Cases & Commentaries

Is the "Surgical Personality" a Threat to Patient Safety?

Spotlight Case
Commentary By Charles L. Bosk, PhD

Case Objectives

  • Describe the myth of the "surgical
    personality"
  • Identify features of highly reliable
    organizations
  • Describe steps that can be taken to
    improve the culture of safety in medicine

Case & Commentary: Part 1

A 7-year-old boy with acute lymphocytic
leukemia presented for insertion of a portacath. The surgeon
utilized a supraclavicular approach for the guidewire placement and
was having significant difficulty obtaining venous access. During
this period, the surgeon began to yell at the members of the
operating room (OR) team for a variety of issues, including the
degree of chatter in the OR, the failure of the OR staff to
anticipate his next request, and their failure to move the patient
into his desired position to place a Bovie pad. This behavior did
not surprise the OR team, as this surgeon had a reputation for
being “old school” and possessing poor communication
skills.

On the next attempt to pass the guidewire, it
appeared to pass into the left ventricle. This was noted by both
the X-ray technician and the anesthesiologist, neither of whom were
willing to speak up given the senior surgeon’s reputation of
berating team members who gave unsolicited input on “his
case.”

The first joke I ever heard about surgeons had as
its punch line: “Oh, that’s God, he just thinks he is a
surgeon.” The act of practicing surgery requires a very
specific skill set—excellent eye–hand coordination that
translates into excellent manual skills, the ability to act
decisively on uncertain knowledge under time-limited situations,
and a willingness to improvise when the unexpected occurs—all
of which creates the aura of the surgeon as a Hemingwayesque hero
who displays grace under pressure. But neither the aura nor the
skill set preordains a certain personality. In fact, there is great
variation in social skills, interpersonal style, and individual
demeanor within any group of surgeons—what is shared
by both self-effacing and soft-spoken surgeons and by arrogant,
brashly assertive ones is the ability to rise to the occasion, to
do what is necessary, to project a calming confidence when odds
suddenly and unexpectedly become long. Nonetheless, the myth of a
surgical personality persists in the organizational culture of the
modern hospital.

One of the surgeons I shadowed while gathering
data for Forgive and Remember: Managing Medical Failure
(1)
appeared to be the perfect embodiment of the surgical personality.
It was as if he entered the operating room directly from central
casting. He strode into rooms and instantly commanded the
spotlight. His grooming was immaculate; his unwrinkled surgical
scrub suits possessed a military crease. His posture was ramrod
straight. He was tyrannical in the demands that he made upon
residents, nurses, and, to be fair, himself. He directed public
verbal abuse at residents when their performance failed to meet his
unsparing standards.(1)

Had I shadowed only one surgeon, I might have
conflated this surgeon’s boorish behavior with those
qualities necessary to achieve clinical excellence. However, I saw
a number of this surgeon’s colleagues who achieved the same
results, displayed the same level of surgical skill, and were able
to make the same time-pressured decisions under conditions of
uncertainty while treating others with respect.

A surgical personality exists, although it is
misnamed and overly specified. As illustrated in this case, its
features include wielding authority in an overbearing way and
treating subordinates in a psychologically abusive manner.
Individuals in positions of authority who misuse authority to
humiliate those under their control are not in short supply in the
workplace, medical or otherwise. As with most clichés and
stereotypes, probably more surgeons behave this way than other
physicians; however, there is no shortage of the surgical
personality among physicians in all specialties. Exactly how this
particular style became associated with, tolerated by, and perhaps
even encouraged within surgery is a topic worthy of some
reflection.

The practice of surgery has always been closely
associated with the battlefield. Some of the hierarchical patterns
of authority so observable in surgical practice and training surely
owe something to surgery’s close connection with the
military. The attending surgeons whom I observed in the 1970s (for
the first edition of Forgive and Remember) honed their
skills serving in MASH units in Korea; they were trained by
physicians who learned their craft in World War II; and many
surgeons, now in their early sixties, saw service in Vietnam.

Surgeons have always served in the military, but
they have never been of the military, in that many surgeons
(particularly those exhibiting the surgical personality) maintain a
near complete disregard for organizational rules and behavior. This
characteristic is surely maddening to administrators who try to
create rule-based order within the hospital. “True
surgeons” will not allow what they feel is in their
patients’ best interest to be compromised by organizational
policies and procedures. Yet, the same surgeon that treats
organizational rules with such disdain demands total obedience from
those that work under them.

At one time, the demands for quick compliance
with orders and the intolerance of delay may well have served the
patient’s interest. But those days are long gone. Surgical
procedures now require complex teamwork among radiologists,
anesthesiologists, nurses, and a variety of specialists. For
instance, the development of minimally invasive fiber-optic surgery
has increased the demands for coordination within the operative
suite. Procedures that were once two-handed have become
four-handed.(2)
This evolution in the nature of surgery now means that the surgical
personality is not just a vestigial presence but a
counterproductive one as well.

Case & Commentary: Part 2

The dilator and peel-away covering were placed
over the wire and the catheter was threaded into place. The surgeon
then injected multiple boluses of saline and Hypaque dye, and the
child became tachycardic and hypotensive, with narrowing of the
pulse pressure. Severe respiratory variation was noted on the pulse
oximeter tracing. The anesthesiologist voiced his belief that the
surgeon had placed the device in the pericardial space and demanded
that he perform an immediate pericardiocentesis. Instead, the
surgeon insisted on removing the portacath and closing the skin
incision. Over the next 10 minutes, the child’s
cardiovascular status deteriorated, requiring boluses of
epinephrine. Once pericardiocentesis was finally performed, the
child immediately improved and more than 200 cc of bloody fluid
were drained. Ultimately, the patient required two
pericardiocenteses and was intubated overnight in the PICU. He
required readmission and a repeat surgery several weeks later and
had a delay in administration of his intrathecal
chemotherapy.

