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Metacognition, Error Management and Intellectual Humility


Bill Bigelow
Wilfred G Bigelow

Cardiac Surgery Chair Chris Caldarone described Thoralf Sundt as a summa cum laude graduate of Princeton, in the same class as Jim Rutka. Thor finished medical school at Johns Hopkins and surgical residency at the Massachusetts General Hospital. He completed cardiothoracic training at Washington University in St. Louis and Harefield Hospital in England.

Thor drew attention to the Bigelow family of surgeons who practiced in Boston and quoted generously from Bill Bigelow's book Cold Hearts. He emphasized Bill's interest in the relationship of the mind and body to the practice of medicine, as well of the importance of teaching "the limits of what we know", a touching reference to the intellectual humility of this brilliant surgeon.

Thor presented a difficult case- a 40 year old father of two children who had undergone prior radiation for Hodgkin's disease. Following coronary bypass and mitral valve reconstruction, he returned with endocarditis. His second operation required a Cabral aortic root replacement with reimplantation of the coronary arteries. The patient developed right ventricular failure and eventually died, despite mechanical support with a right ventricular assist device. At post-mortem examination, the right coronary graft was kinked, so no amount of right ventricular assist would solve the problem.

Thoralf M. Sundt
Thoralf M. Sundt

The axiom "check the right coronary artery if the right ventricle is failing" is now the answer to a standard board examination question, but it was completely overlooked during this tragic case. The case inspired Thor's interest in metacognition – the study of cognition as typified by Daniel Kahneman, Nobel laureate in economics. His book ‘Thinking Fast and Slow" is a current New York Times best seller. Surgeons are decision –makers and they rely heavily on fast thinking. It is important for management of complex problems to also include slow thinking . This has been well illustrated in previous rounds and publications by our colleague Carol- Anne Moulton (1).

"Surgeons rely on heuristics (rules of thumb and shortcuts to conclusions) and their decisions are influenced by biases. Important components of surgical thinking are pattern recognition, availability and recency bias, hedonic impact (acceptability), selective attention, fixation (for example on the right ventricle instead of the right coronary) and intuitive decision making (the fast track)." Thor drew our attention to "How We Know What Isn't So?" by Thomas Gilovich. He told an interesting anecdote about his son's refusal to accept Gilovich's disproving the notion of "the hot hand" in basketball. His son was a college basketball player, and like most athletes and sports fans, he still believes in the mythology of the "hot hand".

"In general, we find the unexpected to be unpleasant; the amygdala reacts because it does not like the unexpected. Francis Bacon and Bill Bigelow knew well the problem of confirmation bias. We reject disconfirmatory evidence, even after we have seen convincing evidence against our perceptually biased view."

Thor emphasized the importance of team work in the management of errors. He quoted Denis Cortese, the former CEO of the Mayo Clinic. "When doctors work together before graduation, their collaboration is called cheating, when they work together after, it is called collaboration." This is a problematical approach to teaching team work. Complexity leads to errors and errors can be managed in three general ways: 1. Avoid them, 2. Trap them and 3. Mitigate them. High reliability organizations manage error by stepping back, trapping the error and then mitigating it. Thor recommends "mindful engagement- not checklists". He recognized that he was speaking in a "checklist monastery", but stated nonetheless that he feels mindful engagement is even better, i.e. asking each team member to say what they think and what they worry about during the team huddle - to speak before the crisis, not simply listen to a recitation of the checklist. Thor conducted a briefing study on mindful engagement. He found that it cut the time that the circulating nurse is out of the operating room in half, and cut errors in half.

He quoted Tony Dungee, All-American football player at the University of Minnesota and Super Bowl winning coach of the Indiana Colts: "I don't know anyone who performs better if you yell at them". This approach worked well in Dungee's practice, though it goes against the style of Vince Lombardi, John Madden and other more punitive coaches.

Thor presented a second case, a Christmas day cardiac transplant on a patient with a left ventricular assist device. The perfusionist knew in advance that there would be problems, but did not speak up. The transplant resulted in air embolization, causing fatal cerebral damage. Like the perfusionist, most people won't speak up, even when they know that there is a problem- even if they themselves may be harmed (see Marv Tile's comment below).

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Non-Technical Skills for surgeons like communication and leadership are evaluated in 360 degree assessments at Massachusetts General Hospital. Thor showed his own 360 assessment, including less flattering comments made by his colleagues under the headings of "start to do the following" and "stop doing these things."

Thor closed on a gracious note, reminding us that "we all want to be like Bill Bigelow, imitating his humility, his open-mindedness, and his kindness and consideration".

In the discussion period, Bernie Goldman told the story about Bigelow's humility in the laboratory. "We were fixed on the outcome and didn't realize that we had not found hibernin - the imaginary hormone that allows the groundhog to hibernate. It was only when outside people- the organic chemists - looked at our work that we finally found our isolated magic molecule was a solvent eluted from for the plastic tubing used in our separation process. We had a fixed focus." The importance of asking others was a recurring theme in the lecture. Bigelow published this embarrassing lesson in a famous article in the journal Surgery.

Chris Caldarone commented on the data showing that interns sign out with a slow, extremely detailed process that would take pages to record. Intermediate staff use paragraphs, and senior staff use extremely short words or facts. "We only mention out of pattern patients: ‘Watch this guy, the rest are OK'". Kahneman points out that fast thinking like that can be quite problematic. Novices think algorithmically and therefore slowly. Experts think fast, but they have more risk of confirmation bias. Outsiders pause and ask: "Are we ready?" at single points of vulnerability. At those points, the team should go to a low energy, cautious state, similar to Carol-Anne Moulton's work on slowing down in crises.

Avery Nathens asked about how teamwork should be taught. Thor feels that it is probably best done through role modeling. He has tried crew resource management, using a day spent with representatives of the airline industry. "These lessons don't last." He is trying to transform a whole department, but has not yet found the ideal technique.

Marv Tile recommended the book "Surgeons, Pilots and Astronauts" and told the story of the navigator who, though he knew the plane was running out of gas, did not speak up against the authority gradient, so that he would not offend the pilot and first officer. Andrew Dueck said work hour limitations, the assignment of an acute care service, nurse changeovers in the operating room and 12 hour cases are causes of handover errors that we can't control. Thor answered that "continuity was our remedy in the old days - no time off, endless hours on call." This has drawn attention to better signoffs and importance of mindful engagement. To bring each new participant up to speed, the airlines use an action plan called "creating a team and maintaining a team". It requires a thorough briefing, not just "I am covering lunch".

David Latter asked about the larger team, the physiotherapists and others who are not usually considered part of the surgical cockpit crew.

"To address this, Bruce Keogh in the UK has dropped reporting outcome by surgeon and reports instead the outcome by surgical team. Anecdotally, Members of Parliament were shocked to learn from that study that half the surgeons were below average, unlike in Lake Wobegon, the apocryphal Minnesota community, ‘where all the women are strong, all the men are goodlooking, and all the children are above average'."


(1) Moulton, C., Regehr, G, Lingard, L., Merritt C., Macrae, H. Slowing down When You Should': Initiators and Influences of the Transition from the Routine to the Effortful. Journal of Gastrointestinal Surgery, 14.6: 1019-1026, 2010.

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