaway reaction.

A 9-foot thick concrete shield on top of the reactor blew off and fell to the ground with, one assumes, a loud sound. A total of 45 people died right then or over the next few months, and thousands would likely die from cancer from the released radiation.

Children in that area of the Ukraine have to look at painted pictures of trees on the walls in their schools because they are not allowed to walk in the woods. Too much radiation out there.

To this day.

Charge of the Light Brigade

Now we shift gears a little and look at errors in military history.

“Attack what? What guns, Sir?”

Half a league, half a league, half a league onwards,

All in the valley of death rode the six hundred.

…

Cannon to the right of them,

Cannon to the left of them,

Cannon to the front of them volley’d and thunder’d.

The Charge of the Light Brigade

—Alfred Lord Tennyson 1854

Industry gave us some errors to analyze. And there’s a certain thrill in turning a company around. Profits are nice.

The Chernobyl paradigm cranked the whole subject up a notch. Error analysis takes on genuine palpable significance as a 9 foot thick chunk of burning, radioactive concrete falls on your head.

But to really sink your teeth into the land of the mondo error, go military. From sticks and rocks, to arrows and javelins, through muskets and bayonets, and all the way up to our smart bombs and night-vision laser-guided missiles, man has always put some innovative thought into killing his fellow man. Whether you ride in the Pharaoh’s war chariot, the German Tiger tank, or the Stealth bomber, the military goal is always the same—kill the other guy, don’t get killed yourself.

Errors in the military world are easy to spot. Ask Custer’s troopers scattered around the hills and ravines of the Little Bighorn. Ask Pickett’s infantrymen carpeting the ground on Cemetery Ridge in Gettysburg.

Let’s do a “system” review on the charge that inspired Lord Tennyson’s most famous poem, The Charge of the Light Brigade.

How Did this Error “Evolve”?

October 25, 1854 found Britain and France at war with Russia. Troops faced each other on the Crimean Peninsula, a part of southern Russia jutting into the Black Sea. A British detachment of cavalry, the Light Brigade, about 600 mounted men, faced Russian lines near the Russian city of Balaclava.

FIGURE 4-4 The heroic yet ill-fated “Charge of the Light Brigade” has been caught in this previously unpublished and rare photograph. Studying historical disasters uncovers the same mistakes we make in the hospital today. Miscommunication, misunderstanding, and, oh, did I say miscommunication? Disastrous for the Light Brigade, disastrous for us.

The British officers in charge of the British cavalry, Lord Cardigan (yes, of cardigan sweater fame) and Captain Lewis Nolan were described as follows: “Two such fools could hardly be picked out of the British Army.” Oh, and if that weren’t bad enough, they hated each other. Another cavalry officer thrown into this stew was one named Lord Lucan, who also hated Nolan.

Above these three squabbling ninnies was another officer, Lord Raglan (no sweater named after him), who had earned the unofficial title “Lord Look-On” because he couldn’t figure out what was going on during battle and so would often just have his troops sit there and do nothing. Everyone hated him for this, and he hated them back.

So everybody hated everybody, and no one knew anything.

On the big day, the battle had begun, and all the involved officers were clueless. Other British troops had attacked one part of the Russian line, and the Russians were retreating. But a lot of the other Russian lines were intact. At this time, armies used black powder for their muskets and their cannons, so there was much smoke, noise, and confusion.

So Lord Raglan (Lord Look-On, who never knew when to do what) ordered an attack “to the front.” He gave the message to Captain Lewis Nolan (one of the “Two such fools could hardly be picked out of the British Army”), who gave the message to another guy, Lord Lucan, the guy Nolan hated. And then to Lord Cardigan (the other of the “Two such fools….”).

So, at this point, the entire “Command and Control” is in place for a complete fiasco.

Then, the following communications occurred.

• Lucan didn’t know where to go and asked, “Attack sir? Attack what? What guns, sir?”

• Raglan knew where he wanted the Light Brigade to go, but he didn’t clarify that to anyone, plus he stayed up on a hill, far away from the Light Brigade.

• Nolan didn’t know where they were supposed to go, so he just waved down a valley and said, “There, my Lord, is your enemy! There are your guns!” So with no knowledge of the ground or the situation, he ordered the Light Brigade down a valley that had guns at the end, plus guns on both sides of the valley.

BOX 4-8 Charge of The Light Brigade

• Goal? Unclear

• Leadership? Poor

• Visibility? Smoky

• Lord Cardigan, with the Light Brigade, did know the situation and said, “the Russians have a battery in the valley on our front and batteries and riflemen on each flank.” But he didn’t think to point this out to any officers above him. He didn’t think to question the judgment of those who ordered the slaughter of his men.

Their’s not to reason why,

Their’s but to do and die.

The Charge of the Light Brigade

—Alfred Lord Tennyson 1854

And die they did: 607 rode down into the valley, 346 rode out.

How Could such an Error Evolve in Medicine?

