11 - Surgical Synergy: Why Surgeon-Anesthesiologist Relationships Matter

In every operating room, in every ward, in every clinic, and every team meeting, a silent battle brews. Conflict, negotiation, identity. Welcome to the Scalpel and Sword podcast, where I, Dr. Lee Sharma, physician and conflict analyst, Explore the hidden negotiations behind modern medicine. Let's trade burnout for boundaries and learn the art of healing with precision and power.

Hello, peaceful warriors. Welcome to the Scalpel and Sword podcast. I am your host, Dr. Lee Sharma, physician and conflict analyst, and I'm thrilled to have on the podcast today, Dr. Julie Hallé. Dr. Hallé is an associate professor of surgery at the University of Toronto. She is a hepatobiliary pancreatic and GI surgical oncologist at the Odette Cancer Center at Sunnybrook Health Sciences. She's also an associate scientist at the Sunnybrook Research Institute. We're going to have a lot of fun listening to my French right here because I just was blown away by all of her experience. She got her medical degree at the Université Laval in Quebec City, Quebec. She also did her complex Surgical Oncology Fellowship at the University of Toronto. She did an advanced hepatobiliary and pancreatic fellowship at the Institut de Recherche sur le Cancer de l'Appareil Digestif in Strasbourg, France. And I'm so thrilled to have her on the podcast today. Welcome, Dr. Hallé.

Hi, thank you so much for having me.

So Dr. Hallé and her colleagues published, to me, one of the most interesting articles I've read in a long time. And this was in JAMA Surgery in May of this year. And it talked about the familiarity of the surgeon-anesthesiologist dyad and how this affected major morbidity after a high-risk elective surgery. And what they did was they actually looked at the number of times that the same surgeon and the same anesthesiologist were doing cases and focused on high-risk GI, low-risk GI oncology, and spine surgery. And what they found was, as you saw an increase in the dyad familiarity, as they operated more together, the 90-day morbidity of these patients actually decreased. What was the genesis of writing this paper?

Well, like a lot of the research I do, it started out of, I wanna say questions, but really frustrations from day-to-day clinical practice. So I work at a pedobiliary surgery, as you mentioned, and where I work in Ontario, Canada, We have a regionalized system, meaning that only 10 hospitals can do this type of surgery and surgeons have to be fellowship trained and have to maintain high volume. We have some very specific requirements we need to maintain as a center and as a surgeon to be allowed to do those procedures. And I found it interesting that none of those requirements involved the anesthesiology team. And so while our hospital is specialized because of the volume outcomes that we all know for decades now, are beneficial to patients with those very unique procedures. We didn't have that type of volume with the anesthesiologists and we have a department with about 50 anesthesiologists. So on number of days I will operate in a year, I could be working with a different anesthesiologist every time. And I did not fully understand that. And so we dug into the volume outcome initially for hepatobiliary surgery. And then we said, okay, let's do more cases. Like the patients will fare better, but what about when you combine the anesthesiologist and the surgeon? It's not just the volume of one and the other, but how well we also work together. And so I did that work initially for the HPBE surgery specialty because that's what I do on a day-to-day basis. And then when that came out and we started talking about building specialized teams, lots of surgeons from other specialties were coming to me or catching me in a hallway and going, well, what about my specialty? I think it's the same thing for us. We also need anesthesiologists we work with more often, more stable teams. Is there data for my specialty? And so that's how we sort of expanded the work to all what we call high-risk procedures, which means it's procedures where patients come in and will have at least a 24-hour hospital stay and a minimum major morbidity, just so that we're able to find a difference, right? If the major morbidity is so low to start with. Laparoscopic cholecystectomy or an oophorectomy, for example, it's very hard to detect a difference.

