- Email: [email protected]
Reaching the parts that are hard to reach: expanding the scope of professional education in anaesthesia
“I would have everie man write what he knowes and no more.”– Montaigne
BRITISH JOURNAL OF ANAESTHESIA Volume 99, Number 4, October 2007 British Journal of Anaesthesia 453–6 (2007) doi:10.1093/bja/aem234
Editorial I Reaching the parts that are hard to reach: expanding the scope of professional education in anaesthesia
Stress and anaesthetists Stress arises when an individual feels obligated to respond to a situation but feels unable to cope with the situation’s demands. Some stress appears to be necessary and beneficial, but if an individual is exposed to levels that he or she finds uncomfortably high, psychological difficulties can result. Stress is caused by an individual’s perception and handling of that stressor,3 so what may be stressful to one individual may not be to another. Also, the ability to cope with stress is not a trait in itself, but appears to be related to an individual’s set of traits or personality.4 Is there, then, a typical ‘anaesthetic personality’? The literature reveals two anecdotal descriptions. In 1977, Howat 5 suggested that the typical anaesthetist ‘wishes to be a member of a team. . .. is by nature
gregarious, likes being with others and usually has good relations with his colleagues. He (by which I mean he or she) often has a keen sense of humour. . .. is of a meticulous, even obsessional turn of mind and yet is prepared to adapt himself to changing circumstances’. Further, he notes: ‘we have heard it said that anaesthetists must be a little paranoid’. Another view was offered by Gaba,6 an expert in human factors issues relating to anaesthesia. He suggested that anaesthesia and intensive care attract a particular type of person who seeks out excitement in the dynamic and fast-paced work required: ‘In all likelihood, the emphasis on direct action and the aura of ‘danger’ lurking just below the surface are key factors that attracted many anaesthetists to this line of medical work rather than others’. More objective study began with the work of Reeve.7 He postulated that if an ideal anaesthetic personality could be identified, then selection procedures could be set up which would recruit individuals who were most suited to the work. If people are dissatisfied with their career, then they are not happy, do ‘not derive much joy from professional work in the specialty and constitute a potential for accidents and errors of judgement’. The empirical work that followed aimed at informing the selection procedure for trainee anaesthetists, to try to avoid this sort of mismatch. Reeve7 administered the Cattell 16 PFQ Form C personality questionnaire to 231 trainee anaesthetists. This questionnaire is based on 16 pairs of ‘opposites’—for instance, trusting – suspicious, confident– unsure, tolerant – critical—each linked by an axis similar to a visual analogue scale. Individuals can be assigned a position along that axis for each dimension. Clarke and colleagues8 and Kluger and colleagues9 reported similar studies using the same questionnaire. Clarke and colleagues aimed at seeing whether differences within the profile affected the job satisfaction of an anaesthetist, and administered the questionnaire to 330 staff anaesthetists. Kluger and colleagues aimed at finding out the personality profile of 167 Australian specialist anaesthetists and relating the findings
# The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved. For Permissions, please e-mail: [email protected]
Downloaded from http://bja.oxfordjournals.org/ at UCSF Library on March 27, 2015
Previous work by Larsson and colleagues1 has outlined how young and inexperienced Swedish anaesthetists have feelings of deep inadequacy and loneliness in the face of difficult clinical situations, and often feel unsupported by their seniors. I am sure that this will ring true for colleagues in other countries too. This is unsatisfactory because they cannot learn well when stressed, and this also leads to concerns about recruiting doctors into the specialty if there is a perception that the working life of anaesthetists is more difficult than it needs to be. This theme is developed in this issue of British Journal of Anaesthesia as Larsson and colleagues report an interviewbased investigation into the sources of stress in the work of established specialist anaesthetists and their strategies for coping with them.2 In this editorial, I would like to explore the specific issue of how stress and personality interact in anaesthesia, but then discuss more generally how anaesthesia education might be expanded to encompass, more mindfully, the less obvious aspects of the total professional knowledge in anaesthesia—of which strategies for coping with stress is but one example.
Editorial I
problems did not have any effect. The authors suggested that to improve job satisfaction, and by implication to reduce stress, more attention should be paid to improving working conditions, including control over decisionmaking, and allowing anaesthetists to have more influence on their own work pace and work schedule. There is now a well-developed understanding of how stress in general can be managed,13 but what Larsson and colleagues offer is an insight into the ways which anaesthetists themselves have evolved to manage it.
