E121 Peter Brennan on Human Factors, Hierarchy in the OR, and Gray's Surgical Anatomy
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Chad Ball 00:12
Welcome to the Cold Steel podcast, hosted by Ameer Farooq and myself, Chad Ball, we consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only masterclasses on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as both a surgeon and perhaps more importantly, as a human.
Ameer Farooq 00:42
This week, we had the pleasure of interviewing Dr. Peter Brennan. Dr. Brennan is an oral maxillofacial surgeon in Portsmouth, England. A tremendously accomplished academic, Dr. Brennan has a keen interest in human factors in surgery. In addition, he's the coeditor of the Gray's Surgical Anatomy textbook. We highly recommend checking out the textbook, as well as the links to Dr. Brennan's prolific work on human factors in surgery. And as always, those links are in the show notes.
Chad Ball 01:10
Can you tell us where you grew up and what your training pathway looked like?
Peter Brennan 01:14
Yeah, well thanks very much, Chad. And please, call me Peter. You know, we talk about lowering gradients, we might talk about that a bit later. So it's Peter, please. Yeah, I was born in the southeast of England and spent 18 years there. And then I went to dental school first and then to medical school in London. And subsequently did my surgical rotation up in Cambridge, which was a lovely, lovely city. And then came down to the south coast and did my specialty training for five or six years. And stayed here ever since, really. So it's a lovely part of the UK. It's lots of sun, we see lots of skin cancer down here. Yeah, lovely part of the world.
Ameer Farooq 02:03
So the real question is, what football team do you support?
Peter Brennan 02:06
Oh, I'm not going to answer that. Because whatever I say is going to be wrong to some of your listeners. So I'm going to keep silent on that one.
Ameer Farooq 02:16
That's fair.
Peter Brennan 02:19
Yeah, there's several. There's some fantastic teams, isn't it, really? You know. They kind of do the rounds, don't they? So, you know, go in and out of favour and things, but I'm gonna keep quiet on it.
Ameer Farooq 02:31
Smart, wise decision. Well, we really wanted to talk to you about a lot of the work that you've done around human factors. I mean, you've done so much work in a variety of different things. But, it seems like human factors in these surgical environments have really become a passion of yours. And you recently did a PhD, which is kind of amazing to think about, as someone who's well into their career, to go back and do that. So clearly, this is a passion of yours. So, can you talk to us about what are human factors, exactly?
Peter Brennan 03:05
I guess the clue's probably in the name, isn't it really? Human. So, as humans, we make lots of errors on a, kind of, daily basis. So I think for me, human factors is, yes, it's a science, but it's also applying common sense when we come to work. And it's looking at the factors that affect our individual performance. It's looking at the factors that affect our relationship and the way we work within teams. Because of course, in surgery, we all work as part of a team. So it's effective communication. It's learning hierarchy. It's situational awareness. It's, it's all of those factors really coming into play. And I suppose, finally, the ergonomics side of things. So how we interact with equipment and things that we use in medical technology.
Ameer Farooq 04:01
It's funny, it's almost like you're describing everything that really matters, that's generally not found in a textbook.
Peter Brennan 04:09
Yeah, yeah. So, a lot of what I've said, you mentioned about my PhD, and thanks for that. It's 270, 275 pages long. And actually, the theme flowing through most of it is common sense application. You know, the number of times when we come to work or we're in the operating room and we work for seven or eight hours, non-stop. And we don't stop to take a break. Now we wouldn't do that in normal day life. I mean, you wouldn't drive from Vancouver to Calgary non-stop, would you? You would stop at a number of points, have a comfort break, have something to eat and drink. But historically, surgeons have worked for 7, 8, 9, 10 hours non-stop. And that's not physiologically correct. Plus the effect it has on the morale of the team, tiredness, fatigue, all those things come into play. So really important.
Ameer Farooq 05:06
Yeah, I couldn't agree more. We're obsessed on the podcast about thinking about all the, sort of, non-technical side of surgery and how to optimize that and become better surgeons. In your PhD, which I definitely had the pleasure of reading, you talk initially about the four domains of Human Factors Analysis, and you go back to these human factors, these four domains, again and again, in a number of your work and a number of your papers. What are those four domains? And how do they pertain to the operating room?
