AANS Neurosurgeon | Volume 28, Number 3, 2019

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To Err Is Humane

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The core goals of neurosurgery residency have remained essentially unchanged for generations — the endowment of trainees with technical expertise, clinical experience, advanced knowledge and academic wherewithal. Yet, the means to achieving those ends have undergone several transformations and in many cases remain a source of active debate or an object lesson in how a small, but insulated, subculture has weathered the sea of changes in medical training.

The Neurosurgeon’s Conundrum

At the heart of this conflict lies the neurosurgeon’s self-concept. If the distilled form of our collective professional purpose is to successfully carry out a number of intellectually complex, physically demanding and genuinely high-stakes tasks day-in and day-out, with a very low error rate, then it follows that the training programs must be infused with a commensurate degree of intensity. Indeed, at their best, neurosurgical residency programs have instilled in trainees a truly compelling sense of extreme ownership, encompassing everything ranging from the care of their patients, to the details of the operations, to the administrative management of their educational and research interests.

Although this more traditional approach to resident training had the advantage of setting an unambiguously high standard. In a less favorable light, it also may have unintentionally contributed to a culture of fear among trainees. Carried to its logical extension, high trainee attrition was more normalized and viewed by some as either an unavoidable consequence of “tough love” or perhaps even a valuable way to “weed out” the weak.

Invariable Evolution

Alongside the incremental changes in duty hours policies (and, eventually, their actual enforcement), these attitudes have eroded — or perhaps evolved — into a general view that, for better or worse, trainees are to be regarded more as students than apprentices. While some would argue that there have been some psychological benefits to this shift, they have also occurred synchronous with broader changes in the attitudes surrounding medical training. The result has been an ego crisis for a field that has been defined by its commitment to forging leaders through trial-by-fire.

Today’s training environment exists in an era of:

  • Escalating malpractice litigation;
  • Moving-target hours restrictions;
  • Highly publicized medical errors;
  • Scrutiny of resident oversight; and
  • Institutional pressure regarding practice efficiency.

The results is that opportunities for independence have been pushed to the later stages of training, replaced by simulation or in some cases abandoned altogether — as in the famed North Service at Massachusetts General Hospital. Taken together with the softening of attitudes towards trainee indoctrination, in many ways, the shiver of fear and anxiety has given way to a shrug of indifference, leaving us wondering: How can we abandon the rod, without spoiling the children of neurosurgery?

Are Neurosurgery Residents Different?

As we previously described, neurosurgical trainees appear to demonstrate a higher degree of innate resistance to burnout — a hypothesis that has since been supported by additional evidence from observational studies.3,4 By extension, this logic also holds that members of our community should be especially well-equipped to receive and internalize constructive feedback in a meaningful fashion — particularly if delivered through practices that are transparent, egalitarian and clearly intended to serve the greater good of the patients, the program and the neurosurgeon’s education. 

Radical Transparency in Neurosurgical Training

Radical transparency is a management strategy developed by Ray Dalio, founder of Bridgewater Associates and author of Principles – a book that outlines this approach and how he believes he was able to drive the success of his hedge firm by “realizing that you have nothing to fear from knowing the truth.”2 Within Bridgewater, radical transparency extends not just to the abstract sharing of ideas and criticism, but also to the public availability of all nearly internal materials, including recordings of meetings, individual performance reviews, records of promotion, disciplinary decisions and so on. Dalio writes:
 

We require people to be extremely open, air disagreements, test each other’s logic, and view discovering mistakes and weaknesses as a good thing that leads to improvement and innovation. It is by continually striving together for the highest levels of truth and excellence that we create meaningful work and meaningful relationships.

There are some obvious differences in the environments; two of the most significant are:

  • Medical errors involve much higher stakes than financial ones.
  • The Match enforces an especially restrictive approach to Human Resources.

Nevertheless, the profound truths at the heart of Dalio’s philosophy hold tremendous potential for revolutionizing neurosurgical training. In a description that could just as easily have been written to outline the Platonic form of a Morbidity and Mortality (M&M) conference, Dalio emphasizes how the commitment to radical transparency has allowed him to:

Create a culture in which it is okay to make mistakes and unacceptable not to learn from them… in which everyone has the right to understand what makes sense and no one has the right to hold a critical opinion without speaking up.

Training Crossroads

Neurosurgical training has reached an odd crossroads — the “Millennial moment” across the medical profession, the age of EPIC and the era of Doctor Death, to name just a few of the cultural oddities whose collisions are inducing our community to rethink its philosophical approach to resident education.1 In many ways, although the high stakes of neurosurgical training bring these issues into sharp relief, they are ultimately not unique. They reflect more profound and unsettling trends in American culture, which have become increasingly unable to a tolerate appraisal with room for anything but admiration. Similarly, although this brief essay has focused on the forces that yielded a culture of indifference among residents, still other insidious trends have created an environment in which many staff and even senior trainees hesitate to deliver honest feedback, for fear of being accused of bullying — or simply having their criticism land on deaf ears.

Evolution in Training is Essential

Our charge is to re-chart the course of our culture, which over-corrected from malignancy to indifference. Our mandate is to re-inject neurosurgical trainees with the sensibility of extreme ownership and the noble truth that a failure is an opportunity to learn, not a demonstration of a personal shortcoming. Radical transparency is ultimately no more than a tool, but perhaps one that will provide a much-needed path forward by promoting a more enlightened perspective on the dialogue between staff and residents and balancing the critical need for hierarchy and experience against the demands of mutual respect, integrity, openness to criticism and, above all, a commitment to truth in the service of patients.

References

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1. Beil, L. (Wondery). (2018). Dr. Death. [Audio podcast].

2. Dalio, R. (2017). Principles life and work. New York: Simon and Schuster.

3. Dyrbye, L. N., Burke, S. E., Hardeman, R. R., Herrin, J., Wittlin, N. M., Yeazel, M., . . . Ryn, M. V. (2018). Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians. Jama, 320(11), 1114.

4. Perry, A., & Graffeo, C. (2018). Like Aloe for Sunscreen: Harm Reduction & Prevention in Neurosurgery Resident Burnout. Retrieved from https://aansneurosurgeon.org/features/like-aloe-for-sunscreen-harm-reduction-prevention-in-neurosurgery-resident-burnout/

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Benjamin Gelber MD | June 19, 2019 at 7:26 pm

I hope Mayo Neurosurgery gets it figured out
Ben Gelber MD
NS ‘79