Comfort Zone

Tagged Complications, comfort zone; Comments 1 ; Posted 11 years ago

One of my surgical mentors made a point of saying “Son, you gotta get out of your comfort zone to excel”. If we operate always within our own comfort zone, we will not add any new surgical problem solving skills to our experience. We will not gain expertise and - relevant to patients – we will decline treatment to sick, high-risk patients.

On the other hand, if we go too far and operate way out of our comfort zone it will create problems, too many complications and unnecessary harm to our trusting patients.

The discussion about “Accountability of doctors” is interesting and emerging not only in Australia but also overseas. Recently, the English NHS published surgeons’ individual performance to “keep the surgeons on their toes”. Our Queensland Health Minister suggested publishing individual surgeons’ performance to make them work harder, try harder and achieve better outcomes.

Most definitely, we need accountability – at various levels. A recent blog covered how registries that are supposed to check on surgical quality provide skewed and false data and lead to the denunciation of units that (as a matter of fact) provide great health care. I gave a few examples of “successful” registries that collect worthless data.

Here I want to give an example of a patient, real or fictional.  Our patient is a woman in her xxx-ties who had treatment for ovarian cancer x years ago. Unfortunately, she developed a recurrence, received more chemotherapy and had a PET-CT scan only recently that was clear.

A few weeks ago she began vomiting, felt ill and finally on the third day presented to the emergency department of a hospital. A CT scan suggested a small bowel obstruction. She spiked a temperature of 38 degrees. A general surgeon was called but s/he declined the invitation to look after her.

I suspect any surgeon would have been concerned that if s/he took her to the operating theatre, there is a possibility she would not do well. I guess there was a realistic chance that he would find a disseminated malignancy, necrotic bowel, etc. in which case there is nothing much anyone could have done. She might even have died within 30 days.

After the first team declined to see her, a second surgical team received a phone call about this woman. They accepted her; she was transferred to the other hospital and the findings from the first emergency centre were confirmed.

This team took the patient to the operating theatre and found …. no cancer. There were loops of bowel involved in adhesions at two different levels. They freed adhesions, resected small bowel in two parts and closed up again. The patient and her family couldn’t believe she survived. A few days ago it did not look like she could live.

The second team might have thought what they would do if the PET CT was incorrect. The reporting of a perioperative death would have come to mind.

No one is comfortable with a patient in acute bowel obstruction. No surgeon would be in his/her comfort zone taking a seriously ill patient to the operating theatre with the patient dying being a real possibility.

The difference between the first and the second surgeon is that one is prepared to leave the comfort zone and the other one is not. For reasons we don’t know. Some teams are comfortable to leave the comfort zone by a mile, others by just a little bit.

Late night, while I type these lines, I receive a phone call from another colleague. “Just wanted to make sure you are around. We take a patient to the operating theatre just now. She is bleeding. We are two O&Gs; we think we’ll be right. Are you happy for us to call you if we need you – just in case?” They were just a tiny little bit out of their comfort zone. Needed reassurance, which they received.

A former trainee who I took under my wings a few years ago, called my a few weeks ago: “Just wanted to see if you are OK with me doing this operation laparoscopically?” I think for a moment. She needs reassurance, confidence. “You’ll be OK. Just make sure you be careful at the xxx step of the procedure and watch out for the xxx structure”. She is slightly out of her comfort zone. Just slightly. She rang me afterwards to tell me how proud she was that she mastered the procedure well. The successful procedure would have extended her zone of comfort and experience.

Under controlled circumstances we sometimes need to be prepared to risk stepping outside our comfort zone - a little. If we are not prepared to do so we will take opportunities away from our patients (to receive health benefits) and from ourselves (to grow our experience).

Where have you stepped outside your comfort zone recently?

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