Peter Brennan 05:39
That's an interesting question. So, I'm sure most of you have heard about the Swiss cheese model of error. So that's, I think it's one of the Swiss cheeses, it's called Emmental, that's got holes in the cheese. And if you imagine slices of those cheese cut, and put on a skewer, and they're slowly rotating round, and every now and again, all those holes are gonna line up. And that's when you get an error. And I mean, for me, most error actually doesn't, it's not the fault of one particular person, it's a whole string of things that align together like those holes in the cheese to cause the error. So those four factors you mentioned, the first one is organizational influences. So when we go to work, pressures put upon us by our hospital. Putting an extra patient onto the operating list, by the management, for example. Putting a bit of pressure or stress on us, that's the first layer. You've then got so-called unsafe supervision. And that is a whole host of things, including not supervising the rest of the team. And that's not just your trainees, or your more junior doctors, that's other members of the team. That's the nursing staff, the anesthesiologist, how you work together. Not engaging with checklists, for example, that's another example of unsafe supervision. And then you've got the area, so-called preconditions to unsafe act. And that's the area where I've spent the last seven or eight years focusing on. And they're the human factors that you can actually actively address and actually block that hole in the Swiss cheese. So they're sort of individual factors, looking after ourselves, optimizing our performance, hydration, eating, tiredness, and fatigue, those type of things. And then the team factors that we started talking about, situational awareness, effective communication, better briefing. And then finally, the fourth layer is, of course, the error itself. So you operate on the wrong side or you cut a bile duct, or whatever it is. That's the final line in the cheese. But so many of these errors are actually preventable.
Chad Ball 08:05
A lot of people have talked about the airline industry and some of the disasters in the cockpit culture and hierarchy, that trend still exists. Probably in North America, Malcolm Gladwell really brought that to the most folks initially. You've also talked a lot about comparisons, both positive and negative, granular and not, between the airline industry and the surgical industry, so to speak. I was wondering if you could frame that for our audience and give us some of your thoughts about those topics.
Peter Brennan 08:34
Yeah, of course, of course. I think it's one simple sentence: you cannot compare aviation and medicine or surgery. Period, full stop. What you can do is you can take lessons and human factors that are used and practiced by aviation, by the nuclear industry, by [inaudible], by Air Traffic Services, and you can apply those into the operating room. And that's what I do. So I never compare aviation to surgery at all. But actually, you know, think things like effective communication, and the way the pilots actually communicate with air traffic in a very clear way, it's unambiguous, there's no margin of error in terms of hierarchy, in terms of taking those breaks, all the things I talk about. But I'm never comparing directly aviation with healthcare.
Ameer Farooq 08:36
I think that's a very fair way of framing it. In that, you're not trying to say that they're the same but that we definitely can learn things. Just like we can learn things from athletes or the military, or any number of different organizations. I do want to zero in on something that you've talked about in your PhD, as well as in other things that you've written about flattening the hierarchy. And, you know, Dr. Ball mentioned Malcolm Gladwell and Malcolm Gladwell has this amazing description in one of his books, where he talks about how the Korean airlines improved their safety outcomes when they actually asked their airline pilots to speak to each other in English in the cockpit. And that effectively, kind of, reset some of the cultural norms around hierarchy and who could speak to whom and who could challenge whom. And so, it certainly lends credence to this idea that it's really a powerful thing to try and flatten the hierarchy in terms of safety. But is that really possible in an operating room? Like, what does that even look like? You know, I can see this scenario where a medical student comes in, fresh on their clerkship rotation, they're fresh on their ward, they come into Dr. Ball's OR, he's doing a Whipple. And they say, "Well, should you really be doing that?" You know? So is it really realistic to even think about having a flat hierarchy in the operating room?
