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The Stretch Circle: A Preoperative Surgical Team Improvisation Exercise

Shahawy, Sarrah MD; Watson, Katie JD; Milad, Magdy P. MD, MS

doi: 10.1097/ACM.0000000000002981
Letters to the Editor

Resident physician, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois;

Associate professor of medical social sciences, medical education, and obstetrics and gynecology, Northwestern Feinberg School of Medicine, Chicago, Illinois.

Chief of gynecology and gynecologic surgery and Albert B. Gerbie, MD, Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Northwestern Feinberg School of Medicine, Chicago, Illinois.

Disclosures: None reported.

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To the Editor:

They stand in a circle facing each other, all with their right arms bent over their heads in a triceps stretch. One person speaks, and the others listen. When she stops speaking, another begins a new stretch and speaks. After several minutes of synchronized stretches and monologues, the group breaks its circle. They put their masks back on and start scrubbing.

This is how our gynecologic surgical team warms up before every surgery. Any one of us can choose the first stretch, and the rest of us will quietly mirror it while the initiator tells the group (1) whether he or she met his or her personal surgical objective for the previous case, (2) feedback from the last case for another member of the surgical team, and (3) his or her personal surgical objective for the upcoming case.

This exercise is a bit of medical improv, which Watson and Fu define as “the adaptation of improvisational theater principles and exercises to enhance such medical skills as communication, teamwork, and cognition.”1 Preliminary evidence suggests that medical improv can be used as an effective training method in medical education.2 The Stretch Circle, our preoperative exercise, is borrowed from a well-known warm-up exercise used in improv that we revised by filling its verbal content with principles from the World Health Organization Surgical Safety Checklist.3 Such exercises require a formal pause in care for pre- and postoperative team debriefings, which have previously been shown to be associated with improved safety processes.4

We recommend that preoperative exercises, such as this one, be used to foster strong surgical team building and communication, identify each team member’s surgical goals, and provide a consistent forum for timely nonhierarchical feedback. Activities such as the Stretch Circle encourage an active approach to holistic improvement, as well as both communal and individual self-reflection among the surgical team. Trainees may also benefit from seeing experienced surgeons model their inner thought process in which they set surgical goals and analyze their own performance. Just like athletic teams warm up, medical improv exercises can be incorporated as routine warm-ups for surgical teams.

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1. Watson K, Fu B. Medical improv: A novel approach to teaching communication and professionalism skills. Ann Intern Med. 2016;165:591–592.
2. Watson K. Perspective: Serious play: Teaching medical skills with improvisational theater techniques. Acad Med. 2011;86:1260–1265.
3. Haynes AB, Weiser TG, Berry WR, et al.; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–499.
4. Sexton JB, Makary MA, Tersigni AR, et al. Teamwork in the operating room: Frontline perspectives among hospitals and operating room personnel. Anesthesiology. 2006;105:877–884.
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