Overview
- Under stress, your thinking brain doesn’t function well, and performance suffers.
- In the operating room, it is critical to be connected to every aspect of the case.
- In surgery, safely making one move at a time, allows a consistent outcome.
- Skillifully navigating adversity from a safe place, yields a good life.
In 2006, I began to work with my golf instructor, David Elaimy, to incorporate athletic performance principles into surgery. It quickly became clear that they are universal principles.
The performance model is “performance = Skill – Interference.” The desired outcome is consistent performance; surgical complications usually occur when interference is present. Interferences include anxiety, anger/frustration, complacency, rushing, and distraction. As you become aware that you are in one of these states, you can calm yourself, refocus, and make each move safely. The most impactful state is frustration, as blood flow to your thinking brain diminishes. You are not at your optimum level of performance. Hence, the rule, “No Action in a Reaction.”
Hardware is defined as the circumstances you cannot control in the moment, and software is your reaction to them. The principles apply to every aspect of life. Stress is not the problem. Your reaction to it is. The surgical suite dramatically compresses the scenario. Here is a situation that occurred many years ago and illustrates the model in action.
Correcting a kyphosis (bent forward deformity) in a high-risk patient.
An older gentleman had undergone a thoracic vertebral body resection via posterior costotransversectomy three weeks earlier. He also underwent a fusion with pedicle screw fixation from three levels above the fractured vertebral body and two levels below. A metal cage filled with bone graft was also placed.
He was completely paraplegic prior to surgery due to a burst fracture with resultant kyphosis and bone impinging on the spinal cord. Over the next few days, he regained about 50% of his neurologic function in his legs and could stand at the bedside with assistance.
Two days after his surgery, on a Wednesday evening, I made rounds on him and noticed that he had redeveloped significant kyphosis. I reviewed his X-rays and found that the lower pedicle screws had pulled out. His medical status was marginal, with congestive heart failure. The decision to perform the index operation was highly controversial. I did not say anything to him that evening; instead, I spoke with his intensive care physician first. He felt it was reasonable to take him back to surgery to replace the rods.
I slept very poorly on Wednesday night, upset that I had not made a better decision earlier to obtain better distal fixation. I talked to him the next morning and was very clear about the problem. I also explained that we had discussed the distal fixation intraoperatively and had felt comfortable that we had been able to place relatively large screws with good fixation. I also explained to him that if we had gone more distally, we probably would not be having this conversation. He was somewhat upset but wanted to proceed with the revision.
I scheduled a conference with his family for 6:00 pm on Thursday evening. I then returned to an extremely busy office that had started at 8:30 and did not end until 5:30. I was about an hour behind for the day and worked through lunch. Around noon, I received news that my mother had passed away.
At 6:00 that evening, I met with the family and the rehab physician. I re-explained the situation in detail and the proposed extension of the fusion and hardware to the upper lumbar spine.
The oldest daughter lit into me. She felt that the decision to perform the first operation was a major mistake and that my judgment was flawed. She looked me in the eye and said, “It appears that you have lost all credibility, haven’t you?” The tirade lasted about half an hour.
Hardware Issues (Circumstances)
- I was upset that I had not made a better intraoperative decision three weeks earlier. I had an internal unease about the fixation at that time, which I did not fully heed.
- Subsequently, I had not slept well the night before this conversation.
- My staff had double-booked me at the office without lunch. I started at 8:30 and did not stop until 5:45, just before the conference.
- My mother had just passed away.
- I had specifically flown back from California to Seattle for his operation to address his condition. I had taken a major risk by deciding to proceed with the operation. The prior surgeon’s assessment that he was not healthy enough to undergo surgery because it was too risky wasn’t unreasonable. I took a different philosophical approach that he embraced, but not his whole family. He was doing well and was regaining a significant amount of his neurological function. I felt that, up to that point, I had made the correct decision.
Awareness
- I was tired and angry. I had done a great job for him, and I also realized that he could have been much worse, even after the surgery. There is often no return of neurological function.
- I was quite defensive. Everyone had been extremely happy with the outcome, but I had never spoken to this family member before.
- I was anxious that another surgery would be too much
- I was aware that I had an excellent relationship with the patient.
- The physiatrist was in the room with me, very supportive of my approach and my understanding of the problem.
- I was attached to the idea that there were only a few spine surgeons in Seattle who could really handle his problem technically. I wasn’t very happy that my entire credibility was in question. Being somewhat of a perfectionist didn’t help.
Software solutions
- I could see that everyone was upset about the whole situation, including me.
- Although I felt extremely upset, angry, and defensive, I was also aware that they had legitimate points. The hardware had failed, and he had to undergo another life-threatening operation. I acknowledged it internally and did not express defensiveness.
- I wanted to walk out of the room, walk out of the case, and just turn it over to someone else. However, I knew that his best chance, since I knew the situation so well, was for me to stay involved.
- I was able to acknowledge and apologize for my role in the problem without becoming defensive. It wasn’t easy.
Outcome
- At the end of the tirade, my patient looked at his daughter and asked, “Are you done?” Then he looked at me and asked, “When can we do it?”
- I was able to go to bed that night in a calm state of mind. Historically, I would have held on to the fact that my credibility had been questioned and would have been quite agitated. However, I slept well and felt ready to go for the surgery the next day.
- I was able to remain clear throughout the surgery, and technically, it went extremely well.
- The patient’s back continued to do well, and his neurologic function slowly improved.
Summary
This process is both harder and easier than it appears. When you are in a reaction, as blood flow to your thinking brain decreases, you lose awareness. Especially when angry, you want to lash out and act immediately. But anger is destructive, and aside from defending yourself, little good comes from acting in this state. Therefore, a sequence of actions has evolved that I call “5-3-2,” which represents the number of words in each step.
No action in a reaction
Flip the switch
Move on
In other words, be aware of the signs that you are angry. Remember that your awareness is compromised. Awareness creates the space you need to choose not to act. Flipping the switch is a deliberate, deep decision not to remain a victim. This is a positive decision, not positive thinking. Then you move on to the next surgical move or into life with awareness, which is at the core of creating a successful, enjoyable life.
