Portal de Periódicos da CAPES

III. In pursuit of excellence in anaesthesia

2012; Elsevier BV; Volume: 110; Issue: 1 Linguagem: Inglês

10.1093/bja/aes445

1471-6771

Cliff Shelton, Andrew F Smith,

Medical History and Innovations

To give one's best, on the field of play or in life. It is not only about winning, but also about participating, making progress against personal goals, striving to be and to do our best in our daily lives.Excellence, as defined by the International Olympic Committee The summer of 2012 saw the Olympic Games come to London, heralded by the UK as an event which would 'inspire a generation'. The core values of the Olympic movement are excellence, friendship, and respect, and the Olympic motto: citius–altius–fortius (faster–higher–stronger) is said to encourage the athlete to aspire to excellence.1The Olympic MuseumThe Olympic Symbols. International Olympic Committee, Lausanne2007Google Scholar In this respect, the world of élite athletics is refreshingly simple: in the Olympics, excellence is precisely measured in seconds, metres, and kilograms. Defining excellence in anaesthesia is more complex, and in the same way that clinical measurement, acumen, and experience interact in clinical practice,2Smith AF Oakey RJ Incidence and significance of errors in a patient 'track and trigger' system during an epidemic of legionnaires' disease: retrospective casenote analysis.Anaesthesia. 2006; 61: 222-228Crossref PubMed Scopus (61) Google Scholar pure measurement lacks the definition to document the range and depth of behaviour that expert practitioners display. In pursuit of a better understanding of the subtleties of anaesthetic practice, researchers therefore frequently use qualitative methodologies to investigate the anaesthetist at work.3Smith AF Pope C Goodwin D Mort M What defines expertise in regional anaesthesia? An observational analysis of practice.Br J Anaesth. 2006; 97: 401-407Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 4Goodwin D Pope C Mort M Smith AF Access, boundaries and their effects: legitimate participation in anaesthesia.Sociol Health Illn. 2005; 27: 855-871Crossref PubMed Scopus (52) Google Scholar, 5Pope C Smith A Goodwin D Mort M Passing on tacit knowledge in anaesthesia: a qualitative study.Med Educ. 2003; 37: 650-655Crossref PubMed Scopus (46) Google Scholar Anaesthetists seldom work alone, and usually work closely with other members of a small team.6Smith AF Mishra K Interaction between anaesthetists, their patients and the anaesthesia team.Br J Anaesth. 2010; 105: 60-68Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar In many countries, nurses administer anaesthetics with varying degrees of supervision from physician anaesthetists.7Smith AF Kane M Milne R Comparative effectiveness and safety of physician and nurse anaesthetists: a narrative systematic review.Br J Anaesth. 2004; 93: 540-545Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar This is the case in Sweden, and Larsson and Holmström's8Larsson J Holmström I How excellent anaesthetists perform in the operating theatre—a qualitative study on non-technical skills.Br J Anaesth. 2013; 110: 115-121Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar article in this issue of the British Journal of Anaesthesia is based on the reasoning that after years of observing and assisting anaesthetists at work, nurse anaesthetists have become connoisseurs of anaesthetic practice. Their study analyses the themes from focus-group interviews conducted with experienced anaesthesia nurses from a number of hospitals, aimed at describing the characteristics of the excellent anaesthetist in the operating theatre environment. Their data thus have high face validity: observation of others over a period of time can give useful insights into their behaviour. Other strengths of the work include the authors' efforts to distinguish between observable behaviour and anaesthetists' personality traits in the interviews, and the frequent referral of emerging findings to larger groups of researchers as the work progressed. The former precaution aimed to prevent nurses simply describing the characteristics of anaesthetists they liked personally, while the latter was intended to prevent either of the two main researchers inadvertently imposing his or her interpretation on the interview data. Six themes emerged from Larsson and Holmström's interviews, four of which may be classified as non-technical skills: organization, communication,9Smith AF Pope C Goodwin D Mort M Communication between anesthesiologists, patients and the anesthesia team: a descriptive study of induction and emergence.Can J Anaesth. 2005; 52: 915-920Crossref PubMed Scopus (47) Google Scholar 10Smith AF Shelly MP Communication skills for anaesthetists: a practical introduction.Can J Anaesth. 