Midway through a complex abdominal operation, a surgical attending, known for explosive tirades and the occasional flying forceps, noticed the bare handle of the overhead light was stained with blood. As each team member changed their gloves, he demanded to know where the sterile cover was and who had grabbed the light, contaminating the entire case. When neither the resident, medical student, nor scrub technician accepted culpability, he swore loudly at each of them and finished the operation in silence.
While mistakes like these unfortunately do happen, this particular incident was avoidable. The medical student had noticed that the bright green sterile cover was absent and had watched both the attending and resident manipulate the light during the case. The student also knew how the attending surgeon dealt with trainee imperfection and dreaded pointing out the surgeon's mistake. Embarrassment, blame, potential negative impact on his grade, and future surgical career: each of these was seen as a likely consequence. The student's conscious decision not to speak up, however, ultimately put the patient at serious risk of infection.
This narrative is a true and most regretful experience of one of the authors. But this story is just one of many. Medical students and residents are significantly less likely to report adverse safety events that harm, or could harm, patients and themselves than attending physicians.1 The anecdote highlights how fear of embarrassment or a punitive response permeates medical culture, which in turn, leads to psychological distress. Chronic emotional and interpersonal stressors such as the psychological stress of one's work environment contribute to the exhaustion, depersonalization, and job dissatisfaction that characterize burnout, which physicians experience in all specialties and at all training levels.2 Surgical training is particularly high risk, with 69% of surgical residents reporting burnout, and the problem is growing.2 It is an epidemic that is costly for all stakeholders: patients, hospitals, and surgeons themselves, who have begun to share their personal burden more publicly to begin a more honest conversation about burnout's ill-effects and mitigate its consequences.3
Burnout is a multifactorial problem that includes both individual and systemic influences. Most research remains in the descriptive and explanatory phase, so it is unclear how to best intervene. Institutions have designed programs intended to address physician wellness; however, much of the focus remains solely on the individual. Curricula for residents have been developed to improve mindfulness, resilience, and wellness, even employing psychological counselors. While these programs should be lauded, their long-term efficacy is still uncertain. Interventions aimed at mitigating burnout must also address institutional and organizational influences, such as the work and learning environments. Medicine, as a field, recruits individuals who are particularly resilient at baseline. In fact, when compared with their peers in other areas of study, medical school entrants actually report lower rates of burnout, a higher quality of life, and have lower rates of mental health problems.4 Thus, burnout primarily begins when students are formally exposed to the rigors of medical training.
Surgeons have an opportunity to take the lead and address burnout in its formative stages, beginning in the operating room. Surgery is high risk and high reward. The intensity, immediacy, and power of the operating room harness an excitement and intrigue that is singular in medicine. At the same time, surgery is punctuated with moments of high anxiety and stress, 2 psychological factors that are intimately linked to burnout.5 Stress in the operating room is encountered at all stages of training, but it begins with the medical students who are exposed to both the joys and anxieties of our field.6 The residents and fellows who continue on to surgical training and thrive in its unique culture face a new burden of responsibility, complications, and failure in real time. And the cycle continues as attending surgeons take on the “noise” of the operating room: not the procedure itself, but the pressures of time, increasing volume, new untrained teams, and administrative and clerical burdens that may distract from the clinical and educational goals of the case. In this paradigm, the stress of the operating room remains a constant.
The kind of specific psychological distress to which the student in the initial narrative was exposed contributes to a toxic work environment that affects everyone in the room, including the patient. The operating room, therefore, is an opportune place to intervene and address one of the significant organizational influences on physician burnout. In this case, the “organization” comprises the processes involved in learning and education, both for the student and the resident. The authors suggest doing so through a lens of “psychological safety.” Psychological safety describes “the degree to which people view (their) environment as conducive to interpersonally risky behaviors like speaking up or asking for help.”7 This concept is broadly applicable within any learning setting, team, or institution, and is known to promote positive learning behaviors and enhance team performance.7 In business it is a foundational concept. At Google, psychological safety is viewed as the most important aspect of a team's dynamics, and teams that demonstrate higher levels of psychological safety have been shown to achieve higher sales numbers.8 Creating a psychologically safe learning environment is embedded in Google's culture, with teams beginning meetings with a live “check-in” and discussion of risks taken in the previous week.