It was the blind leading the blind when the Light Brigade charged into the Valley of Death near Balaclava. Personal resentments, incompetence, lost communication, fear of questioning “superiors”—it all added up. And empty saddles turned into epic poetry.

We’ve emptied saddles in the hospital with the same petty squabbles, lost communications, and fear of questioning superiors. Try this out for a “Medical Balaclava.”

• A patient had a difficult intubation 3 days ago, was sent home, and came back to the ER with difficulty breathing.

• In the ER an esophageal tear is diagnosed, and the patient is admitted to the ICU.

• No one thinks to contact the anesthesiologist, who knew about the bad airway and the tough intubation but didn’t bother to follow up because it was a weekend.

• In the ICU, the nursing staff notes low saturation, applies oxygen, and notifies the surgeon who did the original case (but the anesthesiologist didn’t bother to tell him about the difficult intubation).

• Neither the surgeon nor the anesthesiologist talk to each other much, as they hate each other, but the HMO sort of “shoves” them together.

• The ICU nurses call the surgeon, who tells them he’s busy, this is his clinic day, quit bugging him and call “some intensivist. I don’t care who, call the HMO to see who will see him.”

• The HMO has changed its number, and no nurse is sure who should call.

• The patient continues to languish, with a steadily worsening airway and falling saturation.

• No intensivist is called because everyone thinks someone else has done it.

• That afternoon, the surgeon comes in and sees the patient is just about to code. He demands to know what the hell’s been going on all day, just as the patient has a respiratory arrest.

• No one can intubate the patient, a trach is attempted, but the trach kit did not have a blade in it, and the patient dies.

How Could a Simulator Help Here?

The Simulator can jump through only so many airway and hemodynamic hoops. With the right Simulato-people, the Simulator can jump through an entire Light Brigade of behavioral hoops.

Based on the above (I blush to say), real-life catastrophe, you can arrange the Simulato-people in any way. You bring to life real take-home lessons.

• Role clarity—make sure that the surgeon in charge does, indeed, take charge. Just because a complication occurs on a busy clinic day, you don’t just shuttle your patient off to “some intensivist” without looking at the patient yourself to see how bad he is.

• Clear communication—When a patient looks like death warmed over, you make sure everyone knows. Surgeon, anesthesiologist, respiratory, head nurse of the ICU.

• Resource management—Hey, get the big airway guns involved early, whether that means anesthesia with a fiberoptic or ENT with a knife—mobilize early to secure that all-important airway.

• No blind obedience—If a doc blows off a nurse but the nurse sees big trouble coming (a deteriorating patient), this is no time to play shrinking violet. This is no time to drag out the Nuremberg defense and say, “I was just following orders.” In the Simulator, the ICU nurse should go that extra mile, contact whoever it takes, rattle whatever cage needs rattling, to get the patient the help he needs.

All this you can act out, critique, and discuss in the Simulator. Use the Simulator to stay out of the Valley of Death.

Yapping

“You talk the talk. do you walk the walk?”

Full Metal Jacket

Well, in medical circles, sometimes talking the talk is walking the walk.

• A routine delivery goes sour. Shoulder dystocia, stuck kid, emergent C-section, lose mother and child to a lost airway. Now you have to go out in the lobby and explain to the husband what happened.

• A patient with sleep apnea gets too much narcotic and arrests. No one notices until brain damage occurs. The patient is a 45-year-old father of three, and you have to talk to his 25-year-old daughter.

• An extremely bright 6-year-old with spina bifida just got another ventriculoperitoneal shunt done and asks you, “Since they fixed that, will I be able to move my legs now like the other kids?”

You’re the doc, you have to now talk the talk.

Can a Simulator experience help you out here? Can anything help you navigate through such rough weather?

And it’s not just a question of breaking horrible news to patients. There are other tough clinical scenarios that require skill and tact.

A patient is clearly circling the drain—saturation dropping, respirations shallow, fizzling blood pressure. You know you have to intubate to save the patient, but the patient is saying, “I don’t want that.” His son is saying, “Do everything for Dad.”

A code is in full swing, then the floor charge nurse runs in and says, “This patient is a no code!” and you stop resuscitative efforts. Fifteen minutes later, you find out the patient in the next bed was a no code, and the nurse grabbed the wrong chart.

An anesthesia colleague just had quintuplets and keeps showing up to work exhausted. Time and again you come into the OR and his head is on the machine—he’s sound asleep. What do you tell him? Do you recommend he be fired?

Each of these situations requires talking skills, negotiating skills, thinking skills. At first blush, these “talking assignments” seem absolutely impossible. (How the hell do you explain a catastrophe, a real iatrogenic disaster?)

Well, like any other tough clinical task, you can learn to handle it. Truth to tell, you have to learn to handle it. And, yes, you can do it in a Simulator setting. Some would involve an actual Simulator mannequin (for example, the deteriorating patient who doesn’t want to be intubated), and others would involve actors in a conference room (for example, the daughter of the brain-damaged sleep apnea patient).

