Breaking a sweat - part 1

11 October 2021

Not so long ago, I discussed the concept of psychological safety with a colleague. Just to briefly explain what psychological safety means; it a working culture that makes workers feel safe to speak up, to express doubts when things do not go as they should. A culture that permits asking for help. Meaning, always someone around to hold your hand during residency. Which immediately invoked resistance in me. I mean, it should not be too easy, it’s serious business what a surgeon stands for, right? A typical surgeon’s reflex, I admit. But it was a sincere doubt, because it seemed to be contradictory to an important part of a surgeon’s education. Which involves breaking a sweat, every now and then.

What I mean with breaking a sweat, is learning how to take the right decisions in situations that are uncertain, demanding and where the decision and responsibility is on you. You must learn how to stand for your actions, if necessary, go against the tide and stick your neck out for your patient. In other words, to learn how to take full responsibility. But how? Personally, I know just one way: through challenge. An example is being questioned about a clinical case up to the moment you fall short of answers. That makes you quite uneasy. Another example is being pressurized in various ways, deliberately, by the supervisor. I remember a (hilarious) moment a cardiac surgeon stood impatiently staring at me while performing a minor part of the surgery. I did not let him rush me; I did not really care what he thought. That turned out to be the right ‘answer’. It is, when your supervisor does not always rush in immediately when you ask for help, so that you learn how to solve things yourself. But that doesn’t feel comfortable at all.

Learning how to take responsibility thus involves breaking a sweat every now and then. And if you know you are always safe, well, there’ll be no sweat, will there? But then whèn will you learn how to act properly even while feeling uncomfortable in stressful situations? I will illustrate this with an example of a situation that really taught me something. As a very young resident on a night shift, I cared for an old lady we operated upon that day. She was not well, and I judged she needed surgery again because of an internal bleeding. I called my supervisor and told him in not-so clear descriptions that she might possibly need surgery and whether he was perhaps willing to have a look. He was not very enthusiastic and rather unwilling to get out of his bed. He just sent me back to the ward to make a new judgment. I did what he told me to, but got angrier and angrier, till the point I just picked up the phone at the ward without looking again at the patient. He didn’t answer the phone. He stood there right behind me. “I am already here and so is the OR team” he said. “Next time, speak up about your judgment. Take the risk of being wrong. You are responsible for your patient, and you should act accordingly”. Behind my back, he had called the nurses and jumped on his bike right away. She was operated upon and recovered completely. And I had learned a lesson I would never forget.

Yes, for an outsider this may border on bullying. I also realize that the distinction between breaking a healthy sweat and bullying, can be quite narrow. But this did not feel as bullying.  Yes, it was very uncomfortable, and I did not feel safe. But I realized that, to be able to secure patient safety, you sometimes had to feel unsafe and realize fear sometimes lies in yourself. But my supervisor was behind me, both literally and in figurative speech. I was allowed to participate in surgery (which is considered a sign of approval) and never heard anything again about the whole incident.

After ventilating these same experiences to my colleague, he kept quiet. I was waiting for the ‘yes, but’, but it did not come. Just a smile, at best. And then I realized, what you as reader probably realized all along. These were all perfect examples of a psychological safe environment. Psychological safety is not about being comfortable. On the contrary, it is about being uncomfortable but being allowed to learn. Perhaps, psychological safety will even bring more sweat because it demands you take personal risks, to learn. The abovementioned examples taught me so much because it was psychologically safe. And indeed, in none of these situations I was afraid for punishment or bullying, I only feared failing. I was confronted with my own actions and the only thing my supervisors did, was putting up a mirror. And they judged not my actions, but my ability to self-reflect, learn, and carry responsibility. As soon they were convinced that I had developed this capacity, they stood close (&far) behind me learning how to carry full responsibility.