Complex healthcare requires teams, and very little of today’s healthcare is not complex. No better example are the individuals that make up the operating room team, surgeon, anesthesiologist, nurse anesthetists, circulating nurse, and scrub nurse. Many of the articles and thinking around OR teams have involved metaphorical comparisons to airline cockpit teams and even Formula One pit crews. But can we equate surgical care with a very different team, the musical ensemble? Reading between the lines of a study of musical groups suggests many similarities.
Many words have been expended discussing large surgical volumes and standardization as drivers of surgical quality, but there is no routine or standard operative experience, well occasionally, but always in retrospect. The moment the knife hits the skin, if not even sooner, the “fog” of the surgical battle descends and safely crossing the valley relies on the operative team and their experience. While we may call it rote, it rarely is, and frequently involves little “creativities,” deviations from the routine, that safely and successfully get the patient and team out of the operating room. I mention this as the discussion of musical ensembles often employs the word, “creativity,” a term rarely associated with surgery.
The researchers looking at musical ensembles uncovered qualitative rather than quantitative information.
“Regarding creative product, music ensembles offer a spectrum of creative expression, from well-practiced recitals to spontaneous free improvisation. A wide range of creative processes is also possible; classical music ensemble performance requires controlled cognitive work to reproduce notated music faithfully, while improvised music-making, such as Free Jazz, demands fluid, spontaneous creative artistic production. ... Each musician in an ensemble brings a unique personality, motivation, and cognitive style to the group setting. Situational variables are rich with possibilities as well. Musical ensembles vary widely in the extent, to which their performances incorporate spontaneous creativity, yet even well-rehearsed groups need to respond in real-time to interpersonal gestures, concert hall conditions, and aesthetic reactions of the audience. These micro-adjustments constitute a key feature of musical creativity and underlie the power of live performances”
Substituting surgery for music and any member of the operative team for musician and you begin to capture many aspects of surgery’s “live performances. When surgery follows the written “score” the value of team rehearsal, i.e., surgical volume fosters an environment where team communication coordinates efforts with both speech and those “interpersonal gestures,” like eye contact and body posture. Surgery that finds itself facing unique circumstances, and a need for improvisation, requires “novel recombination and expression of ideas …commonly described in terms of a widening and loosening of associations between elements in memory.” Again, experience as a member of a surgical team member helps identify prior “creativities” offering a path forward. Or other circumstances, experience suggests reining in the associations, falling back upon the dogma of standard care.
“Creative cognition in the individual is a balance between spontaneous insight and cognitive control. Musical improvisation is an excellent embodiment of these processes as it relies on spontaneous decisions built upon individual expertise and the boundaries of musical styles.”
The ability to switch between those styles of thought separate attending surgeons from the trainee, master from apprentice, episodic from consistent team membership.
As with all human performance, errors occur, and it is in part, the mastery in the room that predicts the recovery from those errors – resilience in the face of distress. Surgical teams are again like ensembles, “ … musicians in resilient ensembles respond to performance errors or perturbations flexibly by expanding their cognitive effort and moving away from a rote performance. Specifically, the musicians used bodily coordination and mutual gaze to beckon towards relevant information. In less resilient ensembles, however, individuals increased their effort but focused on individual technique, thereby exacerbating the error.” When surgical teams encounter difficult situations, their first reaction is to slow down, pause, regroup, and then move on. Ad hoc teams, put together for the benefit of scheduling rather than coordination do not have the social experience, the team building, necessary to act cohesively, leaving the surgeon adrift if not alone.
Perhaps medical teams should be treated more like musical ensembles, the various roles not considered so interchangeable; more importantly, credit and blame should be apportioned to the team, not its putative leader. Frank Sinatra, of all people, sang my point best:
To start at the ground and reach for the top
To have such a wonderful career, I just gotta stop
Stop and turn around to thank everyone that sits on the stand.
Cause I wouldn't have made it without them, here's to the band!
That is a truth that surgeons, as the team’s leader, should share; with one another and with administrations that more and more frequently see us all as faceless FTEs.
Source: Factors affecting group creativity: lessons from musical ensembles Current Opinion in Behavioral Sciences DOI: 10.1016/j.cobehav.2018.12.013