However it’s done, it’s worth learning to talk the talk.

The two-DVD set, How to Deal with Anger & Other Emotions, takes on the toughest talking assignments you could ever possibly handle. (AUTHOR’S NOTE: I highly recommend getting this DVD set. Learn its lessons. Use the set to teach your residents and medical students.)

This superb teaching vehicle has developed a mnemonic, CONES, for “have to tell” situations.

C: Context—Make sure the conversation is set in the proper context—a private room, everybody sitting down—look the people in the eyes and shake their hand. You want to make a connection, both physically with your demeanor and physically in the sense of making everyone comfortable.

O: Opening shot—You set the mood by saying, “I’d like some time to tell you about something that happened to your mother.” There’s no candy-coating bad news, and you must eventually spin out the details, but you have to start the big ball rolling somehow, and this seems to be the best way to do it.

N: Narrative—Do a “Just the facts, ma’am” chronologic description of what happened. At each stage of the event, you can detail what you were thinking. For example, in the shoulder dystocia case, you could say: “At this point, we thought the delivery was going well, but actually the shoulder was stuck.”

E: Emotions—Acknowledge the emotions of the listeners. “I know this comes as a terrible shock,” you can say. “This is terribly hard on you, and to tell you the truth it is terribly hard on the whole team in the intensive care unit.”

S: Strategy and summary—No matter what has happened, the goal is to keep in touch, keep the family members informed, and work toward solving the problem. Even if the only solution is discovering exactly what went wrong, that is at least a strategy.

This might look neat and tidy, but no rugged explanation fits into neat pigeonholes. Emotion pokes its head into every phase of the conversation. (Wouldn’t you get emotional if you were getting bad news?)

The How to Deal with Anger and other Emotions DVD set lays out eight scenarios. In each, the explaining doctor uses the CONES technique. (He is the most unflappable and professional speaker I’ve ever seen. This guy could probably talk his way past St. Peter at the Pearly Gates no matter how stained his soul!)

To respect their copyright, I’ll create my own scenarios and use of the CONES technique. And to throw the CONES technique in relief, I’ll show how to do it wrong first.

Caveat: Certain medical professionals do not need to learn this information. Scan the list below and see if you belong.

You never make a mistake.

You never have to deliver bad news.

Everyone you deal with loves, respects, and worships you; and they would never get angry with you.

If you don’t belong to that list, read on.

Any doctor in clinical practice has had a few train crashes, just as Thomas the Train jumps the tracks in Figure 4-5. Let’s read about a case where the Thomas the Train crash involved a finger.

FIGURE 4-5 What made Thomas jump the tracks and crash? Poor planning, not knowing what was ahead. One huge benefit of practicing “train crashes” in the simulator? Everyone walks away from these accidents. Bruised egos, yes; it’s true that you sometimes have to brush off your ego after you “crash the train.” But no patient ever gets hurt.

FIGURE 4-6 “Just how did I lose my finger, anyway?” the patient asks. No one tells him, no one explains. And guess what? The patient sues. Surprise, surprise. In the simulator, you can create these problems (pretending to cut off a finger, no need to do it for real, please) and then see how the residents handle this difficult task. Just how do you break bad news to a patient? How do you explain a complication or bad outcome? You might as well practice this in the simulator because one fine day you will have to do it for real.

First, How to Do It Wrong: A Lost Finger

Mr. O’Shaughnessy entered the hospital for a radical prostatectomy. His arms were tucked for the procedure. At the end of the operation, with his arms still tucked, the foot of the bed was brought up.

His right index finger got squished and amputated.

The patient woke up in the PACU in so much pain from his prostate operation that it took him a while to register his hand pain.

Back on the floor now, Mr. O’Shaughnessy noticed that his left hand had five digits, and his now-throbbing right hand had but four!

Something’s amiss!

“What happened?” Mr. O’Shaughnessy asked the floor nurse.

The floor nurse didn’t know, he had just come on shift. Maybe the nurse from the last shift knew.

No luck there.

Did the surgeon know? No, the surgeon was busy, hard to reach, and when finally contacted didn’t want to talk about it.

BOX 4-10 The Lost Finger

• No one talks

• No one explains

• Get my lawyer

The next morning on rounds, the surgeon looked at “Mr. O’S’s bandages” in the perineum and didn’t talk at all about the hand.

The anesthesiologist on the case was so freaked out by this thing that he stuck his head in the sand and refused to see the patient.

“What happened?” Mr. O’Shaughnessy kept asking. “What happened to my finger, will someone just tell me?”

Surgeon—nope.

Anesthesiologist—gone.

Nurse from OR—nope.

This one, that one, the other one, the administrator, the butcher, the baker, the candlestick maker, rich man, poor man, beggar man, thief—nobody knows nuthin’!

Mr. O’Shaughnessy sued.

At the trial, he said, “I know things can go wrong. And I was so thankful to get through that big operation alive, I wanted to hug everyone at that hospital.