Peter Brennan 11:02
Yeah, good question. Good question. So first and foremost, there has to be a hierarchy. Full stop. There has to be an overall attending, a consultant, as they're called in the UK, who is ultimately responsible for that patient. But the difficulty is actually setting it, so the hierarchy is sufficiently shallow, so you're not then on a pedestal that no one feels that they're able to actively challenge it. So we would advocate, and we've published on this, and there's a nice, easy to read, short article in the British Medical Journal published a couple of years ago, about empowering junior doctors to speak up. So I think, first and foremost, what you, as the team leader, need to do is, when you have your briefing, introduce everyone. You can call yourself by your first name, by Dr. Ball, it doesn't matter. As long as you say to the team, "look, if there's anything you're not happy about, if you want me to clarify, if there's anything you're not sure, please just speak up." And you do that in a nice, warm, open way, rather than with your arms folded. 90% of communication is nonverbal. And the key is actually to do this without fear of retribution. So if that medical student has a point, or they want to say something, "actually, I thought it wasn't a Whipple today, it was something else." Then if, of course, it was a Whipple, you can say, "well, yes, actually the next patient's this or that." But you're then not shouting at that trainee or medical student. You're not angry with them, you're giving them a nice calm response. So they walk away not feeling anxious that they've said something silly. And of course, they may have said something that isn't particularly relevant. But you know, you've actually gone away and given them that experience that they can speak up. And to be perfectly honest with you, most people don't need to speak up because you're flying the airplane, you're the attending, you're in charge, you know what you're doing. It's just that rare situation where something just doesn't seem quite right for the rest of the team. And if the team can speak up, without fear, they will then do so. They're your eyes and ears, as far as I'm concerned.
Chad Ball 13:29
You know, I love the way that you frame that environment. I think we can all see it, listening to you, we can visualize it. Would you agree that a lot of that really is creating that environment. I mean, it's incumbent upon whoever the quote-unquote leader is in that room or in that environment. Knowing the first names of everybody, having them maybe call you by the first name in a culture like Canada, interacting with the medical student, talking about their weekend. Just sort of creating those relationships and that environment that welcomes commentary, or questions, or concerns, as the day goes on, is an art in itself, probably.
Peter Brennan 14:11
Absolutely correct. And some people will feel uncomfortable, either calling a senior colleague by their first name, or the colleague doesn't want to be called by the first time, and that's absolutely fine. But what's important is that you've lowered that gradient to a point where someone can feel able to speak up if they need to. And of course, bear in mind that in aviation, there were a number of fatal air crashes going back to the 60s and 70s, and even the 80s, where there was a steep hierarchy, and the first officer felt unable to challenge. So this isn't going to happen overnight. You know, it's an evolving thing that's going to take many years to filter, right through health care around the world. It's not an instant fix, but all of us need to be doing our part. And as it is in the UK, it's spreading exponentially. I mean, people are coming back and saying, "You know what, you know, we did the briefing, we've empowered the team, the team feel so much happier now. You know, I'm getting staff wanting to come and work in my theater rather than wanting to go and work in Dr. Jones's theater, for example." So it's all about empowerment, it's about happy teams, morale, and all the other things we talk about as well, Chad.
Ameer Farooq 15:30
You mentioned right at the top that a lot of the things that talk about in human factors is, almost common sense, right? Like, if you're doing something for a long period of time, it's nice to have sleep, and it's nice to have adequate nutrition and all these kinds of things. But, I wonder, again, if that is actually achievable for most people in most settings. I think about the days when I was a junior resident responsible for 80+ patients in the hospital overnight, running around, trying to get to the OR, trying to see patients in the emergency department, trying to stop doctor... you know, oh, sorry, that never happens... But you know, Whipple patients from getting sick. And then, for someone to suggest that I should get more sleep, or I should be able to get more nutrition, it almost would feel defeating to me. Yeah. So, I'm wondering, practically, what does that look like? And I know from following you on Twitter that you actually will take breaks during a long OR. So, can you talk about what does it practically look like to get better nutrition, better sleep, pay attention to those types of human factors?