Stress management as a professional skill These coping strategies do overlap with some of the generic stress management advice, but also go beyond it. They are in this sense specific and unique to our profession. If something here is part of the essence of expertise in anaesthesia, is it possible, first, to describe it and second, to use that knowledge to enhance the training of young anaesthetists? This is the line of argument behind Larsson and colleagues’ work, and the one which we ourselves have pursued.14 – 16 Expertise in anaesthesia, in common with other fields, rests on the successful relationship between different forms of knowledge. There is ‘explicit’ knowledge, which can be readily written down, codified, and communicated in textbooks and journals and set out in examination syllabuses. There is also ‘tacit’ knowledge, defined as ‘knowledge that has not been (and perhaps cannot be) formulated explicitly and therefore cannot be stored or transferred entirely by impersonal means’.14 It is typically acquired by demonstration followed by practice. However, the tacit/explicit division may be artificial: first, in that each relies on the other to make it work in practice and second, in that there are ways of transmitting tacit knowledge, for instance, by making and distributing a video recording of an expert performing a regional anaesthetic block. Thus, where syllabuses for anaesthesia education are set out in terms of knowledge, skills, and attitudes, within each aspect there are both tacit and explicit elements. The acquisition and testing of explicit knowledge are straightforward, but to return to the first question posed above, is it possible to describe the tacit elements of anaesthetic practice? We have shown14 – 16 that it is, but as many of these qualities cannot be measured or quantified, alternative research approaches must be used. The title of this editorial is taken from a piece by Pope, a leading healthcare qualitative researcher in the United Kingdom, and underlines the point that the typical research methods used in the biomedical sciences are not adequate for this task.17 Qualitative methodology may lead to feelings of unfamiliarity or even scepticism among those brought up in the biomedical tradition, but they lend themselves perfectly to a richer understanding of how anaesthetists act and think. Typically, they combine a range of methods—usually observation and interviews—though
454
Downloaded from http://bja.oxfordjournals.org/ at UCSF Library on March 27, 2015
to similar research undertaken in other countries. The comparison of such studies can be difficult, but all three found that anaesthetists were more likely to be bright than dim, serious than happy, independent than dependent, shy than bold, trusting than suspicious, and careful than casual. All appear to contradict the two descriptions at the start of this section. Reeve7 developed his work by distinguishing two types of trainee, judged successful and unsuccessful on the basis of seniors’ assessments of their clinical prowess, and compared their personality findings. The successful trainees demonstrated greater detachment, mental quickness, drive and determination, stability, high standards, selfsufficiency, openness, and self-control. Why might these findings be important? There is little evidence within anaesthesia, but in aviation Stokes and Kite10 suggested that a ‘pilot’s personality traits do not necessarily cause mishaps or failures, but they may enable them – that is, they may contribute to the establishment of conditions which, in combination with other factors, make failures more probable’. Stress can lead to error in that individuals have a limited ability for cognitive processing. Many commonly performed tasks are done on mental ‘autopilot’ but, during periods of stress, such behaviour may be bypassed by other mental processing. Thus, in anaesthesia, if well-practised skills apparently fail, it may be because of concurrent stress or personality deficiencies.9 ‘Premature closure’ (making a decision before all relevant information has been identified) can also occur and may also be considered hazardous. Defensive personality traits may become manifest, rendering pilots unable to work as part of the team. This failing has certainly been the cause of many aviation accidents.10 What, then, is stressful about anaesthesia? All the foregoing assumes that anaesthesia is stressful and some (mostly anaesthetists!) have suggested that it is. Jackson11 has identified some potential stressors: the noisy environment of surgical machinery, ventilators, monitors, and alarms; uncomfortable chairs and poorly designed work spaces. Anaesthetists can also experience difficult interpersonal relationships from working with other specialties with their range of personalities, competencies, motivation, and degrees of cooperation. However, Nyssen and colleagues’3 study found that mean stress levels among anaesthetists were not higher than in the other working populations studied. This would be consistent with the premise that, although anaesthesia may well be stressful, anaesthetists are well placed to cope with it, whether through their underlying personality or through strategies they have developed. Kinzl and colleagues12 studied job satisfaction, physical health, emotional well-being, and working conditions (as assessed by the Instrument for Stress-related Job Analysis) in 125 Austrian and Swiss anaesthetists. Control over work had a strong effect on job satisfaction in anaesthetists, especially time control and participation, whereas task demands and task-related