“If someone had just sat down with me and told me what happened to my finger, then that would have been that. But no one talked to me.”

Let’s Take a Different Tack, the CONES Approach

C—Context

Anesthesiologist and surgeon enter the patient’s room after his amputated finger is cleaned and dressed. Mr. O’Shaughnessy has enough pain meds on board to be comfortable but not so much that he’s woozy and out of it.

The doctors turn off the TV, close the door, and pull up their chairs. Mr. O’Shaughnessy’s wife is present. The kids are out in the waiting room, so they can be informed soon after.

O—Opening shot

“We’re here to talk to you today about what happened to your hand.”

This is, after all, the issue that draws everyone together. No beating around the bush and inquiring after other things—the surgical drains, the sore throat from the endotracheal tube.

N—Narrative

The surgeon starts out, “We had finished the operation and were getting ready to wake you up. We were taking notes on how much fluid you’d gotten, how much blood you’d lost, making sure you were doing OK.”

Then the anesthesiologist takes up the thread, “Part of the operation is putting the foot of the bed down, then at the end we put the foot of the bed up. There’s an elbow there, and when that elbow folded up, your finger got pinched in there and cut off. At the time, I was watching your vital signs and breathing, and I didn’t check under the blankets, where your finger was getting hurt.”

“You were still asleep from the anesthetic, so you couldn’t let us know we were pinching your finger.”

“The circulating nurse saw the blood when she pulled off the blanket,” the surgeon says, “and that’s when we saw the damage. I asked the anesthesiologist to keep you asleep and let the hand doctor look over your finger and see if he could reattach it. But the hand doctor said the damage was too much, so he cleaned it up and closed it to keep out infection.”

That’s it. Just a chronology of the events, with some additions on what the doctors were thinking at the time. Not editorializing or excusing, just explaining.

E—Emotions

“I know this must be a terrible shock to you,” the anesthesiologist says. “You came in here for a prostate operation, and here you have lost a finger.”

Acknowledge the anger the patient must feel. (Think how you would feel if this had happened to you.)

“Here you have pain that you expected from your prostate operation,” the surgeon adds, “and now there’s this terrible pain in your hand too. That has to be so maddening.”

S—Strategy and summary

“So where do we go from here,” the anesthesiologist says. “We are certainly going to review our policy on making sure we are more careful when we lift the foot of the bed from now on.”

The surgeon takes it from there, “We’ll have the hand surgeon come by and make sure your injured hand is taken care of. We’re terribly sorry this occurred and want you to know that. If you need help with management of your pain, we’ll have a pain specialist see you. And if any questions come up or other problems, here’s my card, with my own cell phone on it. Call anytime.”

Both doctors stand and shake, well, O’Shaughnessy’s left hand. Making that physical connection is important. You are making a link with the patient. OK, a screw-up happened, but at least you’ve been up front and honest about it. You’ve told him what happened, how it happened, and what you intend to do about it.

This CONES episode went smooth as silk, but of course it assumed a completely silent and accepting patient, who never once spoke up, protested, or complained.

A cardboard cutout patient, not a real one.

Here goes the same episode with more realistic patient reactions.

C—Context

“God damn, it’s about time you got in here,” Mr. O’Shaughnessy says.

“What the hell did you do to my husband?” Mrs. O’Shaughnessy shouts, “You’re operating on his prostate and you cut off his finger. Who’s watching him, huh? Do I have to go in there and make sure you don’t cut him to pieces?”

The doctors turn off the TV, close the door, and pull up their chairs. The kids are out in the waiting room, so they can get informed soon after.

O—Opening shot.

“We’re here to talk to you today about what happened to your hand.”

“You sure as hell ARE here to talk about my hand,” Mr. O’Shaughnessy says, “or at least what’s left of it. You’ll excuse me if I don’t ‘give you five’ for a job well done!”

This is, after all, the issue that draws everyone together. No beating around the bush and inquiring after other things—the surgical drains, the sore throat from the endotracheal tube.

N—Narrative

“Did you count the blood he lost when you squashed his hand?” Mrs. O’Shaughnessy says, “God, never in a million years.”

Then the anesthesiologist takes up the thread: “Part of the operation is putting the foot of the bed down, then at the end we put the foot of the bed up. There’s an elbow there, and when that elbow folded up your finger got pinched in there and was cut off. At the time, I was watching your vital signs and breathing, and I didn’t check under the blankets, where your finger was getting hurt.”

“You were still asleep from the anesthetic, so you couldn’t let us know we were pinching your finger.”

That’s it. Just a chronology of the events, with some additions on what the doctors were thinking at the time. Not editorializing or excusing, just explaining.

E—Emotions

“I know this must be a terrible shock to you,” the anesthesiologist says. “You came in here for a prostate operation, and here you have lost a finger.”

“Easy for you to say it’s a shock, I’m the guy who looks like a freak now,” Mr. O’Shaughnessy says.