Right. It's so cool that your research is organic. It's coming out of your personal experience. I have a question as a surgeon, and I would like to answer this question. And I think that's where all stellar research comes from. I think it's also really neat that your colleagues approached you and said, hey, we want to know how this affects us as well. And I think one of the things that you bring out in the paper Is that some specialties like yours, where you are having different anesthesiologists every time? There are other specialties like cardiac surgery, lung surgery, where some of that's already built in. And so we already know on some level that there are some specialties where this is already happening. So looking at advanced GYN surgery, looking at what you do, it's very illuminating. And one of the things I thought was really interesting too, as you started to look at this trend of the diet with the anesthesiologist and the surgeon. Was that it wasn't even just as you looked at the familiarity, that it was actually linear. As these surgeon-anesthesiologist team operated more and more together, that actually outcomes continued to improve. So there wasn't really a minimum threshold. They said, okay, if we do this many surgeries, we're good. It's really one of those things that as this team is together, the outcomes are continuing to improve. What kind of things came out in the research that you feel like supported or kind of led to that improvement in outcome?

Yeah, I'm glad you picked up on that. It's really like every single case we do together matters, and we really tortured the data to find a cutoff because when we talk with policymakers, the OR executive, people who make the schedule, who build the teams, they wanna hear a number. They wanna know, this is what I need to aim for, and once I aim for that, we're good, right? It's like this sort of target, but we're not able to find that. There is no target. We just need to improve and stabilize teams. And I think our research is just based on population data, so we cannot say why this happens. We can only hypothesize based on other things that have been written, both in the healthcare space, but also in business, or in sports, or in education, where we have more what we call sort of business psychology data to support how teams are being built. And based on that, we know first and foremost that Non-technical skills in the operating room are absolutely crucial, right? When we do analyses of errors in the OR, most often it's related to communication or collaboration problems and not on technical skills. So we know those are really important. We've been trying to teach them in residency to faculty and continuing professional developments for years. But I think that there's something that happens when people work together more where those skills are enhanced. And where those skills are better applied together. And that is very hard to teach, and I'll come back to that in one moment. And so, when we have teams that work together more often, it creates what some people have called transactive memory systems, which means that the 2 people working together often sort of create a common understanding of what the norms of the work are, what the goals are, what the resources are, how we both work, and that creates More cohesion, more trust as well, and more likelihood of offering help, but also accepting help, and in sometimes an implicit way. And so, all of that probably translates in the operating room in better uptake of best practices, better response to stress and difficult situations. And it doesn't need to be something catastrophic or dramatic. Sometimes it's small things and we're just better able to manage them together. And that has a downward impact on the patient. And I think the important thing here is also that we cannot recreate that officially. So I think after the question of what's the target, the second question I get most often when I talk about this is, so what is it that those stable teams do that's different that we need to replicate? And, and my answer to that now is you cannot put familiarity in a bottle, and it's not something that will become a medicine. You can take it before you get into the operating room and suddenly people that have never worked together will function as if they had worked together often. There is something implicit about stability of the team and familiarity of the anesthesiology surgery dyad that you cannot replicate with pathways or protocols and so on. You just have to make people work together more often. That's the only way to do it. And that might be more complex sometimes from an organizational perspective, but I think that's really where the secret is.

That is amazing. And that insight into sort of that team dynamic and team creation, it's not something that you can, like you said, formulate. It's not something that's process-driven. It's something that's created over time as the surgeon and the anesthesiologist work together. And one of the things, you state that so beautifully that, you know, sometimes people was like, is there a secret sauce? Is there something that we can apply to make this happen? It's like, no, it's something that occurs over time. And there's a trust that occurs in that relationship as you work with people. There's a humility, there's a level of acceptance that you feel more transparent with that team. If you have concerns about something, you're more likely to share it. And one of the things, as you put that in the article, is that that familiarity breeds a way of looking at things, a way of approaching problems. And in the conflict resolution literature, we often refer to that as a worldview, that you've created a common worldview.

Yeah.