Editorial I
teachers and learners spend together provide a ‘short-cut’, or perhaps accelerate in some way, the progression towards expertise? This is not straightforward in theory, as it suggests we must make visible and audible things that are often neither seen nor heard. We have highlighted a number of ways of doing this,14 24 but have not so far tested the effect of these suggestions. Experienced practitioners can help simply by talking about what they do. Verbalizing how they are thinking as they balance different sources of knowledge about the patient ‘unlocks’ their experience and makes it available for learning. Talking through practical techniques and exploring the wider scope of practice in discussion can also help, and both are uniquely suited to workplace teaching. Anecdotes from practice (‘cautionary tales’) can also provide vivid and memorable learning points. The morbidity and mortality sections of departmental meetings are also worthwhile starting-points for anaesthetists to share the knowledge born of experience. Larsson and colleagues25 have previously described how anaesthetists have different ‘ways of understanding’ their work, and such themes help specialists explain, and trainees appreciate, the essence of expert anaesthetic practice. In the rush to embrace ‘evidence-based’ practice, we should not forget what it is that makes us effective as expert anaesthetists and shapes our professional identity and consciousness. Developing and testing such approaches is the next step we should take towards expanding the scope of professional education in anaesthesia. A. F. Smith Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK E-mail: [email protected]
References 1 Larsson J, Rosenqvist U, Holmstro¨m I. Being a young and inexperienced trainee anaesthetist: a phenomenological study on tough working conditions. Acta Anaesthesiol Scand 2006; 50: 653 – 8 2 Larsson J, Rosenqvist U, Holmstro¨m I. Enjoying work or burdened by it? How anaesthetists experience and handle difficulties at work: a qualitative study. Br J Anaes 2007; 99: 493 – 9 3 Nyssen AS, Hansez I, Baele P, Lamy M, De Keyser V. Occupational stress and burnout in anaesthesia. Br J Anaesth 2003; 90: 333 –7 4 Magnusson D. Situational determinants of stress: an interactional perspective. In: Goldberg L, Breznitz S, eds. Handbook of Stress. New York: Free Press, 1982 5 Howat DDC. Anaesthesia as a career. Anaesthesia 1977; 32: 979 – 93 6 Gaba D. Human error in dynamic medical domains. In: Bogner MS, ed. Human Error in Medicine. New Jersey: Lawrence Erlbaum Associates, 1994 7 Reeve P. Selection of anaesthetists: is there a better method? In: Lunn JN, ed. Quality of Care in Anaesthetic Practice. London: Royal Society of Medicine, 1984
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documentary analysis and video may also be used. Analysis proceeds by induction, that is, the themes and findings arise not from some pre-specified hypothesis, but are suggested by the data themselves. Clearly, researchers will have some prior knowledge of the subject—there is never a completely ‘blank canvas’—but should take pains to ensure that this does not overtly colour their view as the work unfolds. One of the strengths of qualitative work is that it builds up a picture of its subject as it makes sense to those being studied and of course potential bias from the researchers should not be allowed to interfere with this. (Note that the problem of finding what one sets out to find is not unique to any one’s research approach. Precisely the same caveats apply in quantitative work, although randomization and blinding can be used to prevent the influencing of results, whether subconscious or deliberate.) There are, too, a number of different ‘schools’ within qualitative research methodology—for instance, Larsson and colleagues adopted a phenomenological perspective, whereas we used an ethnographic approach—but the principles of rigour in research and attention to method hold for all. A past editorial in British Journal of Anaesthesia is a useful review18 and there are now a number of checklists and guides available to help readers understand the workings of qualitative papers.19 20 The second, more difficult but practically important question is, can we help trainees ‘short-circuit’ some of the more laborious, inefficient, and possibly damaging experiences as they learn anaesthesia? How do we make that tacit knowledge more readily available for learning? In the context of stress management, Larsson and colleagues have documented anaesthetists’ strategy of mental readjustment in the face of difficult situations to allow threats to be converted into challenges and of realising that, although there may be a serious risk for the patient, the anaesthetist’s professional identity can remain intact. This is but one example of what have been termed ‘metacompetences’,21 that is, the overarching qualities that act like a glue to bind all the individual facts, practical skills, and attitudes together into the polished all-round performance that is expert anaesthetic practice. Many of these qualities have been itemized in the work of Greaves and Grant,22 and in the development of the anaesthetists’ nontechnical skills system.23 Often these elements are thought of as part of the general professionalism of anaesthesia. Again, there is very little in the anaesthesia literature about this, as is often the case with elements of the ‘unofficial syllabus’ of professional education. As Kearney20 notes, ‘Formal teaching of attitudes rarely occurs; learning attitudes occurs often and by accident through the “informal curriculum”. Future work could explore how anaesthetists handle uncertainty in their work, the relationship with their feelings of control over their work, and the place of affect and emotion in anaesthetic practice. The final issue is how the transfer of tacit knowledge can be promoted. Can enriching and intensifying the time