Acknowledge the anger the patient must feel. (Think how you would feel if this had happened to you.)

“Here you have pain that you expected from your prostate operation,” the surgeon adds, “and now there’s this terrible pain in your hand too. That has to be so maddening.”

“Well, it is maddening,” Mr. O’Shaughnessy says, “but hell, at least someone’s giving me some answers. Where do we go from here? Cut off one on the other side to make me look even?”

S—Strategy and summary

“So where do we go from here?” the anesthesiologist says. “We are certainly going to review our policy on making sure we are more careful when we lift the foot of the bed from now on.”

Then the surgeon takes it from there, “We’ll have the hand surgeon come by and make sure your injured hand is taken care of. We’re terribly sorry this occurred and want you to know it. If you need help with management of your pain, we’ll have a pain specialist see you.”

“Well, OK fellas, thanks for stopping by,” Mr. O’Shaughnessy says, “but be more careful next time, will ya? I’ve never played the piano before, but if I ever decide to learn,” he holds up his hands and wiggles his 9 fingers, “I’m already behind the 8 ball.”

Humor’s good! Not that explaining a medical error should turn into a Comedy Central routine, but humor shows you’ve kept a relationship with a patient.

That’s what CONES is all about, keeping a relationship with a patient. It’s not a trick for bamboozling a patient. It’s not smoke and mirrors to hide a mistake. It’s not a miracle to “make it all better.” No matter what happens, no matter the news, you want to keep that door open to the patient or that family.

CONES holds that door open.

Negotiating

“Your money or your life!”

“Is there a third option?”

—The last words of a poor negotiator

Chernobyl was a samovar with attitude.

Negotiating is yapping with attitude.

Medical folk negotiate and need to know the craft. A detour into the business world can help. The Douglas Stone, Bruce Patton, and Sheila Heen book Difficult Conversations: How to Discuss What Matters Most does us a world of good. These clever cusses hail from Harvard, and their book ended up on the New York Times business bestseller list, so they must have something going on. Let’s fast rope right into the heart of this puppy, lift their best ideas, give them a medical twist, then get out quick before they notice we’re peeking.

(While they’re siccing their lawyers on me, some of you go out and buy their book, so they won’t be able to accuse me of hurting their sales.)

To bite the head off this book and suck its guts out, let’s look at a typical medical negotiation. Then let’s rip-off, er, borrow, the lessons learned from our Harvard brethren.

FIGURE 4-7 Pointing fingers, the favorite pastime of all doctors in all specialties in all hospitals. because the simulator is a place to practice everything, you should find time to practice that core clinical competence of interpersonal and communication skills. Get residents out of this finger-pointing habit. Teach them to communicate with their colleagues in a professional manner, keeping the discussion above-board and free of emotion. Then later they can go out and slash the bastard’s tires in the parking lot.

An Intensive Care Unit Anywhere in the US of A

Surgeon: “Go to hell!”

Anesthesiologist: “No, YOU go to hell!”

OK, let’s tap the vast fields of Harvardian knowledge to analyze this negotiation. What can we, as medical professionals, draw from this discourse?

First, using the techniques included in Difficult Conversations, we’ll look at the short version of this ICU conversation.

Sort out what happened.

Look at the emotions involved.

Stake out your identity.

Look at the purpose of this conversation.

Look at the issue as a disinterested third party.

Explore both sides of the story, staying away from blame and finger pointing.

Come up with an option that helps both sides.

Draw on standards that can help out.

Keep communicating as the solution appears.

Applied to this mini-conversation, then, the Difficult Conversations approach might look like this.

Sort out what happened.

The surgeon yelled, the anesthesiologist yelled back.

Look at the emotions involved.

Ticked off and ditto on the ticked off.

Stake out your identity.

BOX 4-11 Difficult Conversations

Each thinks he has cornered the market on truth.

Look at the purpose of this conversation.

To prove who’s tougher.

Look at the issue as a disinterested third party.

Hopeless.

Explore both sides of the story, staying away from blame and finger pointing.

Well, according to the surgeon, the anesthesiologist’s a moron. And according to you, the surgeon is a moron. To me, looking from the outside, I see a pair of morons.

Come up with an option that helps both sides.

Pistols at 20 paces. See you at dawn.

Draw on standards that will help out.

I’ll draw a target on both your chests.

Keep communicating as the solution appears.

Where’s your life insurance stuff?

Hard to draw much from that. We’ll need to flesh out circumstances a little to make sense of this ICU mini-drama.

The Case in Point

Hiram McGillicutty is a 59-year-old man who’s led a life ill-advised and poorly executed. Demon liquor is no stranger to Hiram, nor is the nefarious tobacco plant. As if that weren’t enough, Hiram has been looking for love in all the wrong places and has become a frequent flyer at the sexually transmitted disease clinic.