That everybody has. And as you are all approaching the same problem, you're approaching it with a very similar level of understanding, a very similar level of goals, and that's just going to create a better outcome. And you've definitely shown that in this paper. It's also very interesting because you talked about this, and you also talked about working with policymakers and people in governance in the operating room, that we'd love to have the whole team. All together every single time. We'd love to have the same scrub and the same circulator. We'd love to have that every single time, but that may not always happen. And so at least starting with having a surgeon and anesthesiologist that are together and having that dyad grow. Sometimes you may not have the luxury of having the exact same team every single time, as much as we'd all love to have that.

Mm-hmm.

But especially in a large hospital system, and I'm sure that you've got a large, busy surgical schedule, you may not have the same team every single time. Having the same anesthesiologist may be more of an approachable goal.

I think it absolutely is. And you're right, the entire team matters, right? The thing is, I had data for anesthesiologists and surgeons in our populational data in Ontario, so I couldn't study the scrub nurse or the circulator or anesthesia assistants, but I would suspect that we would find similar results. And to me, it just makes sense, but I got that comment several times from surgeons and anesthesiologists, like, Yeah, well, that's very nice data, but like, don't we all know that already? I'm like, yeah, I think we intuitively know it, but there is no data. And without data, you cannot go to leadership because they'll tell you, yeah, sure, it's important, but if they don't have something that they'd have to answer to, then change doesn't happen. Even with the data, change is very, very difficult to trigger or to make happen. And it's kind of surprising to me because it won't necessarily be always the same team. And I don't think that that— What's the message is just to increase, stabilize the teams so they can differ from one day to the other, but on, on the overall picture, it will be a stable team. And there is scheduling complexity, of course, because if we look at the anesthesiologists and the surgeons, we take post-call days for the anesthesiologist. We take vacations. Like there's all sorts of things that happen that limit the ability to always be together. But I think we can do better in what we're doing right now, which is to some extent, a little haphazard. And so when we're looking at new models of care, what I find interesting is that's a zero-cost change. Like right now, when we're asking for quality improvement, I'm always told the same thing by the people I work with in leadership is, we don't have resources. If you wanna make changes, try to make them cost-neutral. This is cost-neutral. There is nothing that we need to input. We just need to use the same people, but reorganize the way they work. And so from that perspective, I don't know why it's so difficult to make it happen. We're still going through the motions. There's always resistance to change. And one of the things we're doing, looking at costs next, is sort of costing this because I wonder if we're going to find that we're actually saving money with this approach. And like, we haven't even looked at that data yet. We're just starting the analysis, but I would be very curious to see that.

Absolutely, 100%. And it's one of those things, as you said, as you're going to people trying to make policy changes, it's quite one thing to walk in there and say, intuitively, we know that having this familiarity between the surgeon and anesthesiologist is going to improve patient outcomes. It's quite another to have hard data that actually shows that you had a 3% decrease and a 4% decrease in morbidity 90 days out which is significant with having the same diet. One of the things that you also bring up in the paper that I think is so cool, that there has been research in operating room processes approving efficiency. And so that data exists, but this is data that proves that we actually have improved patient outcomes, which is what we want. And so it's really hard if you're going to people saying, we're not asking to spend more money. We are literally asking to have a team-based approach where we have a surgeon and anesthesiologist who are together more often, who actually understand how each other work. And then we have information that says this improves our patient outcome. It's really hard to argue with that. And I agree with you, a lot of times if you're trying to put a dollar sign on, there's no dollar signs. We're not asking for any new staff. We're not asking for new equipment. We're not asking for more time. We are literally asking you to take the same resources you have, but actually combine them in this way. So it's beautiful to have the data 'cause it makes it so much easier to make the policy.