Once it becomes clear that a particular practice
or leadership style hinders our achieving important goals, the
question arises: Why did we tolerate this state of affairs for so
long? So long as social arrangements seem natural, so long as they
go unchallenged, and so long as we cannot imagine an alternative,
we tolerate them. Wisdom is said to reside in recognizing that
which we are powerless to change, so why aggravate ourselves over
the unchangeable? The question is not why “the natural”
order is tolerated. Rather, we need to ask: Under what conditions
are social arrangements once thought unassailable and uncontested
challenged?

The most obvious challenge to the unthinking
acceptance of the surgical personality came with the publication of
the Institute of Medicine (IOM) report on the prevalence of
preventable adverse events in medicine.(3)
That document identified dysfunctional
responses to error characterized by “naming, blaming, and
shaming” individuals.(1)
The problem with such responses
is that they inhibit the sharing of knowledge that would serve to
prevent mistakes from being repeated. The IOM report not only
decried dysfunctional approaches to managing errors; it also
pointed to lessons that medicine had to learn from industries that
had made significant progress in emphasizing safety.

In high-technology organizations, in which
production processes are characterized by tight coupling—in
other words, the timing of sequencing is critical—and complex
or unpredictable interactions, accidents have been said to be
“normal.” The seemingly oxymoronic term,
“normal
accident,” indicates that accidents are a consequence of
the way work is organized. Small errors, innocent in themselves,
combine stochastically with other minor deviations to create
unexpected, unpredictable accidents and errors. Normal accident
theory suggests that, in complex human endeavors, accidents are
inevitable and that efforts at prevention yield limited
results.

A number of theorists who have studied
high-technology organizations that manage to operate without
baleful consequences challenge this counsel of despair. These
theorists have developed the theory of highly
reliable organizations.(1,5)
For example, on the flight decks
of aircraft carriers, safety is achieved in multiple ways. Any
member of the crew is empowered to wave off a
landing—judgments of safety trump formal rank. Crew members
are rotated through the different assignments of the flight deck,
so all workers possess not only an understanding of their
responsibility but also a global knowledge of flight deck
operations. Finally, the lessons of experience are communicated
through a dense oral culture—inexperienced workers are
schooled through vivid narratives elaborating threats to
safety.

Karl Weick has shown that organizational culture
is itself a source of high reliability and safety.(6)
Two elements are critical to
safety cultures. First, there is the inculcation of core values in
members of an organization or profession. This has an important
consequence: when activities are dispersed and not amenable to
supervision from a central source, organizational leaders can have
some confidence in the rationales that support decisions made in
the field. Second, those in charge communicate to other team
members how important they are for early detection and
communication of impending problems. For Weick, “safety
cultures” seek wisdom rather than knowledge alone, couple
confidence in skill with humility, and promote respectful and
“heedful” interactions. Had this been the culture in
the OR during the case described above, the X-ray technician and
anesthesiologist might have felt free to express their concerns
about the guidewire placement, which could have prevented this
error.

A number of factors are critical if safety
cultures are to become a reality rather than a rhetorical goal.
First, there needs to be an increased emphasis on the importance of
teamwork early in medical training. Next, physicians need to be
taught the dangers that “the captain of the ship”
doctrine presents to safety. A dense oral culture that celebrates
the benefits to safety and quality care that teamwork provides
(similar to that which exists on aircraft carrier flight decks)
needs to be developed and circulated. When I did the fieldwork for
Forgive and Remember, the oral culture of surgeons
celebrated individual professional responsibility. Now, that oral
culture needs to be reformulated so that heroic action that creates
safety is seen to flow from the coordinated action of team members.
Finally, there needs to be intolerance from organizational leaders
of the behaviors that characterizes the “surgical
personality.” The system changes necessary for high quality
and safe care are impossible unless we recognize and change those
counterproductive behaviors that, in too many cases, have been
allowed to persist without challenge.(7)

Charles L. Bosk, PhD
Professor and Graduate Chair
Department of Sociology, University of Pennsylvania

Faculty Disclosure: Dr. Bosk has
declared that neither he, nor any immediate member of his family,
has a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, his commentary
does not include information regarding investigational or off-label
use of pharmaceutical products or medical devices.

References

1. Bosk CL. Forgive and Remember: Managing
Medical Failure. 2nd ed. Chicago, IL: University of Chicago Press;
2003.

2. Zetka J. The Surgeon and the Scope. Ithaca,
NY: Cornell University Press; 2004.

3. Kohn L, Corrigan J, Donaldson M, eds. To Err
is Human: Building A Safer Health Care System. Washington, DC:
National Academy Press; 2000.

4. Weick K, Roberts KH. Collective mind in
organizations: heedful interrelating on flight decks. Adm Sci Q.
1993;38:357-381.

5. Roberts KH. Some characteristics of one type
of high reliability organization. Organ Sci. 1990;1:160-176.

6. Weick K. Culture as a source of high
reliability. Calif Manage Rev. 1987;29:112-127.

7. Reason J. Human Error. Cambridge, England:
Cambridge University Press; 1990.