And now Mr. McGillicutty, after many errors in judgment and yet more forays into the sins of the flesh, has come to this. He resides on a ventilator. Two weeks ago, he entered the hospital with hemoptysis, was found to have a lung tumor, and had a lobectomy. His health, frail in the best of times and little helped by his largely liquid diet in the outside world, is now so bad that he can’t wean from the ventilator.

Caring for Mr. McGillicutty are an anesthesiologist and a surgeon, now at loggerheads about a clinical decision.

From day 1, these two specialists have gone at it hammer and tongs. The surgeon wanted a thoracic epidural to help with pain control, but the anesthesiologist didn’t want to place one for fear of some bleeding into the epidural space. “Humph,” the surgeon says, “if the anesthesiologist had a little guts, that epidural would have helped with pain control, McGillicutty would be able to take bigger breaths, and we wouldn’t be in this fix now!”

Blood loss was high during the operation, and the anesthesiologist is still steaming about that. “Humph, a better surgeon would have kept that bleeding down, and McGillicutty wouldn’t be in this fix now!”

Clashes continued over nutrition, sedation meds, talking with the family, and discharge plans. Even the written chart, the Holy of Holies, is getting sprinkled with barbed comments.

“Will defer to anesthesia regarding patient’s ongoing delirium, probably secondary to anesthetic medications.”

“Will request dietary help, as surgery department seems to think low lipids will help this cachectic man who clearly needs lipids.”

And now things have come to a head in, of all places, the tippy toes.

On rounds that morning, the anesthesiologist noted that McGillicutty’s toenails are tremendously long, curling all the way around and digging into the meat of his toes.

“Well, this man may live rough on the outside, but now he’s under our care, and we have to take care of him,” the anesthesiologist says, “let’s get Podiatry in here to clip those toenails.”

When the surgeon hears this, he blows a gasket, “A Podiatry consult, on a guy ventilator-bound forever more! What a waste. Just soak his feet a little and forget about it. God Almighty, what next, a Plastic Surgery consult for a nose job on this guy?”

They meet in the hallway and exchange views, leading to the (now famous) discussion.

“Go to hell.”

“No, you go to hell.”

Let’s go back and use the Difficult Conversations approach, now that we know a little more. [AUTHOR’S NOTE: my listing of the nine steps is a gross oversimplification of their best-selling book. I’m just trying to demonstrate their main ideas in a clinical venue.]

For argument’s sake, my negotiating angle is from the point of the view of the anesthesiologist.

1. Sort out what happened.

In a tough conversation, your first inclination is to get on your high horse and say, “Damn it, I’m right and that other bastard is dead wrong!” As the anesthesiologist who noted the toenails, I know that we should fix the toenails and I know that the surgeon is an obstreperous bastard who would say anything to get my goat, even if I’m right. Hell, especially if I’m right.

Difficult Conversations maintains that most arguments are not about getting the facts right. Rather, most arguments are “not about what is true, they are about what is important” (p. 10).

So, as Mr. McGillicutty languishes on that ventilator, and I’m slugging it out with the surgeon, I have to change gears. It does no good to jump up and down and say, “Those toes are too infected.” Rather, I have to steer the discussion to what’s important here. What would do Mr. McGillicutty the most good, and how can we work together to make it happen.

2. Look at the emotions involved.

Nothing puts on the blinders like emotion. I, as clinician, as doctor helping take care of Mr. McGillicutty, have an emotional stake in this patient. And if I see things one way, and that damned SOB of a surgeon sees it another way; well, then, to hell with the surgeon!

Take a minute to recognize this emotion, let it wash over and past you, then move on. I recognize I’m wound up about this, but I should be big enough to rise above these emotions and, gulp, stop arguing for a minute and look at things from the surgeon’s point of view.

That surgeon, too, has been working on Mr. McGillicutty for a while. He first saw Hiram when he initially came in, so he’s actually known the patient longer than I have. The surgeon has had to deal with a lot of frustration with this case and is wound up too.

The devil’s not as black as he’s painted when you sit down and talk with him.

All that blood loss I was complaining about? Well, the tumor was more stuck down than you could tell from the CT scan. McGillicutty is bad protoplasm, and nothing works with him, nothing gets better, nothing is easy. No free lunch ever, and the complications just keep on coming.

So this request for a Podiatry consult comes across as a flippant thing, in the light of all of Hiram’s “real” problems.

OK, we’re talking now, not just yelling at each other. And now I know a little about what the surgeon’s thinking and he might be just that much more receptive to me since I’ve taken time to listen to him.

The ice is breaking.

3. Stake out your identity.

OK, who’s in charge here? Who’s the consultant, and who’s the “real” doctor? No one comes into the hospital to have an anesthetic, after all, they come into the hospital to get an operation, and the anesthetic is incidental, truth be told.

But this is the ICU, and anesthesiologists often serve as intensivists, so Mr. McGillicutty starts to slip under “my” (the anesthesiologist/intensivist) wing.