Psychological safety already has established applications in surgery. Operating room teams who demonstrate higher levels of psychological safety are better able to successfully implement new technologies.9 To understand its effects on resident education, the authors asked surgical residents at their own institution to nominate attending surgeons deemed expert surgical educators. Ten out of 12 of those surgeons interviewed independently and organically discussed the importance of creating a culture of psychological safety. These educators implicitly recognized that fostering a supportive work environment is critical to minimizing medical student and trainee stress to maximize learning. However, the impact of psychological safety on burnout in surgery—and medicine in general—is unknown. Here, a novel application of this well-established principle may provide a means of addressing one of the most pressing issues in our field today.
We suggest several ways to begin applying this framework. First, taking a cue from Google's “timeout” prior to meetings, psychological safety interventions could be integrated into the operative workflow during the pause of the timeout. Individuals could be encouraged to state an educational goal, ensure team members ask and remember each other's names, or even explicitly engage students, trainees, and staff to promote psychological safety by asking them to speak up during the case if concerns arise. Including the anesthesia team and operating room staff would effectively establish a “team mentality” and shared responsibility for outcomes instead of relying on the agency and direction of 1 individual.
Second, discussion of prior failures during the case should be promoted, both to normalize the humanity of our profession and to emphasize concepts to reduce errors in the future. The idea of “failing faster to succeed sooner” is a useful core axiom from the business community. In this vein, the anecdote at the beginning of this article should be articulated to medical students at an opportune time early in their surgical rotation to empower them to speak up for the patient and avoid a serious adverse event. Fallibility becomes a vehicle for positive change instead of punishment.
Finally, future research should focus on the influence of psychological safety on burnout using validated metrics. Numerous situations are ripe for study. For example, it is known that familiarity of team members with one another not only significantly improves perioperative efficacy, but also can have a positive impact on important patient outcomes.10 Knowledge of the procedure may reduce anxiety and stress for the scrub technicians, circulators, anesthesia team, and other operating room personnel, which in turn can reduce the excess “noise” of the operating room via an efficient workflow. Familiarity and kinship also promotes a sense of a work “family,” which can improve social resilience, a key component to improve well-being and combat burnout. While the benefit of specialization and team familiarity is known, its impact on provider burnout is not. Interventions geared to promoting psychological safety in established work teams may provide an opportunity to address wellness at the missing institutional or “organizational” level.
Surgeons have an opportunity to start changing the environment in which we operate, quite literally. Through a lens of psychological safety, surgeons could potentially align both education and wellness in their work environment by reducing the psychological stressors in the operating room that contribute to burnout. Practice, collaboration, experimentation, feedback solicitation, and reflection on mistakes should be encouraged, and not seen as a route to punishment. A culture of psychological safety could allow students and trainees to overcome learning anxieties and defensiveness, reduce stress, engage in positive learning behaviors, and ultimately mitigate the high rates of physician burnout. Future studies should focus on the specific impact of psychological safety on burnout and resilience, as each is woven into the fabric of our profession.
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5. Lebares CC, Guvva EV, Ascher NL, et al. Burnout and stress among US surgery residents: psychological distress and resilience. J Am Coll Surg
6. Dyrbye LN, Thomas MR, Huntington JL, et al. Personal life events and medical student burnout: a multicenter study. Acad Med
7. Edmondson AC, Higgins M, Singer S, et al. Understanding psychological safety in health care and education organizations: a comparative perspective. Res Hum Dev
8. Wisdom J, Wei H. Cultivating Great Teams: What Health Care Can Learn from Google
[NEJM Catalyst]. February 21, 2017. Available at: https://catalyst.nejm.org/psychological-safety-great-teams/
. Accessed August 21, 2018.
9. Edmondson AC. Framing for learning: lessons in successful technology implementation. California Manage Rev
10. Grant MC, Hanna A, Benson A, et al. Dedicated operating room teams and clinical outcomes in an enhanced recovery after surgery pathway for colorectal surgery. J Am Coll Surg