Yeah, and I think the systems we have now, whether it's artificial intelligence, for example, we can build ways to make that scheduling happen, right, without somebody spending dozens of hours having headaches over a spreadsheet. Now we have the ability to make this happen more easily and in an automated way. One thing though I don't wanna dismiss here is that there can be unforeseen consequences from reorganizing models of care, and So we're trying to look at that right now. First, we're interviewing anesthesiologists across the country in Canada to see what are their perspectives about this, because it's a big change for them. If you want to increase the familiarity, so the number of times they work with a surgeon more often, this means they'll have to be somewhat specialized, right? Like they'll have to focus on one area of surgery to build that familiarity with specific surgeons. And that's, unless it's for cardiac anesthesiologists, that's a big shift in the way they would work. So we wanna understand what are their perspectives on this so that we can address that in how those care models are built. We're also doing a census of care models around Canada and the United States to see what currently exists and what might be some of the challenges associated with the different care models. The second thing is, I think to be able to do that, you need to have a certain number of core surgeons and anesthesiologists, right? Like some small community hospitals or rural hospitals where there might be like 6 or 7 anesthesiologists may not be able to do that for practical reasons. That also has to be taken into consideration. And third, what we've heard lots of anesthesiologists is that they're actually worried that by changing the scheduling so that they're a bit more specialized, they're going to lose expertise in other areas. And so when they're faced with other high-risk cases emergently, or even in their elective practice, they will be less comfortable and that those patients may pay the price. And so right now I won't divulge all these results, but I was just looking at our final set of results that this morning we looked at for anesthesiologists that have higher Mm-hmm. hepatobiliary volume. We use hepatobiliary as the case study for this. Does that impact their volume of non-hepatobiliary cases? And it doesn't. So people who work a lot and they will do a lot of all types of procedures. So it's possible to have a practice that has a high volume of hepatobiliary cases maintaining volume of other types of procedures. And then the other piece is whether like having a high volume of hepatobiliary cases would impact outcomes for other patients they care for. I'm trying to sort of alleviate some of the concerns that have been voiced. And not forgetting there can be unforeseen consequences. And so I think we need to address those as we build the models. But yeah, to me it's common sense. And unfortunately, I think in healthcare, common sense doesn't always prevail. And so we need to work hard to make it more prevalent in our day-to-day organization.

Absolutely. I think it's so cool that while you've put out this wonderful piece of data and while it seems like it's, yeah, This is an easy thing too, that you're actually looking at unforeseen consequences. And anytime you do that before you World War, you know, apply a policy in a large swath, that you've already looked at the possible ramifications of that policy. So if there is a concern, you're already trying to answer that. I think that's one of the keys to having positive change in healthcare is that, yes, we have a great idea and yes, we have data, but let's look at the things that could possibly maybe be good. And have that data going into it. I work at a very small community hospital. I'm a GYN MIG surgeon, so I do robotics and laparoscopies. And the way my day is structured on my OR day, I tend to have the same anesthesiologist every single time. And we are good friends. We are socialized outside of work as well. His wife is my good friend, my husband. We all do things together. And I can honestly say that when he's there with me. That I feel like I'm more relaxed. I am more confident. Um, we work together, we handle things very well together. If we have something that we're having to deal with, we know each other well enough that we can handle it. And so I literally cannot wait to show him this because I think it's going to be like, see, George, there's a reason why we work well together. It's because we have data that says that when we work together, our outcomes improve. And that's really cool.

I have the same experience, to be honest. I have a group of anesthesiologists that I hang out with. They're all excellent. And while we don't have that familiarity-based system, if I have a huge case, something that's high risk, that's out of the ordinary, I will like go and talk with the anesthesia department and ask if one of them can be booked into my room. And it's not to say the other ones are not excellent, they are as well, but there is something about walking in the room and knowing the person you're going to work with that makes me go, huh, this is going to be easier today. And sometimes we get in trouble still, but we Go through it and we troubleshoot it and we're able to do that. And, and there's no like what-ifs or whatever because we're so used to having that teamwork together. And the piece about addressing unforeseen consequences and so on, to me, the important thing was to talk about people about this cause the thing that I hate most are papers that stay on a shelf. I mean, not shelves these days. They're online on PubMed, but if it just stays there for people to read and it's not implemented in practice, I feel like I have to—

Yeah.

Um, the target with the research. I wanna drive real changes and, and try to set the example for how that change can happen in an institution. So we get the data, but after that, like, try to work really hard on knowledge translation. And knowledge translation piece is about talking to people on the ground and asking them what's happening, listening sometimes to things I don't necessarily wanna hear, or I don't necessarily agree with, but being open to it.