My identity, then, is a kind of adopted “primary care giver.” I have a stake in McGillicutty getting better, not just surviving the anesthetic. Once I make that clear to the surgeon, he may see me less as a meddler and more as a genuine player in this drama.

4. Look at the purpose of this conversation.

Why are we here? Is this some head-butting turf battle between two Alpine billygoats, or is it a cooperative effort between two specialists.

If the conversation spins out of control or emotions yank us back to a battle-stance, we should both pause and remember one thing: Hiram McGillicutty is the purpose of our job. We’re not here to prove anesthesia is “better” than surgery or that you are “smarter” than I am. We are here, in the hospital, for one reason and one reason only—to serve the patient.

5. Look at the issue as a disinterested third party.

Forget the operation, forget the blood, forget the epidural. Just waltz in now and give McGillicutty the once-over right now, like a medical student coming on the service the first day.

No allegiance to surgery. No allegiance to anesthesia.

Just—what’s wrong with Hiram, what can we fix, what can’t we fix?

Look over the chart, do a physical exam, start from ground zero.

Would such a “start from the very beginning” approach argue for the Podiatry consult, yes or no?

6. Explore both sides of the story, staying away from blame and finger pointing.

Podiatry consult—what will it cost? Will it really help anything?

Soaking the feet and addressing more important issues—will that work? Just add up the pros and cons and go from there.

7. Come up with an option that helps both sides.

How about soaks for 2 days; then, if that doesn’t help, go with the podiatrists? That way each side gets to see how it unfolds.

8. Draw on standards that can help out.

Fever, inability to wean from the ventilator, and worsening redness in the toes would be objective signs that the foot situation is worsening. No need for a value judgment or the wisdom of Solomon—just use these standard medical measures to keep tabs on McGillicutty’s progress.

9. Keep communicating as the solution appears.

The discussion then goes from a finger-pointing shouting match to a collegial discussion, using the main points of Difficult Conversations. After a time, Podiatry comes, clips the nails, and the feet improve. Later, Hiram improves enough to work his way off the ventilator, to live to fight another day!

Hooray for Mr. McGillicutty!

Now, does the anesthesiologist gloat, do the post-touchdown victory dance, and stick his tongue out at the surgeon?

No! This is the time to capitalize on the success of good communication! Rather than lording my “success” at “showing the surgeon up,” I enjoy McGillicutty’s success as a co-victory for both of us doctors!

We helped get Hiram better. And in the future, we’ll work even better together!

[To repeat, here. The above scenario is not a replacement for the many lessons from Difficult Conversations, and I take this time to encourage you to buy this book or borrow it from the library.]

Wait a minute! What the heck does this have to do with a book on Simulators? How can you “do” this scenario with a Simulator?

Substitute the mannequin for “Hiram” and have the discussion at his bedside or out in the hallway with an actor playing the surgeon.

And now to let you in on a little secret.

The above scenario played out exactly as described when I was working in an intensive care unit shortly after I finished my training at Emory. A homeless person with terrible hygiene was stuck on a ventilator. I insisted we clean him from head to toe.

“He may be dirty out there, but now he’s our responsibility. Make him neat as a pin.”

During the cleaning we discovered the toenail problem.

A kind Podiatrist fixed the patient’s feet; and, I’ll be damned, right after that the patient got off the ventilator! The low level infection must have been just enough of a “septic burden” to keep the patient stuck on the ventilator. Fix the infection, fix the septic burden. voila! A cure.

Living

This is the last of the “Behavioral Stuff Writ Gritty for Medical Folk.”

True confession time—this is not exactly Simulator material. It is, rather, just a damned good behavioral lesson for anyone anywhere, medical or otherwise. Just as we rappelled into Difficult Conversations to extract some useful ideas, now we’re going to grab the rope again and jump into The 7 Habits of Highly Effective People.

Stephen R. Covey touches a real nerve with his discussion of how to lead a more effective life. (I got the book on tape, and Covey himself does the reading. Damned great it is, too, and worth listening to more than once!) Because the Simulator teaches medical professionals, and because medical professionals lead such hectic and stressful lives, it’s worth looking at Covey’s insights. I’ll try to weave his ideas into a medical setting.

His seven habits are:

Be proactive.

Begin with the end in mind.

Put first things first.

Think win–win.

Seek first to understand, then to be understood.

Synergize.

Sharpen the saw.

Put into a medical professional’s life, Covey’s seven habits could look like this:

1. Be proactive.

Rather than just react to things as they arise, make an effort to “take the bull by the horns” and make stuff happen yourself. For example, rather than just getting ticked off that rounds are so dull in your ICU, go ahead and make them more exciting! Bring in a laptop and show some educational imaging from a DVD. Become a teacher and put some zing in those rounds. Rather than sitting around and complaining about slow turnover in the ORs (a reactive stance), call an OR committee and find out how you can better the system (a proactive stance).

Keep in mind the words of the poem:

“I am the master of my fate:

I am the captain of my soul.”