Peter Brennan 16:43
Okay, okay. Let me just give you a couple of things to think about then. So if you're awake for more than 18 hours, your cognitive function is the same as being about two to three times over the UK alcohol limit. And I guess that's a similar limit in Canada. And of course, this creeps up on you slowly, so you don't even realize it's happening. And people then say, "well, yes, I can perform at the same standard." And of course, it's happening really slowly. So you don't even know it's happening. I mean, if you take hydration, for example. So if you lose one to three kilograms in body weight through perspiration, because you're operating for seven or eight hours, your cognitive function falls by 20%. Again, this happens really slowly, you're not even aware it's happening, but your cognitive function falls by 20%. There's lots of published papers around that, both from the military and from others. So we've actually looked at taking breaks, maybe every three to four hours. It doesn't need to be a long break, maybe 15, 20 minutes. If it's safe to do so. If you're at a point in the surgery where you can stop, walk away, go and have a comfort break, have a drink, something to eat, little chat, take your mind off things. And then when you go back in there, you've optimized your performance and you'll actually speed up, and you'll actually catch that time up in the majority of cases. So, lots of colleagues have now been trying this. And they come back and say, "Well, you know what? That as a seven, eight hour procedure, and I took a 15 minute break, and I've done it in six and a half hours." And it's like, well, yes, because it's basic, common sense. You wouldn't drive for seven or eight hours non-stop, you would stop and take a break. So we leave common sense at the front door of the hospital, on many occasions when we go to work. And I was exactly the same. I used to operate for eight, nine hours non-stop, until my eyes were opened to human factor some years ago. And having made the switch, I'd never go back. And all of the team that we work with, they all now look forward to working with us because they know that if it's a nine hour operation, we might take one or even two rest breaks. And catch up, hydrate, have something to eat, and go back and carry on. It makes a massive difference.
Chad Ball 19:16
You're giving us such great concepts to really contemplate and hopefully engage in our surgical practices. I'm curious, though, with these concepts, in particular sleep deprivation or sleep hygiene, and we've talked about that on the podcast with a couple of different wellness-type folks as well. How do you account for or frame, just genetic variability. Sleep gene, no sleep gene. And just the ability of some hyper-performers to work incredibly long hours. I don't necessarily mean, you know, a two hour case compared to an eight hour case, but just maybe even a day and a half of call here. Just in the sort of older school structures. Because we all clearly see that in our colleagues. Folks that really seem to do it with elegance and grace, and other folks that really struggle.
Peter Brennan 20:10
Yeah. And I'm very much in that latter camp. If I don't get adequate sleep, I'm irritable the following day, I'm tired. And I look at those people with some envy, if I'm honest with you. But there is a genetic variability, but I think the same principles will still apply. That their performance will slowly be sliding. You cannot maintain that 100% performance for 24, 36 hours. It is impossible. Despite what they might say, or what you might seemingly think, they are slowly deteriorating. And we would even say, if you're doing a long shift, for example, and yes it is, or it can be, very, very difficult to actually take a little bit of a break. You need to put that oxygen mask on and look after yourself, as they say on the flights. Put your own mask on before helping others. You need to look after yourself. So, we often say well, give the [inaudible] maybe to the sister on the ward, if that's possible. Go off and just take a 20 minute catnap. 15, 20 minutes, that can make a massive, massive difference. And I guess there's a difference as well between tiredness and fatigue. So tiredness is an acute phase really. So you haven't had a night's sleep. That's tired. Fatigue is cumulative. And I guess that's something we're all beginning to feel now with, with a pandemic, it just creeps up on us. That's a much longer-term effect, of course.
Chad Ball 21:58
I was hoping we could switch gears for the last part of it here, we're respectful of your time, and talk about the editorship of Gray's Surgical Anatomy. I'm curious how you got involved with that textbook and if you could give us some of the historical context of the text, because it is so important.
