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Surgery and Jazz

The Art of Improvisation in the Evidence-based Medicine Era

Martellucci, Jacopo MD

doi: 10.1097/SLA.0000000000000782
Surgical Perspectives

Technical skills seem to be necessary but not sufficient to ensure patient safety. Paying attention to nontechnical skills will increase the likelihood of maintaining high levels of error-free performance. As in jazz music, improvisation is essential for correct management of the surgical performance and any possible error.

From the Emergency and Mini-invasive Surgery, Careggi University Hospital, Florence, Italy.

Reprints: Jacopo Martellucci, MD, Emergency and Mini-invasive Surgery I, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy. E-mail:

Disclosure: The author declares no conflicts of interest.

In recent years, many articles have been published about the evaluation of learning and training for surgical technical skills. These articles suggest and confirm that, in the era of evidence-based medicine, a proper assessment and validation of technical skills is ever more important, and increasingly complex and reliable simulators are available for this purpose.

Thanks to technological evolution and studies such as the ones published by Annals of Surgery, contemporary surgical practice is, at first sight, more sophisticated, efficient, and effective than ever before.

Despite this, the incidence of adverse events during surgical care is still reported at approximately 15% of cases1 in retrospective series, and in reality, it is probably greater. The actual number of adverse events during operative treatment is not routinely charted, because some will have no clinical impact and others are remedied. However, most technical errors occur in routine operations with experienced surgeons, under conditions of increased patient complexity or systems failure. Commonly recommended interventions, including restricting high-complexity operations to experienced surgeons, additional training for inexperienced surgeons, and stricter supervision of trainees, are likely to address only a minority of technical errors.2

Although the most commonly cited systems factors contributing to errors were inexperience/lack of competence in a surgical task (53% of incidents), communication breakdowns among personnel and fatigue or excessive workload were reported to be factors in 43% and 33% of adverse events, respectively. Moreover, surgeons reported significantly more systems failures in incidents involving emergency surgical care or during unplanned changes in procedure,3 and a strong relationship between teamwork failure and technical error has been demonstrated.4 Therefore, improved technical skills seem to be necessary but not sufficient to ensure patient safety. Paying attention to nontechnical skills, such as teamwork, leadership, situational awareness, decision making, and communication, will increase the likelihood of maintaining high levels of error-free performance.

Communication is acknowledged as a key component of team performance but in surgery, it is often assumed to be a desirable and inherent attribute rather than being regarded as an important and acquired clinical skill, which may need to be applied with care.5 It is increasingly recognized that leadership skills are a key requirement in being successful in surgery, regardless of specialty and at all levels of experience and seniority. Where the emphasis was previously on technical ability, knowledge, and diagnostic acumen, we now know that nontechnical skills such as communication and leadership contribute significantly to patient safety, experience, and outcomes, and should be valued.6

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The operation team organizational model consists of a group of different specialists who, under great duress, make fast, irreversible decisions, are highly interdependent, are dedicated to creation and novelty, and act with little certainty where it is all going to end.

Considering this definition, jazz is more than a metaphor for organizing. Jazz bands actually are organizations designed for innovation, and the design elements from jazz can be applied to other organizations seeking to innovate. Furthermore, in order for jazz bands to be successful, they require a commitment to a mind-set, a culture, practices and structures, and a leadership framework that is strikingly similar to what it takes in the surgical team. Like jazz musicians, surgeons simultaneously discover targets and aim at them, create rules and follow rules, and engage in directed activity often by being clearer about which directions are not right than about specified final results. Their activity is controlled but not predetermined. Musicians and surgeons both rely on precise but wordless communication, dexterity built through years of practice, and the ability to respond to the unexpected.

Despite organizational and training models used, checklists filled, and surgical experience validated, every operation is still a performance. There is a beginning, a middle, and an end, and, as a soloist, no going back once you have started. Working as a team or an ensemble making split-second decisions or keeping the show on the road even if you are not sure you can handle a situation that is rapidly going downhill can give surgeons and musicians a similar feeling. Both disciplines involve unspoken ways of acting.

The fundamental design element for jazz groups, surgical teams, and leaders in general consists of the compliance to the set of nonnegotiable rules essential for improvisation that must exist in order that chaos can lead to creativity and does not result in something unfavorable. Although in our daily practice terms such as improvisation, innovation, or surgical research are often confused, and at times are used as synonyms, they have totally different definitions. A wide variety of novel technical procedures are developed and sometimes published without being first subjected to rigorous peer review. These results sometimes are born from improvisation. Often, these new techniques have undoubtedly contributed to the progress of surgery, but in other cases, measured in the immediate or long term, side effects can be unpredictable and cause serious harm. This means that improvisation in surgery cannot be separated from evidence-based medicine guidelines and best practice parameters, besides a rigorous scientific method of analysis and evaluation of the outcomes.

Just as with a jazz band leader, the ability of the surgeon to allow himself to become a partner, not a dictator, is critical. Leadership is essential for creating a climate characterized by psychological safety and for promoting collaborative problem solving focused on patient safety. Problem solving during a surgical procedure often means improvisation. To improvise in a positive way, surgeons and musicians must feel free to take risks and to act, working in a context of mutual trust with the team. Successful quality management occurs when people are newly authorized to paraphrase, embellish, and reassemble their prevailing routines, extemporaneously. Furthermore, they are encouraged to think while doing rather than be guided solely by plans. Thus, when a team shares improvisation rights, it tends to encourage the flexible treatment of preplanned material, which means that surgical quality improvement and jazz improvisation are closely aligned.