—William Ernest Henley

Believe it and make it happen in your hospital.

2. Begin with the end in mind.

Don’t just drift through your days rudderless. Get up in the morning with a plan for the day. Then go out and make it happen. This can be as simple as writing yourself a note the day before. As you leave your desk on Monday, leave yourself a note: “Tuesday: finish the monthly Q/A report before you go home.”

There. Now stick to it.

That way, that damned Q/A report won’t be hanging over your head and gnawing an ulcer through your stomach for the next few weeks.

You identified it, you’ll do it, boom, done.

3. Put first things first.

Most of us run around like chickens with our heads cut off, doing millions of little things and forgetting the important ones. When all is said and done, and they’re about to put the lid on us, we’ll little regret the e-mails we responded to, but we’ll much regret the times we didn’t hug our kids. So put those first things first, and in our madcap days take the time to be with the people who matter.

Practical suggestion: Skip one TV show and write a letter to a friend. A real, paper and pen letter they can hold in their hand.

Another practical suggestion: by all means be efficient and time-conscious when doing things; but when being with loved ones, turn off the efficiency meter. That time is well spent. That time is golden. Treasure it like a fine wine you sip. Don’t gulp that time down.

Don’t do that extra call for the big bucks next weekend. Go to the zoo with the kids instead. Stay home and whip up pancakes and laugh about the mess you make. That is a treasure beyond counting.

4. Think win–win.

Don’t bring people down so you can look like the lone champion. Rather, bring everyone up, then everyone wins.

A concrete example from the hospital: You learn transesophageal echocardiography. Should you remain the lone guru, the sole “high priest” of transesophageal echocardiography, so all must bow before you and worship your expertise?

No!

Teach anyone who’s interested. First of all, by teaching, you yourself will review and learn it better. Second, by having more people around who know the technology, more patients get good care. Hey, they’ll be less likely to call you in if someone else knows how to do it, so you’ll be able to spend more time with the kids.

FIGURE 4-8 Sharpen the saw, one of the seven habits of highly effective (if careless in this case) people. Although the book may sound a little corny and come across as a little “touchy-feely,” it teaches some great lessons. Transfer those seven habits into the hospital setting and you’ve got yourself a much more effective doctor.

You win, the kids win, your colleagues win, the patients win.

Win–win.

5. Seek first to understand, then to be understood.

So you’re in the position of teacher, and you want to get some point across. And you’re dying to break out in a lecture and tell your students flat out what they need to do.

Rein it in! Debrief time is not lecture time!

Listen to the students, understand what they were thinking. Find out what they were thinking, for example, when they gave epinephrine.

To make a true “Aha” moment, you need to dig into what they understand, what their point of view is, before you “solve it for them.”

By first understanding, you lay the groundwork to be understood.

This may sound like some semantic trickery, but it’s actually the way to go.

6. Synergize.

This emphasizes the importance of teamwork, of adding 1 and 1 and getting 3 from the magic of the combined effort.

Whoa, enter the Simulator!

Instead of making the Simulator an “anesthesia only” domain, bring in other specialties, other professions. ICU nurses can learn from you and you from them. Medical intensivists may have a few tricks up their sleeves that we don’t. No better place to learn it than the Simulator.

7. Sharpen the saw.

This final habit emphasizes the idea of self-renewal. Keep learning more. (In a sense, that’s the idea behind getting CME credits each year.) Periodically step back a little, look your life over, and ask yourself, “What kind of footprint am I leaving on the world? Is that a worthy footprint? How can I make a better footprint?” Then work toward that.

BOX 4-12 Seven Habits, Shortened a Little

As a medical professional, what are you doing with your life? Is this the kind of life you’d be proud to say, at the end of days, that you lived? Maybe you can connect better with your patients? Connect better with the staff? Maybe you need to learn a new skill to be more valuable, to be sharper?

A little behind on one facet of your profession? Go to a conference and brush up.

Don’t rest on your oars! Keep paddling!

That’s it for “Behavioral Stuff Writ Large for Medical Folk.” Although some of this stuff flew off at a tangent to Simulators, I think it all has merit.

You should be able to use these lessons in your Simulator for teaching and learning.

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Working on Communication Skills in the Simulator

CRISIS RESOURCE MANAGEMENT

Conceptualizing

COMMUNICATION AND BEHAVIORAL STUFF WRIT GRITTY FOR MEDICAL FOLK

Learning

How About Medical Education?

Enter the Simulator

Errors

Show Me the Money

A Samovar with Attitude

How Did this Error “Evolve”?

How Could Such an Error Evolve in Medicine?

How Could a Simulator Help?

Charge of the Light Brigade

How Did this Error “Evolve”?

How Could such an Error Evolve in Medicine?

How Could a Simulator Help Here?

Yapping

First, How to Do It Wrong: A Lost Finger

Let’s Take a Different Tack, the CONES Approach

Negotiating

An Intensive Care Unit Anywhere in the US of A

The Case in Point

Living

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