As a profession, surgery is sometimes depicted as relying on the skills and expertise of highly trained, highly qualified individuals. But in reality, it is much more of a team pursuit and, as much medical literature attests, the skills of teamwork and collaboration are valued at least equally alongside the technical and procedural skills of carrying out surgery itself.
Healthcare as a whole can be described as a network of teams within teams, and all professionals are required to become adept at liaising with professionals in other departments, in other clinical settings, in oversight and multidisciplinary teams and so on. But focusing in on what happens in the surgical department and in the operating room, team structure and communication is an essential part of service delivery.
The Royal College of Surgeons (RCS) is clear about the importance and value of strong teamwork and communication skills to achieving successful surgical outcomes. It states that “surgeons have a duty to promote a positive working environment and effective surgical team working that enhances the performance of their team” and makes explicit the point that “team working is at the centre of safe, effective patient care.” According to Tørring et al, “communicating and relating for the purpose of task orientation” is linked to improved quality of treatment and patient safety, plus an enhanced ability for surgical professionals to learn from mistakes in fast-paced, high-pressure environments.
The RCS is also clear about what is at stake when standards of communication and collaboration are not what they should be. It refers to “growing evidence” from research studies that link medical errors in the operating room to shortcomings in team work and communication. One such study, authored by Healey, Undre and Vincent, connects “adverse events” during surgery to team structure and design itself. The paper further argues that rapid developments in surgical technology, such as the widespread adoption of laparoscopic techniques, are likely to have had a negative impact on teamwork and understanding of roles in operating rooms. While tools and capabilities have changed rapidly, adaptation in terms of team organisation and communication has largely been “ad hoc and variable”, undermining robust and structured approaches to task organisation.
However, if a lag in team dynamics catching up with technological capabilities is a cause for concern, technology is also helping to narrow the gap in other ways. Through the internet, through real-time remote communications, through audio-video streaming and recording, through digital resource sharing platforms and, as in the case of Proximie, through next-gen experiential technologies like Augmented Reality (AR), technology is opening up new pathways to collaboration that are helping surgical teams work more effectively, share expertise more freely and drive up clinical standards.
Why surgeons need to talk
During a surgical procedure, the stakes placed on effective communication and coordination could not be any higher – the patient’s well-being, perhaps even their life is on the line. Successful outcomes do not depend solely on the skill and expertise of individuals, but on the transfer of knowledge and professional dialogue that takes place within surgical teams.
For example, junior grade surgeons are required to operate under the supervision of a consultant, who may sometimes be present in theatre to preside over proceedings. If not, they will offer direction and guidance in pre-operative meetings, and summary oversight in post-operative debriefings. In any of these scenarios, effective means of communication are essential to ensure the team works efficiently and successfully.
Similarly, trainee surgeons learn by watching and doing, by observing skilled practitioners in their work, by operating themselves under the guidance of a senior faculty member. This extends into ongoing professional development and lifelong learning. Peer mentoring and coaching, which can be considered formal approaches to collaboration, are widely recognised as key means by which CPD amongst surgeons takes place. Yet there are concerns that, as workloads mount and expectations around patient flow increase, opportunities for meaningful peer learning are decreasing.
One study observes that, while a culture of “peer-to-peer advisory” in major academic hospitals tends to thrive, in private clinical settings it is much less evident. Another argues that structured feedback and professional discussion fades rapidly after core training. A third suggests that trainees themselves are getting less and less time in the operating room, meaning they get less time to observe and ask questions, but also to have their own practice observed and be provided with guidance.
The fact that there is so much research interest in this area underlines the level of importance the professional and academic community places on peer-to-peer coaching and on collaboration and teamwork in general. Most of the studies that raise concerns over obstacles to effective collaboration are also looking for solutions. The majority find them in technology of one sort or another.
Digital technology has evolved numerous ways to extend and improve lines of communication across all walks of life, and many of them are being applied in surgical settings. For example, in the paper by Elbuluk et al which explores the discrepancies in ‘peer-to-peer advisory’ culture between academic and private surgical settings, the impact of a group messaging platform – a WhatsApp for surgeons, if you like – is assessed. The opportunities this tool opened up for young surgeons in particular to discuss cases with fellow professionals reportedly had a notable impact on standards of patient care, with the authors noting that the “rapid feedback” it enabled trainees to get from a host of sources fitted well with the realities of modern practice.
In a paper by Britto et al published in The BMJ which explores the creation of Learning Healthcare Systems in US clinical settings, the authors discuss the use of a “Pinterest-like” resource sharing platform which served as an “online community commons” where team members can ‘pin’ a wide variety of digital resources for colleagues to reuse, curate, adapt and share. Categories of the type of resources shared include “shared knowledge, shared tools and resources, shared standards and shared situational awareness.”
Video features heavily in the literature available on digital tools being used to aid peer-to-peer collaboration within surgical teams, particularly with regards to applications in coaching and professional development. Many of these studies focus on the use of video recordings of procedures as a basis for mentoring and discussion, replacing or supplementing intraoperative learning by creating space for deeper, more focused and structured analysis.
According to Greenberg et al, the opportunity to review a video of a procedure and discuss observations with a mentor or peer is being successfully applied to developing technical, cognitive and interpersonal skills in the operating room, as well as strategies for managing stress. Hu et al (2012) highlight how these strategies are being used for development purposes by surgeons of all levels of expertise. Hu et al (2017) find evidence of better learning outcomes, with mentors able to make more teaching points per unit of time compared to making observations during procedures and apparently better results for the development of higher-level concepts like decision-making.
Video is also being used during ‘live’ procedures as a communication and collaboration tool, both to support coaching and skills development and to help teams actually carry out operations. Indeed, video’s most widespread application in surgery is probably as a visualisation tool, with examples like laparoscopy using cameras and screens to reinvent what practitioners can see anatomically and how surgery itself can be carried out.
The Proximie platform aids visualisation in different ways, namely by connecting practitioners over distance, allowing consultants, specialists and trainees to observe via video link when the normal rules of space and time would otherwise make it impossible. The AR overlay adds extra depth to the collaboration. Rather than just watching and talking, as standard AV communications systems allow, Proximie allows participants in the conversation to show – by gesturing with their hands in the camera’s field of vision, so what they are pointing to is superimposed on the video feed of the patient’s anatomy, by annotating that stream with sketches, by overlaying anatomical diagrams for reference.
Proximie is being used all over the world to facilitate peer-to-peer collaboration between surgeons in a wide variety of ways. It is helping more procedures be delivered in better time by linking general practitioners to consultants and experts based elsewhere who can oversee specialist procedures without physically being in the operating room. It is upskilling surgical teams by linking them to the very best research specialists in a particular field, wherever they happen to be based, for remote coaching and mentoring. And it is also being used to develop an extensive library of AR-enhanced video recordings of procedures carried out by experts to serve as a learning tool for the global surgical community.
At the heart of all of this is a simple concept – the easier it is for professionals to talk and share and collaborate in their work, the more we use technology to remove barriers to that happening, the faster and higher we can develop skill, the better quality service we can provide, and the better outcomes for patients will be.