CARE (Colleague Advertency Respect and Enquiry)

From the book Tao Te Ching, Lao Tzu (T’zu), translated caring as his “first treasure,” and wrote:

 'from caring comes courage.'

The word courage is derived from the Latin word “cor”.

The Latin - "colere " which means to tend to the earth, care, cultivate and nurture – is the derivative of the word culture.

The environment in which surgeons work can be unforgiving and even hostile. The frequent reply to the question ‘how are you?’ is often met with a shrug and plaintive reply, ‘surviving.’ We know of colleagues (consultants and trainees) who go to work and literally do not have any interaction with other colleagues – nobody bothers, and nobody asks.

Surgical meetings have been described as ‘watching a pack of dogs going round sniffing each other.’  This is not only a reflection of posturing and bravado that appears to be commonplace today, it is also gender-biased. Have you noticed at meetings and in commentaries that replies are statements of ego and self-aggrandisement? We seldom see or hear genuine curiosity or appreciation. Outwardly the community demonstrates compassion, but inwardly it betrays itself. Are we really willing to learn? Do we really listen to our colleagues? Reason should not be a pretext to exert power. Giving people space to think and talk while actively listening offers more ideas and opportunities.

Work is a social construct, people are dependent on people. We should be caring for people who are caring for people. If you feel valued and appreciated, then work will become easier. Machines do not have emotions, people do. Everyone has needs. Basic human needs are a recognition of one’s identity to be included (team or organisation) and to be informed.  Identity can be defined as simply being allowed to be ‘you’. It is inclusive of the whole person in every sense – self, values, morals, beliefs, and gender – diversity is thus implicit and includes neurodiversity. Inclusion engenders a sense of belonging and safety.  Are we psychologically safe? 

We are also hard-wired to seek information – withholding information is a statement of exclusion. It is wielded as an instrument of power and subordination. The failure to satisfy the ‘I’s’ can leave many feeling unwanted and undervalued. Ignoring someone, is in some ways worse than pointing a finger. Lack of inclusion erodes the sense of self-worth that engenders doubt and sadness. Anxiety and a feeling of loss of control is caused by not being informed. We are experiencing increased levels of burn out and witnessing an increase in early retirement. We believe this is because our professional colleagues do not feel cared for or valued. Attitudes appear to arise from hidden agendas that continue to be perpetuated by a historical hierarchical system. Attention to the ‘I’s is the fundamental role of all leaders. But it is not just the role of the leader, we are all leaders every day and everywhere and we believe this is the duty of individuals, our societies, and colleges. We need to flatten our organisations.

The authors are cognisant of all the publications on bullying and harassment at work, and recognise that surgical teams have been cited on social media and vilified in the press for poor behaviours. We believe this is symptomatic of the fact the demand of the service leaves little time for caring for oneself and acknowledging others around you might need care as well. We believe that there are three pivotal periods in your life where you might be in more need of CARE than any other stage:

• The trainee entering the profession or speciality.
• The newly appointed consultant.
• The senior consultant nearing retirement.

The following are not meant to be quixotic ideals, but a simple list of percipient statements adapted from a Barry-Wehmiller blog (CEO Bob Chapman who headlined the FST online conference in 2020).  They collated under themes and although some may appear to be the same, we believe the nuances are different.

The surgeons’ reputation

1. There are no messiahs and your theatre shoes are ‘not wet from walking on water’. This is a reality check – obvious, but we feel must be stated. The ‘god complex’ goes hand in hand with the ‘martyr complex’. Our bad experiences are justified as something that one has to suffer.  Surgery is a very humbling specialty – everyone is an expert, everyone can have an off day and there is no place for super egos or one-upmanship. Surgeons believe they do important work. Tell them why, and that what they do matters. Connect them with the people who use the product of their labors. Use your network and praise generously.
2. Surgeons do not think rules apply to them. It is necessary to challenge the status quo and the way things are done. That is how we improve. Some things we do require protocols. These are not ‘tablets of stone’ that demand unwavering compliance. Record why you feel it is not appropriate. However, quality will be achieved through the restless discontent of the status quo provided it is audited through rapid PDSA cycles.

