Human factors
rolling out and improving on other resources that help surgeons (and surgical teams), as well as patients (and their families), to identify better, healthier, and more empowering ways of working together. This ensures that every member of the team is working in a healthy and enfranchised way, optimising their own and others’ health and well-being. Critical elements of these systems include crisis toolkits, traffic light systems and flow charts, which are to be put in place alongside psychoeducation, counselling and support.
Changing to true health partnerships From a professional clinical and occupational psychological perspective, dynamics play a role in setting up unintended risks and fostering mutually coercive health inequalities (for both clinicians and patients). We need to better understand the role of patients, as exists in the Western healthcare system. For example, I would recommend tools that help surgical patients and surgeons properly engage with the healthcare process in a non-blaming and supportive way. I would recommend that everyone involved in the process is given the space to take stock, and to engage in a healthy and responsible manner. These resources are tied within both patient
and surgeon pathways, and embedded in evolving resources, such as the development of a checklist that is quick to use. This checklist allows surgeons to avoid adverse events by checking they are mentally fit and prepared to operate. This is based on the aviation pre- flight checklist; similar to the Federal Aviation Administration’s, which has the acronym IAMSAFE, encouraging a pilot to self-check for illness, medication, stress, alcohol, fatigue and emotion prior to take-off. The surgeon checklist, with the acronym FEBRILE, is being spearheaded by myself and championed by CBS, enabling
surgeons to check they are able to carry out surgery safely, and to highlight any issues that might need addressing. Fear: Rating of worry levels, from manageable to overwhelming. Energy levels: A check of physical wellbeing. Balance: Is there a healthy work/life balance with adequate space for hobbies, fitness and downtime? Resources: Access to support resources in the workplace (and at home). Inappropriate coping strategies: Is there any reliance on alcohol, drugs, medication, or any other potentially detrimental approach? Life events: Whether they’re experiencing any big changes, such as divorce, children leaving for college, bereavement or similar. Effective leadership (or engagement): Whether there is a reassuring compassionate direction from management (as well as one’s supportive environment).
Better compassion-based systemic integration Surgeons are in a vulnerable position, psychologically, within a very high stress occupation. The work I am undertaking with CBS emphasises it is ok for surgeons to say, ‘I am human’, and to address their own needs; consider the age-old oxygen mask aeroplane analogy: if you don’t keep yourself alive, how are you going to help others? We have to look at a very integrated intelligent system that ideally clearly links up checks, checklists, balancing, and technical tools. These all lead the way to a more enfranchised and holistically healthy working environment.
Clearer communication and expectations These now need to be renegotiated within a much clearer and fluid process. This process cannot rely on surgeons to be responsible
The Confederation of British Surgery
The Confederation of British Surgery (
www.cbsgb.co.uk), which is the UK’s only trade union to be recognised under UK law to protect the welfare of the whole surgical team, recognises the need to address stress before it impacts mental health, and is now offering resources that will specifically address the pressures of surgery, such as adverse events, medico-legal stresses and the seismic shift from traditional leadership approaches, with the key being in addressing potential issues at an early stage. A counselling service is provided free of
charge to members of the Confederation via Health Assured (
https://www.healthassured. org/employee-assistance-programmes/), which is renowned for offering inclusive and bespoke support with a real focus on wellbeing. Support is offered via comprehensive 24/7 telephone helplines, therapeutic interventions, critical incident stress management, and face- to-face assistance. The holistic service also includes webinars, debt support, personal legal information, access to a health and wellbeing portal, mood trackers, a chat facility, mini-health checks and other wellbeing resources.
for, or to control, the patients. In addition, the patients’ families need to be positively engaged with the psychoeducation, as well as developing within the patient the reality that the surgeon will solve all, while the patient remains passive, disengaged and judgemental. The health consumer needs to consider lifestyle factors that will prepare and improve their health and well-being before surgery, as well as taking steps to understand and address their own self-care, much like in the FEBRILE acronym. This more co-responsible, collaborative engagement in health links to each person taking positive responsible ownership over their own care and health, and works with them to understand that the surgeons and surgical teams are finite precious health resources. Health consumers need to recognise the multifaceted responsibilities of surgeons, while surgeons and surgical teams should assess their own work-life balance and realise that they cannot simply attribute emotional issues or complex stress to their patients but must take pro-active action themselves to manage their own lives and health.
Creating culture and values of kindness Addressing the global perspective of how stress affects the entire environment includes both the clinician and the patient. One of the largest internal problems within the profession of surgery is bullying among staff. A recent study identified bullying as one of the most significant contributing factors for psychological distress among surgeons and surgical teams. This needs to be addressed and we must find a positive innovation. The interconnecting relationship between adverse events and toxic work culture is likely to create a vicious cycle of continuing problems. Adverse events in surgery, such as wrong patient, wrong site, wrong procedure, or retained foreign body, account for high-level stress in surgeons, who are rarely offered support during investigations. According to GMC research, five doctors
under investigation committed suicide between 2018 and 2020. Empowering surgeons to positively seek support prior to burnout is key in reducing adverse events in surgery, which account for over £2 billion in legal expenses annually. With more support for surgeons and improved mental health resources, adverse and never events are also likely to decrease. Linking up real, lived support and ways to
change vicious cycles to virtuous cycles has led to the Confederation piloting a bullying and harassment helpline, currently available to all members of the British Association of
July 2023 I
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