Anger in the operating room

This scene looks familiar to most people who ever worked in the operating room. A high-power doctor, say a cardiac surgeon, is doing a long and complicated case. The stakes are high, the chances for complications significant, and he dreads any mistakes. Everybody in the room senses a tense situation, and all people walk on eggshells. It’s so quiet, that the circulating nurse can hear herself thinking: what’s going to happen and when? No messages from outside the room are allowed, and the intercom is turned off. No interruptions. Then it hits. It’s either a wrong instrument handed by a scrub nurse, or bad help from the assistant; it really doesn’t matter. One can hear a scream, frequently combined with leg stomping, arm gesture, with or without throwing of the instrument. The lid of the kettle came off. So what’s happened? Let’s see the incident from two different points of view: the surgeon and the OR nurse.

The surgeon always is able to explain his reaction: he has the patient’s well-being on his mind, he is his patient’s the best and only advocate. Someone is harming his patient, and he will use all his power for that not to happen. In this room, he is in charge and as a captain-of-the-ship, and he is ultimately responsible for the final results of the surgery.

The nurse, not feeling responsible for the event, is thinking ‘Why do I have to work with this jerk?’ Next, she is evaluating her bi-weekly paychecks to see if it’s worth it to change her specialty or even the hospital she is working for.

What’s going on? And of course, I’m talking about the extremes.

The given situation is beyond the doctor’s ability to control. He lets the pressure-cooker’s valve to blow off, and immediately it makes him feel better. Then comes guilt, and he feels like a parent after spanking a child. Finally, he ends up a loser, he just doesn’t know it yet. Then he tries to save his face and present himself as a ‘tough guy’ and likes the saying, that to be a good cardiac surgeon you have to be a little SOB. And after all, it’s only for the good of his patient.

Nurses respond in two general manners. Most of them try to ignore the outbursts. Some attempt to justify them, saying it’s not directed towards them, that the surgeon is under a lot of pressure and that he has the patient’s well-being on his mind. Some feel proud to be a part of a prestigious ‘heart team’. Some have a ‘battered wife syndrome’ and conclude it must be their fault. Only a few had enough and look for a change in working environment.

During my medical career, I’ve witnessed more than fifty shades of anger and responses it generated.

There is no evidence, that expressing the anger is better than keeping it under the lid.

There is no truth that a person can’t control it, it’s the way he has been wired.

Anger management is not about learning how to suppress your anger; it’s about learning how to deal with it and use it positively. One has to identify the triggers, recognize the prodromal signs and learn how to dissipate the stressful situation and find healthier ways to express your anger. And don’t be quick to assign the blame.

But most of the time, angry surgeons don’t feel they have problems; the people who have to work with them do.

I witnessed many angry situations and was a target of several of them. I saw the patterns.

They were certainly doctors, some of them good ones, who had a knack for blowing off the lid. Some wanted to shift the blame from the beginning, some wanted to show the real or implied power, some just because they thought it looked good. The triggers were unforeseen events, like delays in the OR, mistakes in scheduling and major and even minor mishaps during the procedure. Arguing with an angry surgeon is usually unsuccessful because it only fuels the fire. One has to modify the reaction, having in mind the respect for the patients and co-workers.

My feeling is that the best way to handle the anger problem is to develop the attitude not to be bothered even by the most extreme circumstances. I know it seems unrealistic, but it often worked for me, particularly at the end of my career in the operating room. Not all the time though; but when I was able to achieve this mental status it worked beautifully. One can attempt to feel detached from the everyday trouble and seem as if he or she’s watching all the earthly events from the above. I know it seems unrealistic, but is not impossible.

More on anger in the operating room in my next post.