Peter Brennan 22:16
Oh, thank you. Yeah, thanks so much. This, for me, whenever I think about this book, it puts a shiver down my spine. It's actually doing that, even as I'm speaking now. And I can put hand on heart, that's really honest. I mean, basically, I've done some work with the editor of Gray's Anatomy itself, Professor Susan Standring. And we've actually published various anatomical variants that we found during surgery and what have you. And I think about 2016, I think it was, I met her at the Royal College of Surgeons. And we were just talking about it. Gray's Anatomy itself is the most amazing reference book, it's an enormous textbook, as you know. But it's not really a surgical book. You can pick up Gray's, the whole of Gray's, and you go into the operating room, and you wouldn't know how to do an anterior resection, for example. So we had this concept of actually bringing it back to Henry Gray's original book, which was 1858. And, in fact, the book's called Anatomy, Descriptive and Surgical. It's very much a surgical anatomy text. And as I've said, over the years, Gray's itself has moved away from that and become a reference text of anatomy. So we contacted the publishers, they were really, really keen to get involved. We had to write a detailed proposal. And so we did all that, then got approved. And then, we invited a Canadian surgeon, who actually works in Vancouver, called Sam Wiseman, who I think had contacted the publishers independently and said, "Oh, there's a need for this book." So the book had been approved, and we brought him in. And then, just a question of, of course, having a name like Gray's Surgical Anatomy. You know, we invited world-class surgeons, all over. And of course, as soon as you send them an email, and you say about the history, and it will bring Henry Gray's book to the 21st century, people were absolutely delighted. And we evolved a lot of residents, a lot of a lot of trainees. I think that's so important. That's empowering them. Making sure that the level is set correctly. So a huge amount of undertaking. I think there was something like 10,000 emails that were sent in the last year or so, between us. And I was really insistent that we have an opening chapter about human factors. So before you pick up that knife, you have to understand how error happens and ways to reduce medical error in the OR. And then the most surreal moment, Chad, was, I was at the Edinburgh College of Surgeons, giving a talk about human factors, funnily enough, in November 2019. And I had the proof copy of the Gray's Surgical Anatomy. All the proofs were done online with PDFs and whatever, but they produced me a single PDF, I'm sorry, a single hard copy of the book. And in the College Library, there's an original proof edition of the 1858 book by Henry Gray, where he's made numerous corrections in pencil and pen. And to actually hold those two books together was, I think, probably the most surreal moment of my life. And to actually open the page on, in fact, we opened up one of the head and neck pages, and there was the infratemporal fossa. And to see the drawing that had been done by Henry Carter, and an operative surgical picture of a live operation, that was there. And it looked almost identical. It was like, wow, we've just made 150 years of history here. It's an immense honour and privilege to help contribute and help the future generation of surgeons. Honestly, it's a real, surreal experience and I can't wait to do the next edition, really.
Chad Ball 26:26
That's an amazing story. You know, the conceptual framework with which Gray's and you have styled the delivery and the communication of that information is interesting. Can you talk about that a little bit to the audience? And maybe, why it's structured a little bit more different than traditional anatomical books?
Peter Brennan 26:47
Yeah, no, absolutely. So when you look at Gray's original book, as I said, it's called Descriptive and Surgery, he talked about the surgical anatomy. So, you can cut along this particular muscle, and you're absolutely safe. And you sort of veer off a bit, and then you're going to hit a major artery, or you're gonna cut a nerve. And so that, for me, was the kind of lesson, if you like. We want to produce a book that you can actually read. Almost like a roadmap. You can actually read that. Yes, you can learn the anatomy as you go along. But it will give you the tools and the knowledge to safely operate. And so we've used operative pictures throughout the book, as you know. That's complemented in certain situations with cadaveric materials, such as the brain, when you have the whole brain exposed, or the brain cut and sagittal sections, and so forth. There's also quite a lot of online videos, as well. So I think there's about 60 or 70 online videos, both of surgical procedures, and cadaveric dissection. Again, with surgeons talking the reader and the observer through the relevant anatomy, so they can safely perform the operation. We've also included anatomical variants and things that you would see during surgery. And then there's multiple choice questions as well, to enable you to kind of think about that afterwards. Have you learned the chapter? I mean, there's lots of bits missing. We could have written a book three times the size, I guess. But it was written based on the curriculum in the UK and the US and Canada, for surgical practice. For example, it doesn't include a huge amount of obstetrics, of gynecology, of eye surgery, for example. It's very much a book for surgeons that would be sitting their surgical exams. But yeah, I can't wait to do the second edition and expand upon it as well, if we can. Hopefully the publishers will give us a bit more space to include a lot more stuff.