The individual surgeon

1. Surgeons are people – we are all different. Even though we are ‘cut from the same cloth’, there is no such thing as the same.
2. Surgeons do and think. We are often accused of the former and less than the latter. We should regard ourselves as peers who are entitled to think, and we should cease to compete as thinkers. Thinking is sometimes better than doing. To think is to exist ‘cogito ergo sum’.
3. Surgeons must be hard. There is a thin line between confidence and arrogance. Deep down many of us have had our moments and misgivings, but it is often perceived as a weakness to discuss them – this is not healthy. We should welcome feelings, as feelings are so interwoven with our thinking, and to exclude one will deny both.
4. Surgeons are rambunctious. This is the regolith and moraine of quixotic historical stereotypes. Some still are, but many are not. It is certainly less prevalent in the new generation.
5. Surgeons like to get on with it – while this is admirable, time and reflection are important tools in decision making.
6. Surgeons like to be in control (or like to think they are in control). Do not tell surgeons what to do but invite them to reflect and contribute.
7. Surgeons want to know what is expected of them and how they are doing – feedback and acknowledgement is important. Whenever possible, give them ways to figure that out for themselves. When that is not possible give people regular and useful feedback. That includes praise. Praise, appreciation, and respect create a psychologically safe environment.
8. Surgeons believe they are competent. Let them demonstrate it. Help them do work that builds on their strengths and give them encouragement.
9. Surgeons dread harm and losses. The very nature of our work means that the outcome cannot always be guaranteed. We need to be honest with the patient, ourselves, and our colleagues. Above all we need to be able to look ourselves in the mirror and be able to say, ‘I have done my best’. Colleagues need to be able to reaffirm; acknowledge, articulate, and not assume.
10. Surgeons are a cognitive species that like explanations and value peer recommendation. Please share the explanations and do not assume.
11. Surgeons want to grow and develop. Offer them opportunities as individuals and teams and departments.
12. Surgeons are goal directed, and share the goals and aspirations for the team. A team with a good reputation in education and research is an attractor.
13. Surgeons like to think they are good. Great – we want good surgeons. But we would like to see your data. We work in a ‘show me environment.’ Edward Deming said, ‘In God we trust…everyone else requires data’.
14. Surgeons like to think they are better – we can only aspire to better ourselves each day.

Surgeons are human

1. People have names, surgeons have names. We are not cells on a ‘holiday-payday-rota-excel-spreadsheet’. Use names, first names or use a name that they are comfortable with. When in doubt, ask them what they would like you to call them.
2. Surgeons are people and people like to be thanked. Thank them for their work, for their effort, for helping other people. The ratio of praise to criticism is really 5:1.
3. Surgeons want to be recognised and applauded. Say well done!
4. Surgeons are fallible. Mishaps happen – learn and do not blame. Humility goes a long way, as it could be you next time.

Surgical behaviors

1. Surgeons tend to do things a particular way because that is ‘the way we have always done it around here.’ This is a dogma that stifles creativity and enquiry.
2. Surgeons tend to do things in a particular way. It may appear to be odd, but have you thought that this might be a ritual to ‘get into the zone’. Respect.
3. Surgeons believe the way they do things is better than anyone else. ‘My recipe and way of doing things is better’. Wrong – it is different, and it works for you. But who is doing it best? Who had the lowest wound infection and why? Aren’t you curious? Positive deviance rules.
4. Surgeons are customers in everyday life. We all have expectations when we pay for services. We can all identify and agree on what is excellent service, good service, and poor service. Well, the patient pays for the surgeons’ service though taxes. The operative word in NHS is SERVICE. We are all here to serve. Our visceral expectations of the service outside the hospital, should apply to our own service delivery within the hospital.

The surgical identity

1. The ‘club culture’ with the ‘brogue-blazer-tie’ uniform is of yesteryear but the ‘rites of passage’ still pervade, and exclusive membership is manifest in societies that threaten sameness of thought.
2. Cultures, colleges, and societies, consciously and unconsciously, resist difference. We should be championing and welcoming our inherent diversity of identity and thinking. Therein lies solutions and possibilities. Our workforce has never been so diverse, and we are better off.
3. Above all we are equal, no matter our station.