1999; 46: 1082-1088Crossref PubMed Scopus (40) Google Scholar maintaining situation-awareness during practical work, and leadership. These themes triangulate with those previously identified by cognitive psychologists.11Flin R Patey R Glavin R Maran N Anaesthetists' non-technical skills.Br J Anaesth. 2012; 105: 38-44Abstract Full Text Full Text PDF Scopus (286) Google Scholar Larsson and Holmström's two remaining themes: that the excellent anaesthetist is 'patient-centred', and 'humble to the complexity of anaesthesia, admitting own fallibility', relate more to values and attitudes than to skills. The first of these, 'patient-centredness', is much discussed in healthcare at present but has a variety of definitions with diverse implications. Usually, though, the notion of patient-centredness encompasses elements of respect for patients' autonomy, information-giving, shared decision-making, and empathy, and has been identified as a desirable characteristic in previous research.12Soltner C Giquello JA Manrigal-Martin C Beydon L Continuous care and empathic anaesthesiologist attitude in the preoperative period: impact on patient anxiety and satisfaction.Br J Anaesth. 2011; 106: 680-686Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 13Markham R Smith AF The limits to patient choice: an example from anaesthesia.Br Med J. 2003; 326: 863-864Crossref PubMed Scopus (9) Google Scholar, 14Edward GM Naald NV Oort FJ et al.Information gain in patients using a multimedia website with tailored information on anaesthesia.Br J Anaesth. 2011; 106: 319-324Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar However, the role of humility in clinical practice has hitherto remained the preserve of the essayist. In his essay 'A gentle and humane temper', Coulehan15Coulehan J A gentle and humane temper.Perspect Biol Med. 2011; 54: 202-216Crossref Scopus (23) Google Scholar suggests that humility is composed of four personal characteristics: 'unpretentious openness, honest self-disclosure, avoidance of arrogance, and modulation of self-interest'. There is great similarity between this definition by an expert medical ethicist and the dialogue from the focus groups in Larsson and Holmström's study. However, a conflict has also been noted between humility and 'traditional' medical character traits such as assertiveness, confidence, and resilience.15Coulehan J A gentle and humane temper.Perspect Biol Med. 2011; 54: 202-216Crossref Scopus (23) Google Scholar, 16Chochinov HM Humility and the practice of medicine: tasting humble pie.Can Med Assoc J. 2010; 182: 1217-1218Crossref Scopus (13) Google Scholar, 17Coulehan J On humility.Ann Intern Med. 2010; 153: 200-201Crossref PubMed Scopus (36) Google Scholar It is possible that medical training may itself be responsible for 'the slow but steady relinquishment of humility' as these characteristics are acquired. If this is true, how does it come about? Surely, no medical teacher consciously tries to extinguish the traits associated with humility? Maybe the message is subconscious. It has been suggested that in medical education, there is not one curriculum, but three: the 'formal curriculum' is stated, intended and endorsed by the educational institution, the 'informal curriculum' consists of unscripted, interpersonal teaching, and learning, and the 'hidden curriculum' originates from the structure or culture of the educational institution.18Hafferty FW Beyond curriculum reform: confronting medicine's hidden curriculum.Acad Med. 1998; 73: 403-407Crossref PubMed Scopus (1181) Google Scholar Humility in the face of the dangers of anaesthesia, and the constant awareness of, and vigilance for, problems threatening the anaesthetized patient, also invites parallels with notions of safety in high-reliability organizations.19Van Beuzekom M Akerboom S Boer F Hudson P Patient safety: latent risk factors.Br J Anaesth. 2010; 105: 52-59Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar 20Reason J Human error: models and management.Br Med J. 2000; 320: 768-770Crossref PubMed Scopus (3630) Google Scholar Such organizations—including aircraft carriers, nuclear power plants, and air traffic control—are dynamic and potentially hazardous operations that in fact have many fewer accidents than one might expect. Features of high-reliability organizations are apparent in Larsson and Holmström's data. The predominant culture in such organizations shows a high level of mindfulness (situation awareness and understanding of the ubiquity and capriciousness of risk), deference to specific expertise regardless of an individual's position in the hierarchy, and a fair culture in which people feel able to report errors made by themselves and others. Such organizations also expect their members to adopt a leadership role if a specific situation demands it.21Weick KE Sutcliffe KM Obstfield D Organizing for high reliability: processes of collective mindfulness.Res Organ Behav. 