Editorial II
17 18 19 20 21 22
23
24 25
descriptive study of induction and emergence. Can J Anesth 2005; 52: 915 – 20 Pope C, Mays N. Qualitative research: reaching the parts other methods cannot reach. Br Med J 1995; 311: 42 – 5 Merry AF, Davies JM, Maltby JR. Qualitative research in health care. Br J Anaesth 2000: 84: 552 – 5 Pope C, Ziebland S, Mays N. Analysing qualitative data. Br Med J 2000; 320: 114 – 6 Greenhalgh T, Taylor R. Papers that go beyond numbers (qualitative research). Br Med J 1997; 315: 740 – 3 Kearney RA. Defining professionalism in anaesthesiology. Med Educ 2005; 39: 769 – 76 Greaves JD, Grant J. Watching anaesthetists work: using the professional judgement of consultants to assess the developing clinical competence of trainees. Br J Anaesth 2000; 84: 525 – 33 Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists’ non-technical skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth 2003; 90: 580– 8 Smith A, Goodwin D, Mort M, Pope C. Encouraging expertise in the use of monitoring. J Clin Anesth 2003; 15: 644 Larsson J, Holmstro¨m I, Rosenqvist U. Professional artist, good Samaritan, servant co-ordinator: four ways of understanding the anaesthetist’s work. Acta Anaesthesiol Scand 2003; 47: 787 – 93
British Journal of Anaesthesia 99 (4): 456 –60 (2007) doi:10.1093/bja/aem243
Editorial II Muscle relaxation and depth of anaesthesia: where is the missing link? 1
In the last few years, several monitors have been developed to assess the depth of anaesthesia and to discriminate between its pharmacodynamic components. Most of those monitors have been initially designed to assess the hypnotic component of anaesthesia. Experience has progressively revealed that several factors other than external artifacts can alter the interpretation of what is said to be the depth of anaesthesia, that is, the value of the indices.1 Among those factors, the pharmacodynamic interaction between anaesthetic agents plays a key role,2 and neuromuscular blocking agents (NMBAs) can, theoretically, be involved in that interaction. The calculation of depth of anaesthesia indices is frequently based on EEG recordings. The frequency band associated with EMG activity is close to that of the EEG. As NMBAs modulate EMG activity, they may artificially modify the calculated index3 or suppress valuable information from the signal. Given these theoretical considerations, the variability of the algorithms involved in the calculation of indices, and the limited evidence-based information, actually predicting how a given index may be affected by neuromuscular block during anaesthesia is not easy. Specific studies are needed to address this issue.
Influence of muscle relaxation on depth of anaesthesia In 1946, Gray and Halton4 first suggested that NMBA may affect the depth of the hypnotic or the antinociceptive components of anaesthesia. As NMBAs cross the blood– brain barrier to a very small extent, a hypothetical effect on depth of anaesthesia can only be explained by indirect mechanisms [Fig. 1: (1) and (2)]: the reduction in the amount of proprioceptive inputs to the brain emerging from peripheral muscles and a direct central effect of NMBA metabolites. The first mechanism refers to the de-afferention theory. It has been demonstrated that sensory deprivation causes a decrease in EEG power and a shift towards slower frequencies.5 A reduction in the amount of proprioceptive inputs to the reticulo-thalamic activating system would reduce the level of arousal6 and explain why NMBA administered in dogs during an isoflurane-induced burst suppression pattern significantly increased the periods of isoelectricity.7 However, muscle relaxation does not produce complete sensory deprivation. Should such an effect exist in humans, it would be poorly detectable, and
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8 Clarke IMC, Morin JE, Warnell I. Personality factors and the practice of anaesthesia: a psychometric evaluation. Can J Anaesth 1994; 41: 393– 7 9 Kluger MT, Laidlaw T, Khursandi DS. Personality profiles of Australian anaesthetists. Anaesth Intensive Care 1999; 27: 282 – 6 10 Stokes A, Kite K. Stress and pilot personality. In: Stokes A, Kite K, eds. Flight Stress: Stress, Fatigue and Performance in Aviation. Aldershot: Ashgate Publishing Limited, 1994; 151 –94 11 Jackson SH. The role of stress in anaesthetists’ health and wellbeing. Acta Anaesthesiol Scand 1999; 43: 583 – 602 12 Kinzl J, Knotzer H, Traweger C, Lederer T, Heidegger T, Benzer A. Influence of working conditions on job satisfaction of anaesthetists. Br J Anaesth 2005; 94: 211 –5 13 Association of Anaesthetists of Great Britain and Ireland. Stress and Anaesthetists. London: AAGBI, 1999. Available from www. aagbi.org (accessed 27 June 2007). 14 Smith AF, Goodwin D, Mort M, Pope C. Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia. Br J Anaesth 2003; 91: 319– 28 15 Smith AF, Mort M, Goodwin D, Pope C. Making monitoring ‘work’: human-machine interaction and patient safety in anaesthesia. Anaesthesia 2003; 58: 1070 – 8 16 Smith AF, Pope C, Goodwin D, Mort M. Communication between anesthesiologists, patients and the anesthesia team: a