Yeah.

And taking it back and addressing it. And then also having a team of collaborators that have their foot on the ground. So the team that you see on that paper is a team like composed of surgeons from different specialties, but also lots of anesthesiologists that have different expertise and all have busy clinical practices in addition to their research backgrounds that are able to provide input on what's happening and what the data is showing and how we can articulate that into practice changes. So maybe that's a message people wanna hear, like research that stays at a data level will never be impactful, right? You need to try to bring it forward.

Right.

And that comes from talking to people.

Absolutely. It's one of the reasons I was really so thrilled that you agreed to be on the podcast because one of the things that in my research and working with hospitals and physician practices in conflict is that a lot of people in operating rooms don't realize how much conflict impacts not only the flow of what's going on professionally, but also patient outcomes. The research shows that most operating room cases, there are an average of 4 conflicts. And like you said, it's not always big bust up people yelling at each other. It's sometimes a more quiet disagreement. This scrub, this circulator, this surgeon, this anesthesiologist, but still that has an impact on the flow of the case. And what you show in your data is, and this is the reason I love this paper so much, This also, to me, part of the reason why I see this being such a pivotal impact on patient care is that if you have a surgeon and anesthesiologist who are used to working together, they're also used to working through their conflicts together. Even if they've got a disagreement, they've probably dealt with it. They probably know how to deal with it, and it's going to get resolved faster, and it's going to have a less impact on what's going on with the patient. And so the other reason when I read this, I was so thrilled because to me, as I'm working with operating rooms and they're trying to work on conflict management and process systems, this is one of these articles I can say, look, you really should focus on having a surgeon-anesthesiologist dyad that has familiarity, and we have data that says this is going to improve patient outcomes. It's really hard for people to argue with that when you have the hard literature. So, this is the reason I was also so happy to see this. So, your paper's definitely not gonna sit on a shelf. It's definitely going to translate into hospitals making positive changes. And the more that they have that awareness that this impacts patient care, the more motivation hopefully they'll have to do it.

Yeah, I really hope so. Thanks for saying that. And, and it's interesting what you're saying about conflict because I've heard so much talk about conflict, especially in this sort of micro society that is the operating room where we have our own set of norms and way that we work and so on. I find that fascinating. But I've always found conflict approached from the individual perspective, saying when there's conflict, the problem is the individuals that are involved in the conflict. Number one, something was done that led to conflict, and so you have to fix that, or the solution to the conflict revolves at the individual level. And I feel that puts a lot of burden on individuals that most often are really just Doing their best to provide good care to patients. And so it's interesting to me what you're saying right now, to bring that conflict to a process level, which is creating an environment where conflict is less likely to arise or more likely to be easily managed without putting the onus on the individual people. I don't mean by that that we don't have to work through conflict resolution and build the tools individually, but, but many layers, right? And it's interesting to talk about a different layer of it.

Yeah.

Yes. And I love how it is that recognition, it's gonna happen. It's not a sort of, if it happens, it's going to. Nature of what we do. This is a very charged, very pressure-filled environment. And anytime you're in that kind of environment, it sort of follows that's gonna be a question. But at the same time, if you have a relationship with somebody that you know how to work through it, like I know with my anesthesiologist that I love to work with, if there's something going on that maybe I'm not OK, we need to fix this. But you and I work together. We know how to do this. We can communicate well. You mentioned communication early on as being such a big part of what's coming out of this familiarity dyad, that it's much more likely it's going to get resolved faster. And if there's a process in place where it's either formal or informal, and a lot of times, I think when you build familiarity, sometimes that becomes more informal. You're used to working with somebody and they're used to working with you and say that, you know, they're little things and it's easier to resolve. Um, but having that in place just makes it less likely it'll impact the patient. And as people start to see, that's why I love this paper. I'm gonna keep going back to how much I love it because it really does illustrate very beautifully something like you sensed it, your colleagues sensed it. This is intuitive. We kind of know this is the case. And I think that's so beautiful that you put it down on paper. You also mentioned expanding this to other specialties. What specialties are you looking to look at? All the operating rooms? Where are you headed with this research now?