1999; 21: 23-81Google Scholar 22Barach P Small SD Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.Br Med J. 2000; 320: 759-763Crossref PubMed Scopus (796) Google Scholar Finally, although we have dealt with them separately, the themes of humility and patient-centredness may well be related: Chochinov16Chochinov HM Humility and the practice of medicine: tasting humble pie.Can Med Assoc J. 2010; 182: 1217-1218Crossref Scopus (13) Google Scholar draws a connection between them, suggesting that 'physicians who lack humility talk at their patients; physicians who are sufficiently humble talk with their patients'. A rather disheartening finding in Larsson and Holmström's article was that the behaviours that the focus groups deemed to represent excellence were in fact rarely seen in clinical practice. In statistical terms, this makes sense: it is impossible for everybody to be excellent in the sense of 'much better than average'. However, the article suggests that it need not be so uncommon; the criteria for excellence appear to be inclusive and achievable. In terms of education, given that formal anaesthetic training curricula appear to be focused on the acquisition of competence, is the 'hidden' message that excellence is somehow unnecessary or redundant? A further methodological question is whether the use of anaesthesia nurses to judge doctors' practice threatens their right to act as arbiters of what is acceptable and/or excellent practice in their own domain.23Smith AF In search of excellence in anesthesiology.Anesthesiology. 2009; 110: 4-5Crossref PubMed Scopus (31) Google Scholar The counter-question is of course, have they misjudged anaesthesia practice in some way, and the answer here is apparently not. Not only do their observations ring true to physician anaesthetists, but they also echo and in fact expand on previous work based on data from anaesthetists themselves.24Smith AF Glavin R Greaves JD Defining excellence in anaesthesia: the role of personal qualities and practice environment.Br J Anaesth. 2011; 106: 38-43Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar So how do we inspire a generation of trainee anaesthetists to strive for clinical excellence? There are a number of means: role-modelling, assessment, and the creation of the right environment. Role-modelling is a central concept in the delivery of the informal curriculum, in particular with regard to attitudes and values.25Cruess SR Cruess RL Steinert Y Role modelling—making the most of a powerful teaching strategy.Br Med J. 2008; 332: 718-721Crossref Scopus (293) Google Scholar Larsson and Holmström suggest that the answer lies in developing evidence-based role modelling strategies. Their study therefore provides direction for research into role-modelling in the context of anaesthetic training, where the structure of the team may differ from that in ward-based specialities. In the meanwhile, we must remember that role modelling can have profound negative influences as well as positive ones, and we must endeavour to model the excellent behaviour that we expect our trainees to acquire. Assessment is always a powerful force in learning, as it promotes the elements of training that are formally assessed. Professional attitudes are judged as part of anaesthesia education, usually through multi-source feedback.26Castanelli D Kitto S Perceptions, attitudes and beliefs of staff anaesthetists related to multi-source feedback used for their performance appraisal.Br J Anaesth. 2011; 107: 372-377Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Workplace-based assessment is also used, but in the current UK curriculum, trainees are assessed through six different assessment modalities, in five of which the highest possible grade is 'satisfactory'. While the system may allow objective appraisal of progress, it risks giving the impression that excellence is not required and 'good enough' is good enough. Finally, and returning to the Olympic theme, it is obvious that success depends not only on the potential of individuals but also on the people and structures around them. Behind every gold medal winner are many others: coaches, mentors, sponsors, and financial backers. Although constant mindful individual practice, whether in simulation27Boet S Borges BCR Naik VN et al.Complex procedural skills are retained for a minimum of 1 yr after a single high-fidelity simulation training session.Br J Anaesth. 2011; 107: 533-539Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar 28Burtscher MJ Manser T Kolbe M et al.Adaptation in anaesthesia team coordination in response to a simulated critical event and its relationship to clinical performance.Br J Anaesth. 2011; 106: 801-806Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar or in the workplace, is essential to develop expertise, educators in anaesthesia must also create the right environment for others to give their best.24Smith AF Glavin R Greaves JD Defining excellence in anaesthesia: the role of personal qualities and practice environment.Br J Anaesth. 2011; 106: 38-43Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar None declared.