BRITISH JOURNAL OF ANAESTHESIA Volume 99, Number 4, October 2007 British Journal of Anaesthesia 453–6 (2007) doi:10.1093/bja/aem234
Editorial I Reaching the parts that are hard to reach: expanding the scope of professional education in anaesthesia
Stress and anaesthetists Stress arises when an individual feels obligated to respond to a situation but feels unable to cope with the situation’s demands. Some stress appears to be necessary and beneficial, but if an individual is exposed to levels that he or she finds uncomfortably high, psychological difficulties can result. Stress is caused by an individual’s perception and handling of that stressor,3 so what may be stressful to one individual may not be to another. Also, the ability to cope with stress is not a trait in itself, but appears to be related to an individual’s set of traits or personality.4 Is there, then, a typical ‘anaesthetic personality’? The literature reveals two anecdotal descriptions. In 1977, Howat 5 suggested that the typical anaesthetist ‘wishes to be a member of a team. . .. is by nature
gregarious, likes being with others and usually has good relations with his colleagues. He (by which I mean he or she) often has a keen sense of humour. . .. is of a meticulous, even obsessional turn of mind and yet is prepared to adapt himself to changing circumstances’. Further, he notes: ‘we have heard it said that anaesthetists must be a little paranoid’. Another view was offered by Gaba,6 an expert in human factors issues relating to anaesthesia. He suggested that anaesthesia and intensive care attract a particular type of person who seeks out excitement in the dynamic and fast-paced work required: ‘In all likelihood, the emphasis on direct action and the aura of ‘danger’ lurking just below the surface are key factors that attracted many anaesthetists to this line of medical work rather than others’. More objective study began with the work of Reeve.7 He postulated that if an ideal anaesthetic personality could be identified, then selection procedures could be set up which would recruit individuals who were most suited to the work. If people are dissatisfied with their career, then they are not happy, do ‘not derive much joy from professional work in the specialty and constitute a potential for accidents and errors of judgement’. The empirical work that followed aimed at informing the selection procedure for trainee anaesthetists, to try to avoid this sort of mismatch. Reeve7 administered the Cattell 16 PFQ Form C personality questionnaire to 231 trainee anaesthetists. This questionnaire is based on 16 pairs of ‘opposites’—for instance, trusting – suspicious, confident– unsure, tolerant – critical—each linked by an axis similar to a visual analogue scale. Individuals can be assigned a position along that axis for each dimension. Clarke and colleagues8 and Kluger and colleagues9 reported similar studies using the same questionnaire. Clarke and colleagues aimed at seeing whether differences within the profile affected the job satisfaction of an anaesthetist, and administered the questionnaire to 330 staff anaesthetists. Kluger and colleagues aimed at finding out the personality profile of 167 Australian specialist anaesthetists and relating the findings
# The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved. For Permissions, please e-mail: [email protected]
Downloaded from http://bja.oxfordjournals.org/ at UCSF Library on March 27, 2015
Previous work by Larsson and colleagues1 has outlined how young and inexperienced Swedish anaesthetists have feelings of deep inadequacy and loneliness in the face of difficult clinical situations, and often feel unsupported by their seniors. I am sure that this will ring true for colleagues in other countries too. This is unsatisfactory because they cannot learn well when stressed, and this also leads to concerns about recruiting doctors into the specialty if there is a perception that the working life of anaesthetists is more difficult than it needs to be. This theme is developed in this issue of British Journal of Anaesthesia as Larsson and colleagues report an interviewbased investigation into the sources of stress in the work of established specialist anaesthetists and their strategies for coping with them.2 In this editorial, I would like to explore the specific issue of how stress and personality interact in anaesthesia, but then discuss more generally how anaesthesia education might be expanded to encompass, more mindfully, the less obvious aspects of the total professional knowledge in anaesthesia—of which strategies for coping with stress is but one example.
Editorial I
problems did not have any effect. The authors suggested that to improve job satisfaction, and by implication to reduce stress, more attention should be paid to improving working conditions, including control over decisionmaking, and allowing anaesthetists to have more influence on their own work pace and work schedule. There is now a well-developed understanding of how stress in general can be managed,13 but what Larsson and colleagues offer is an insight into the ways which anaesthetists themselves have evolved to manage it.