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The word “improvisation” itself is rooted in the word “proviso,” which means to make a stipulation beforehand, to provide for something in advance, or to do something that is premeditated. By adding the prefix “im” to the word proviso, as when the prefix “im” is added to the word mobile to create immobile, improvise means the opposite of proviso. Thus, improvisation deals with the unforeseen, it works without a prior stipulation, and it works with the unexpected. Jazz improvisation is likened to cuisine, dance, foundation building, a game of chess, a journey, landing an airplane, language, love, marriage, acting, painting, singing, and sports but also teaching and surgery.

Surgery, like jazz music, constantly needs improvisation for the management of surgical steps and surgical errors. Error recovery strategies are just as important as error prevention measures,7 and knowledge, technical skills, and improvisation are the main factors affecting error management.

A surgeon facilitates actions that are consequential and difficult to reverse, that require individual and group expertise, and that are based on changing, complex inputs, and environments that are often ambiguous and interact in unpredictable ways. The only way to manage the unpredictable is through improvisation. The use of a thumbtack for the control of presacral venous bleeding during rectal surgery8 is just one of many examples of improvisation in an operation room.

In surgery, surgical procedures often consist of standardized surgical steps, and in theory, improvisation should not be required or should be useful only in limited situations. As suggested by saxophonist Lee Konitz, improvisation lies on a continuum that ranges from interpretation (taking minor liberties with a melody or choosing novel accents or dynamics while performing it basically as written) through embellishment (whole phrases in the original being anticipated or delayed beyond their usual placements; the melody is rephrased but recognizable) and variation (clusters of notes not in the original melody are inserted, but their relationship to the original melody is made clear), ending in improvisation, which means transforming the melody into patterns, bearing little or no resemblance to the original model or using models altogether different from the melody as the basis for inventing new phrases. Reading these definitions, it is clear that various degrees of improvisation are used in every surgical performance.

The important point is that improvisation does not materialize out of thin air. Instead, it materializes around a simple melody that provides the pretext for real-time composing. Some of that composing is built from precomposed phrases that become meaningful retrospectively, as embellishments of that melody. And some come from elaboration of the embellishments themselves. What is in common with jazz melodies is form, imposed by a sequence of harmonic chords and a scheme of rhythm. Other objects available for improvisation that are more common to surgery range from routines and strategic intent to a set of core values, a credo, a mission statement, rules of engagement, evidence-based guidelines, or basic know-how. So, improvisation is a mixture of the precomposed and the spontaneous, just as surgical action mixes together some proportion of control with innovation, exploitation with exploration, routine with nonroutine, and automatic with controlled. In jazz, improvisation people act to think, which imparts a flavor of retrospectively making sense to improvisation.9

Analyzing strategies used by the artists for generating the note content of the improvisations demonstrates that recalling well-learned ideas from memory and inserting them into the ongoing improvisation and repeating material played in earlier sections of the improvisation are 2 of the most used strategies, recalling similar methods used by surgeons during their surgical practice.10

As bassist-composer Charles Mingus said: “you can't improvise on nothing; you've gotta improvise on something.” Improvisation cannot exist without experience and knowledge. To improve improvisation is to improve memory. As surgeons, we spend endless hours tying knots with one hand, practicing with a piece of string over the back of a chair, building homemade simulators, or looking for other creative methods to learn surgical tricks. As musicians, we practice scales until they become automatic. Once these skills have become deeply embedded in our knowledge, they can be drawn on without having to think. This is the basis of improvisation.

Moreover, improvisation constitutes an important potential source of knowledge, closing the circle of the training. Training and study give knowledge and technical skills, knowledge and technical skills allow a better management of the errors or the unexpected situations through improvisation, and a better improvisation allows an improvement in knowledge and in technical skills.

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It is also interesting to note that playing music and performing surgery have in common several cognitive skills that include great accuracy in motor performance, integration of multimodal sensory and motor information, coordination between eye and hand, spatial visualization, intense concentration, quick reaction time, and efficient mental rotation. It is, therefore, reasonable to speculate that musicians and surgeons may have in common some brain specializations and postulate that experience in playing music may help in performing surgery.11

Moreover, it has been shown that people who played a musical instrument performed laparoscopic tasks on a simulator significantly faster than those who did not, suggesting that the visuospatial abilities used in laparoscopic performance may be enhanced in individuals familiar with playing a musical instrument.12

Various studies have shown that music can increase the speed and accuracy of task performance and if used appropriately, music (mainly classical) may positively affect surgical memory consolidation.

Curiously, surgeons with a particular music background perform worse while mentally loaded.13 A possible explanation for this result could be that musicians are trained to focus their thought process on the musical performance only and block out all other thought processes. Clearly, this finding warrants further investigation and might offer insight into the thought processes that contribute to higher achievements in music or to variations in surgical performance.

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Surgery, like music, and Jazz music in particular, is more than a series of tones set in time, and although the rules are followed, every patient presents different challenges.

Surgery shares with jazz improvisation such features as simultaneous reflection and action, simultaneous rule creation and rule following, patterns of mutually expected responses akin to musicians moving through a melody together, action informed by melodies in the form of codes, continuous mixing of the expected with the novel, and the feature of a heavy reliance on intuitive grasp and imagination.

Alongside the importance of training for the acquisition of surgical technical skills, other factors such as improving communication in the surgical team, developing leadership skills, and exercising improvisational skills through simulation and clinical practice seem to be essential for a complete management of adverse or unexpected events that can occur during surgery.

Faced with the apparent paradox between evidence-based medicine and tailored surgery, the best treatment of every single patient often still needs the valuable intervention of improvisation to be effective. Improvisation in surgery, like in jazz music, is the last thing that distinguishes handicraft from art.

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