The role

1. Surgery is not a function. Decisions come before incisions. Care is more holistic and being a surgeon means a lot more. Role models and mentors are needed, for our task is hard and the road is long.
2. Surgeons cannot work alone. A surgeon in theatre without a team is like a fish out of water. We can only do what we do thanks to the skills and support of a whole team.
3. What is the individuals added value? Let them control as much of their work life as is possible. Help them contribute.

Communication

1. Surgeons can be proud of their reputation and skills. However, we are only as good as our last operation and our reputation is only as good as our last encounter with other people. Operative outcomes alone are not what makes a good surgeon. Maya Angelou shares, 'I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel’.
2. Surgeons like to think they are right – wrong! It is in the very nature of all people to think they are right. In essence, it is a perspective and when working in our highly complex field, multiple perspectives need to be sorted, shared, and acknowledged. After all, is that not the function of an MDT? We all suffer from cognitive infirmities. Conversely ‘I don’t know’ should be respected and not derided as a sign of weakness. That is what multidisciplinary teams are for. It is also acceptable to say no.

The surgical team 

1. Surgeons prefer to work with people that share the same values. Make those explicit and reflect on what they mean to individuals and to the team. Group dynamics are important – take time out for the coffee conversations to clarify expectations and appreciate needs. Pay attention to things that keep the team a safe and enjoyable place to work. Attend to the grumbles early.

Work-life balance

1. Surgeons have a life. Work is just a part of it. People bring their whole selves to work, and they will bring pieces of that life to work with them. Parts of their outside life will have an impact on how they work.

To err is to human

1. Surgeons have off days. Even the best, most productive, most cheerful people have days when they make mistakes, are not productive, and are grumpy. That is part of the deal. Treat them like people and you get their best. You will also have off days.
2. Surgeons as people cannot be consistently rational. However, we can collectively, by instituting and respecting norms that guide the collective effort. This is why we have MDT.
3. Surgeons have ideas and are creative. When they have ideas, they want to share them. When they share them, treat those ideas like the gift that they are. Sure, most ideas need a little tweaking to work. Some ideas will not work at all. But every idea is a gift. Help bring them to fruition. This applies to the trainee and the new appointment alike.
4. Surgeons’ decision-making is based on rules of thumb and is experiential. The Nobel Prize laureate Daniel Kahneman observed this. The person who is probably more up to date on the literature and modern practice is the trainee. They are a very useful source of information and ideas. The senior consultant has probably seen it before! Evidence and experience can go hand in hand, respecting the roles and journeys individuals have made to get to that point.
5. Difficult decisions should be shared, and colleagues who are pondering ‘what is best for my patient?’ should be supported and not branded indecisive or ‘can’t cut it!’.
6. The ‘doing’ surgeons are presumed competent, having passed all the necessary credentialing. Experience is a volume of competency. This is where the science becomes the art. We are all on a journey of mastery – a senior surgeon is on the same journey but has been on the road longer – this is the definition of a ‘sensei’.  We need to value the sensei. Appreciation of mastery over competency should be encouraged at an individual and institutional level.

Bottom Line

Surgeons are people. People want to be treated like people at every level. Treat people like people and a person who feels appreciated will always go the extra mile – this applies to all stages of the surgical career.

We are Fellows of the RCSEd – professional colleagues. Everyone is an expert. There is no room for one-upmanship. Blue on blue fire should be regarded as reprehensible. We should also be mindful of a colleague’s reputation in their presence and in their absence. We should make it our intention not to gossip or to listen to gossip. Nothing but harm will come of it. It is inherently unjust, and unbecoming, especially among Fellows.

We do not have to be friends at work and do not have to be round at each other’s homes every other weekend. Everyone on the team has a role to play, just as members of a football team. Appreciate individual skills, values and the whole being that is brought to work. Leading involves hearts and minds – in that order. It is time to enact the “cor” in “courage” by recognizing “our first treasure – T’zu or care. Let us bring the human element back to the workplace – we can all care and, in these trying times, care will go a long way.

An article by David J O'Regan - Director of the Faculty of Surgical Trainers (FST), Chris Caddy - RCSEd Council Member, Mark Peter - Past Chair of RCSEd Younger Fellows, Haroon Rehman - Chair of RCSEd Trainees' Committee