Stress management as a professional skill These coping strategies do overlap with some of the generic stress management advice, but also go beyond it. They are in this sense specific and unique to our profession. If something here is part of the essence of expertise in anaesthesia, is it possible, first, to describe it and second, to use that knowledge to enhance the training of young anaesthetists? This is the line of argument behind Larsson and colleagues’ work, and the one which we ourselves have pursued.14 – 16 Expertise in anaesthesia, in common with other fields, rests on the successful relationship between different forms of knowledge. There is ‘explicit’ knowledge, which can be readily written down, codified, and communicated in textbooks and journals and set out in examination syllabuses. There is also ‘tacit’ knowledge, defined as ‘knowledge that has not been (and perhaps cannot be) formulated explicitly and therefore cannot be stored or transferred entirely by impersonal means’.14 It is typically acquired by demonstration followed by practice. However, the tacit/explicit division may be artificial: first, in that each relies on the other to make it work in practice and second, in that there are ways of transmitting tacit knowledge, for instance, by making and distributing a video recording of an expert performing a regional anaesthetic block. Thus, where syllabuses for anaesthesia education are set out in terms of knowledge, skills, and attitudes, within each aspect there are both tacit and explicit elements. The acquisition and testing of explicit knowledge are straightforward, but to return to the first question posed above, is it possible to describe the tacit elements of anaesthetic practice? We have shown14 – 16 that it is, but as many of these qualities cannot be measured or quantified, alternative research approaches must be used. The title of this editorial is taken from a piece by Pope, a leading healthcare qualitative researcher in the United Kingdom, and underlines the point that the typical research methods used in the biomedical sciences are not adequate for this task.17 Qualitative methodology may lead to feelings of unfamiliarity or even scepticism among those brought up in the biomedical tradition, but they lend themselves perfectly to a richer understanding of how anaesthetists act and think. Typically, they combine a range of methods—usually observation and interviews—though
454
Downloaded from http://bja.oxfordjournals.org/ at UCSF Library on March 27, 2015
to similar research undertaken in other countries. The comparison of such studies can be difficult, but all three found that anaesthetists were more likely to be bright than dim, serious than happy, independent than dependent, shy than bold, trusting than suspicious, and careful than casual. All appear to contradict the two descriptions at the start of this section. Reeve7 developed his work by distinguishing two types of trainee, judged successful and unsuccessful on the basis of seniors’ assessments of their clinical prowess, and compared their personality findings. The successful trainees demonstrated greater detachment, mental quickness, drive and determination, stability, high standards, selfsufficiency, openness, and self-control. Why might these findings be important? There is little evidence within anaesthesia, but in aviation Stokes and Kite10 suggested that a ‘pilot’s personality traits do not necessarily cause mishaps or failures, but they may enable them – that is, they may contribute to the establishment of conditions which, in combination with other factors, make failures more probable’. Stress can lead to error in that individuals have a limited ability for cognitive processing. Many commonly performed tasks are done on mental ‘autopilot’ but, during periods of stress, such behaviour may be bypassed by other mental processing. Thus, in anaesthesia, if well-practised skills apparently fail, it may be because of concurrent stress or personality deficiencies.9 ‘Premature closure’ (making a decision before all relevant information has been identified) can also occur and may also be considered hazardous. Defensive personality traits may become manifest, rendering pilots unable to work as part of the team. This failing has certainly been the cause of many aviation accidents.10 What, then, is stressful about anaesthesia? All the foregoing assumes that anaesthesia is stressful and some (mostly anaesthetists!) have suggested that it is. Jackson11 has identified some potential stressors: the noisy environment of surgical machinery, ventilators, monitors, and alarms; uncomfortable chairs and poorly designed work spaces. Anaesthetists can also experience difficult interpersonal relationships from working with other specialties with their range of personalities, competencies, motivation, and degrees of cooperation. However, Nyssen and colleagues’3 study found that mean stress levels among anaesthetists were not higher than in the other working populations studied. This would be consistent with the premise that, although anaesthesia may well be stressful, anaesthetists are well placed to cope with it, whether through their underlying personality or through strategies they have developed. Kinzl and colleagues12 studied job satisfaction, physical health, emotional well-being, and working conditions (as assessed by the Instrument for Stress-related Job Analysis) in 125 Austrian and Swiss anaesthetists. Control over work had a strong effect on job satisfaction in anaesthetists, especially time control and participation, whereas task demands and task-related