So right now we've looked at most specialties with high-risk procedures in that paper. There's some where we found a difference in outcome, as you mentioned. So like high-risk GI, that's mostly hepatobiliary. There is low-risk GI, which is colorectal gastric surgery. It's how we differentiate it 'cause the risks are so different between the two. And then gynecology and spine surgery. There's others where we did not find a difference, and some of them is because they already have the systems with high dyad volume where the familiarity is already built in because of the processes in place. That's cardiac, orthopedics, and lung surgery, which to me is kind of a proof of concept, right? It's like once you've already reached a very high level of familiarity, you're not detecting additional improvements in outcomes because you've optimized it, if I can simplify things that way.

Right.

And then there's a few where we were not able to detect a statistical significant difference. It doesn't mean that there is no effect that exists or that can be identified in other settings. It just means that in our settings, we were not able to, but it doesn't mean it doesn't exist in those specialties. So our next steps are building the case for it. So costing will be the first part, seeing if there is improvement in cost when there is increased familiarity, trying to convince our leadership in each hospital that this is a good idea and numbers and money speaks loudly these days in healthcare. So we'll try to get that. And then the second piece is really getting the perspectives of the anesthesiologists on this. So we're going through a set of interviews, we're about halfway through right now to really get their perspectives. And then after that, we'll be sort of trying to build those care models or build blueprints to care models. It might not be the same solution everywhere, right? The way that we schedule is—

Yeah.

inherently different depending on our organization, the number of people that are involved, and so on. But maybe we can have some blueprints that people can follow in their different institutions. So that's the ultimate goal we're hoping to achieve.

Well, I think what you've already published has been so, so helpful and so positive. And I think as you build on that, and especially as you are really trying to address problems in application before they occur, By talking to the anesthesiologists, I think that's going to make it even easier to present this policy. And even a small hospital like mine is going to benefit from this. And as you said, the application may look different for us because we are a smaller institution and the way that our anesthesiologists work may look a little bit different. But one of the things that I'm going to do is I'm going to go to our robotic steering and present this paper. Like, this is something that we should really start looking at. as a way to improve patient care by improving this relationship with our surgeon and our anesthesiologist and having that familiarity. I think you're gonna help a lot of people with this article. I think it's gonna help a lot of patients, which is beautiful.

Thank you so much. Like, the only reason we practice and, and we do research is ultimately to help patients, right? And so if, if that can help just a few patients and improve their outcomes or Reduce their morbidity. To me, the goal has been reached. That will be the important part. So thank you so much for saying that.

Absolutely. No, I look forward to seeing more of your research. I'm gonna be really excited to look for, as you're talking to anesthesiologists and you publish that data, I think that's gonna be so brilliant. So I'm very excited to see that. Dr. Haleh, if people want to reach out to you and ask questions, what's the easiest way for them to find you?

I think email or X, formerly known as Twitter. I also reply on that. So my X handle is @HalleJulie, so my last name and first name, and by email, just julie.halle@sunnybrook.ca. I'm always happy to talk about this topic or help in any way I can. I don't always have all the answers, but I can try to find them.

Well, it has been an absolute pleasure to meet you. Thank you so much for your time and thank you for being on the podcast. We will include your contact information in the show notes. For all of you who tuned in today to Scalpel and Sword, thank you so much for being here and joining us for this wonderful conversation with Dr. Julie Hallé. And until next time you join us, be at peace.

Every episode is an invitation to speak, to negotiate, to choose. I'm Dr. Lee Sharma. Join the dialogue by subscribing to Scalpel and Sword Until next time, peaceful warriors, may your choices be sharp and your voice be even sharper. This podcast is a reflection of lived experience and research in conflict resolution. The Scalpel and Sword is not intended as medical or legal guidance. For personal matters, please consult a qualified professional.