Chad Ball 29:13
I have no doubt they will. It's a beautiful book and I'd encourage all of our listeners to buy it, because it's truly phenomenal. And to your point, maybe it makes me a little odd, but it's the anatomical variants that I always find the most interesting, whether I operated in that region or not, they're fantastic. Yeah, no, it's beautiful. The last question I wanted to ask you specifically though, and I can't comment, obviously, on the UK side of this, because I would certainly be ignorant. But in Canada, in particular, and the US to some degree, there has been a sustained and considerable de-emphasis on anatomical teaching within medical schools. And then, you can imagine the downstream effects of that, anecdotally, that we see. You know, students are further behind when they hit residency. Complete portion of their first year, especially, is just trying to understand anatomy that historically would have been stone cold or clear to them from medical school. And then, also thinking about maybe how that also plays into the long-term practice of non-surgeon clinicians as well. I'm curious, what it's like in the UK and what your thoughts are on that de-emphasis that we've seen over time, here anyway?
Peter Brennan 29:31
Ah, thank you. Yeah. I mean, if I'm honest with you, I think it's very sad that cadaveric dissection seems to be evaporating away. I think, yes, there are a number of tools that can be used. You can learn radiological anatomy, you can have 3D models, for example. You can look at videos and online material. But actually not being able to have that hands on, and it doesn't actually necessarily need to be you doing the dissection. Having cadaveric material, so you can really appreciate those amazing structures and how they interact. And I can tell you, as well, with another hat on, that I wear, I used to be lead for the MRCS, the Member of the Royal College of Surgeons exam in the UK and Ireland. And that's an exam, the entry exam to higher training. So residents will take that about three or four years after medical qualification. And then they enter specialty training in general surgery or plastic surgery or what have you. And so we've actually now, we've got a huge amount of research published around that exam. And we have another paper about to be published very, very soon, about medical school, that predicts performance in the MRCS surgery exam. There's a large anatomy component in that MRCS surgery exam, you know, basic sciences. And it seems that the students who go to the more modern medical schools where there isn't any cadaveric material, they're not performing as well in that exam as those students who have been to the traditional medical schools. So I think cadaveric exposure is really, really important. And I think exposure, no matter what you end up doing, you know, as a physician, as a neurologist, having some understanding of anatomy is really critical. I mean, we had to learn, medical students, I always remember, we had to learn the five layers of the foot. And I had this really bad feeling, because I had already qualified in dentistry beforehand. So I had this really bad feeling when I went to the [inaudible] where I was going to get asked about the foot. And sure enough, that's exactly what happened. And it's like, tell me about the layers... I'm actually not sure that that's actually relevant for every single medical student to learn all of those five layers of the foot. [here] Because, come on, unless you're going to be a foot and ankle surgeon, do you really need to know that? So you know, that. But having a basic understanding of neurology of, of the dermatomes, where the heart valves are in relation to where you put your stethoscope, where the lobes of the lung are. When you're fitting an abdomen, where the cross section, what's the L1, what's the T12? You know, I think that's really important. And sadly, it seems a lot of that is going away. In the UK, a lot of medical schools are teaching more about empathy and communication skills and things. And that's really important as well, don't get me wrong, that's really important. But it seems that anatomy just does seem to be reducing, perhaps in the undergraduate curriculum. And then of course, you become a surgeon and you're like, on a C without a chart. You haven't learned that anatomy. And so, it's a very steep learning curve to try and learn the anatomy for your board exams.
Ameer Farooq 34:35
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your thoughts, comments or feedback. Send us an email at [email protected] or tweet at us @CanJSurg. Thank you.