Editorial I
teachers and learners spend together provide a ‘short-cut’, or perhaps accelerate in some way, the progression towards expertise? This is not straightforward in theory, as it suggests we must make visible and audible things that are often neither seen nor heard. We have highlighted a number of ways of doing this,14 24 but have not so far tested the effect of these suggestions. Experienced practitioners can help simply by talking about what they do. Verbalizing how they are thinking as they balance different sources of knowledge about the patient ‘unlocks’ their experience and makes it available for learning. Talking through practical techniques and exploring the wider scope of practice in discussion can also help, and both are uniquely suited to workplace teaching. Anecdotes from practice (‘cautionary tales’) can also provide vivid and memorable learning points. The morbidity and mortality sections of departmental meetings are also worthwhile starting-points for anaesthetists to share the knowledge born of experience. Larsson and colleagues25 have previously described how anaesthetists have different ‘ways of understanding’ their work, and such themes help specialists explain, and trainees appreciate, the essence of expert anaesthetic practice. In the rush to embrace ‘evidence-based’ practice, we should not forget what it is that makes us effective as expert anaesthetists and shapes our professional identity and consciousness. Developing and testing such approaches is the next step we should take towards expanding the scope of professional education in anaesthesia. A. F. Smith Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK E-mail: [email protected]
References 1 Larsson J, Rosenqvist U, Holmstro¨m I. Being a young and inexperienced trainee anaesthetist: a phenomenological study on tough working conditions. Acta Anaesthesiol Scand 2006; 50: 653 – 8 2 Larsson J, Rosenqvist U, Holmstro¨m I. Enjoying work or burdened by it? How anaesthetists experience and handle difficulties at work: a qualitative study. Br J Anaes 2007; 99: 493 – 9 3 Nyssen AS, Hansez I, Baele P, Lamy M, De Keyser V. Occupational stress and burnout in anaesthesia. Br J Anaesth 2003; 90: 333 –7 4 Magnusson D. Situational determinants of stress: an interactional perspective. In: Goldberg L, Breznitz S, eds. Handbook of Stress. New York: Free Press, 1982 5 Howat DDC. Anaesthesia as a career. Anaesthesia 1977; 32: 979 – 93 6 Gaba D. Human error in dynamic medical domains. In: Bogner MS, ed. Human Error in Medicine. New Jersey: Lawrence Erlbaum Associates, 1994 7 Reeve P. Selection of anaesthetists: is there a better method? In: Lunn JN, ed. Quality of Care in Anaesthetic Practice. London: Royal Society of Medicine, 1984
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documentary analysis and video may also be used. Analysis proceeds by induction, that is, the themes and findings arise not from some pre-specified hypothesis, but are suggested by the data themselves. Clearly, researchers will have some prior knowledge of the subject—there is never a completely ‘blank canvas’—but should take pains to ensure that this does not overtly colour their view as the work unfolds. One of the strengths of qualitative work is that it builds up a picture of its subject as it makes sense to those being studied and of course potential bias from the researchers should not be allowed to interfere with this. (Note that the problem of finding what one sets out to find is not unique to any one’s research approach. Precisely the same caveats apply in quantitative work, although randomization and blinding can be used to prevent the influencing of results, whether subconscious or deliberate.) There are, too, a number of different ‘schools’ within qualitative research methodology—for instance, Larsson and colleagues adopted a phenomenological perspective, whereas we used an ethnographic approach—but the principles of rigour in research and attention to method hold for all. A past editorial in British Journal of Anaesthesia is a useful review18 and there are now a number of checklists and guides available to help readers understand the workings of qualitative papers.19 20 The second, more difficult but practically important question is, can we help trainees ‘short-circuit’ some of the more laborious, inefficient, and possibly damaging experiences as they learn anaesthesia? How do we make that tacit knowledge more readily available for learning? In the context of stress management, Larsson and colleagues have documented anaesthetists’ strategy of mental readjustment in the face of difficult situations to allow threats to be converted into challenges and of realising that, although there may be a serious risk for the patient, the anaesthetist’s professional identity can remain intact. This is but one example of what have been termed ‘metacompetences’,21 that is, the overarching qualities that act like a glue to bind all the individual facts, practical skills, and attitudes together into the polished all-round performance that is expert anaesthetic practice. Many of these qualities have been itemized in the work of Greaves and Grant,22 and in the development of the anaesthetists’ nontechnical skills system.23 Often these elements are thought of as part of the general professionalism of anaesthesia. Again, there is very little in the anaesthesia literature about this, as is often the case with elements of the ‘unofficial syllabus’ of professional education. As Kearney20 notes, ‘Formal teaching of attitudes rarely occurs; learning attitudes occurs often and by accident through the “informal curriculum”. Future work could explore how anaesthetists handle uncertainty in their work, the relationship with their feelings of control over their work, and the place of affect and emotion in anaesthetic practice. The final issue is how the transfer of tacit knowledge can be promoted. Can enriching and intensifying the time
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descriptive study of induction and emergence. Can J Anesth 2005; 52: 915 – 20 Pope C, Mays N. Qualitative research: reaching the parts other methods cannot reach. Br Med J 1995; 311: 42 – 5 Merry AF, Davies JM, Maltby JR. Qualitative research in health care. Br J Anaesth 2000: 84: 552 – 5 Pope C, Ziebland S, Mays N. Analysing qualitative data. Br Med J 2000; 320: 114 – 6 Greenhalgh T, Taylor R. Papers that go beyond numbers (qualitative research). Br Med J 1997; 315: 740 – 3 Kearney RA. Defining professionalism in anaesthesiology. Med Educ 2005; 39: 769 – 76 Greaves JD, Grant J. Watching anaesthetists work: using the professional judgement of consultants to assess the developing clinical competence of trainees. Br J Anaesth 2000; 84: 525 – 33 Fletcher G, Flin R, McGeorge P, Glavin R, Maran N, Patey R. Anaesthetists’ non-technical skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth 2003; 90: 580– 8 Smith A, Goodwin D, Mort M, Pope C. Encouraging expertise in the use of monitoring. J Clin Anesth 2003; 15: 644 Larsson J, Holmstro¨m I, Rosenqvist U. Professional artist, good Samaritan, servant co-ordinator: four ways of understanding the anaesthetist’s work. Acta Anaesthesiol Scand 2003; 47: 787 – 93
British Journal of Anaesthesia 99 (4): 456 –60 (2007) doi:10.1093/bja/aem243
Editorial II Muscle relaxation and depth of anaesthesia: where is the missing link? 1
In the last few years, several monitors have been developed to assess the depth of anaesthesia and to discriminate between its pharmacodynamic components. Most of those monitors have been initially designed to assess the hypnotic component of anaesthesia. Experience has progressively revealed that several factors other than external artifacts can alter the interpretation of what is said to be the depth of anaesthesia, that is, the value of the indices.1 Among those factors, the pharmacodynamic interaction between anaesthetic agents plays a key role,2 and neuromuscular blocking agents (NMBAs) can, theoretically, be involved in that interaction. The calculation of depth of anaesthesia indices is frequently based on EEG recordings. The frequency band associated with EMG activity is close to that of the EEG. As NMBAs modulate EMG activity, they may artificially modify the calculated index3 or suppress valuable information from the signal. Given these theoretical considerations, the variability of the algorithms involved in the calculation of indices, and the limited evidence-based information, actually predicting how a given index may be affected by neuromuscular block during anaesthesia is not easy. Specific studies are needed to address this issue.
Influence of muscle relaxation on depth of anaesthesia In 1946, Gray and Halton4 first suggested that NMBA may affect the depth of the hypnotic or the antinociceptive components of anaesthesia. As NMBAs cross the blood– brain barrier to a very small extent, a hypothetical effect on depth of anaesthesia can only be explained by indirect mechanisms [Fig. 1: (1) and (2)]: the reduction in the amount of proprioceptive inputs to the brain emerging from peripheral muscles and a direct central effect of NMBA metabolites. The first mechanism refers to the de-afferention theory. It has been demonstrated that sensory deprivation causes a decrease in EEG power and a shift towards slower frequencies.5 A reduction in the amount of proprioceptive inputs to the reticulo-thalamic activating system would reduce the level of arousal6 and explain why NMBA administered in dogs during an isoflurane-induced burst suppression pattern significantly increased the periods of isoelectricity.7 However, muscle relaxation does not produce complete sensory deprivation. Should such an effect exist in humans, it would be poorly detectable, and
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8 Clarke IMC, Morin JE, Warnell I. Personality factors and the practice of anaesthesia: a psychometric evaluation. Can J Anaesth 1994; 41: 393– 7 9 Kluger MT, Laidlaw T, Khursandi DS. Personality profiles of Australian anaesthetists. Anaesth Intensive Care 1999; 27: 282 – 6 10 Stokes A, Kite K. Stress and pilot personality. In: Stokes A, Kite K, eds. Flight Stress: Stress, Fatigue and Performance in Aviation. Aldershot: Ashgate Publishing Limited, 1994; 151 –94 11 Jackson SH. The role of stress in anaesthetists’ health and wellbeing. Acta Anaesthesiol Scand 1999; 43: 583 – 602 12 Kinzl J, Knotzer H, Traweger C, Lederer T, Heidegger T, Benzer A. Influence of working conditions on job satisfaction of anaesthetists. Br J Anaesth 2005; 94: 211 –5 13 Association of Anaesthetists of Great Britain and Ireland. Stress and Anaesthetists. London: AAGBI, 1999. Available from www. aagbi.org (accessed 27 June 2007). 14 Smith AF, Goodwin D, Mort M, Pope C. Expertise in practice: an ethnographic study exploring acquisition and use of knowledge in anaesthesia. Br J Anaesth 2003; 91: 319– 28 15 Smith AF, Mort M, Goodwin D, Pope C. Making monitoring ‘work’: human-machine interaction and patient safety in anaesthesia. Anaesthesia 2003; 58: 1070 – 8 16 Smith AF, Pope C, Goodwin D, Mort M. Communication between anesthesiologists, patients and the anesthesia team: a