Association for Academic Surgery (AAS)

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Don’t Forget the Debrief

As a trainee, I had the unfortunate experience of receiving, coding, and calling time of death for a trauma patient that was also my friend. The experience was intensely traumatic, but as is often the case, I carried on for the rest of my shift as there were other patients who needed our help. I compartmentalized and forged ahead, despite being deeply saddened and unable to process the event. While I was met with sympathy, there was no formal debrief.  I know I am not unique. Surgical training is riddled with difficult conversations, intense moments and catastrophic outcomes that often go unaddressed.

Debriefing is a post-experience analytic process including a discussion and analysis of an experience, evaluating, and integrating lessons learned into one’s cognition and consciousness (1).  It has its roots in the military and aviation industry, where it was initially used as a method of performance critique (2). Debriefing provides an opportunity to explore or make sense of what happened during an event or experience as well as identify what went well and areas of opportunity. It is used widely in medical education simulation, but its application to real life may be less ubiquitous (1).  However, I assert that similar techniques could be implemented in real time situations that allow difficult experiences to be processed. This could range from an intraoperative event, near miss or another poor outcome.

In traumatic events such as mass casualty, critical incident stress debriefing (CISD), can be employed to help deal with  physical or psychological symptoms (1). CISD is a specialized form of debriefing addressing issues related to deception, trauma, disaster, or combat-related stress (3). This requires trained facilitators and time (usually 1-3 hours) for detailed review of the event and should certainly be implemented for critical events but may not be practical for other situations.

As the surgical community sheds light on physician burnout, resident attrition, and mental health, we are being tasked with finding ways to improve and protect our mental health and that of our trainees (4). Dr. Gardner notes that the most difficult part of debriefing in real time is creating a zone of safety that is peer-protected. Traditional simulation debriefs include a facilitator, but real time debrief may occur among a multidisciplinary team including physicians, nursing or other ancillary staff without a predetermined leader. Cheng et al describe the following elements as the essential elements of debriefing (5):

  1. Ensure psychologic safety.
  2. Having a debrief stance or basic assumption (Ex. We believe that everyone participating in this simulation is intelligent, capable, cares about doing their best, and wants to improve)
  3. Establish debrief rules.
  4. Establish a shared mental model.
  5. Address key learning objectives.
  6. Use open-ended questions to facilitate discussion and reflection.
  7. Use silence to allow others to formulate thoughts.

Time is often a limiting factor in our ability to debrief. The Plus-Delta Debriefing Model is one that can be done with or without a trained debriefer and can be performed in five minutes or less by the team immediately after any routine or critical event (1,6). In this model, participants are assigned to two groups, plus and delta. The plus group identifies things that went well. The delta group identifies things that need to be changed and suggestions for changing them (6). (Table1)

Table 1. The Plus–Delta Debriefing Model—Example

+ Δ
“Plus” “Delta”
Team identifies what specifically went well Team identifies what specifically to change and do better next time
  • Inga stated the situation clearly out loud for the team and asked for help early: We have a shoulder dystocia, get help
  • Edward closed the loop about where to apply the suprapubic pressure
  • Marie kept track of time and announced it out loud to the team
  • Teammates need to remember to call out each other by name
  • Teammates need to close the loop of communication
  • Ob providers need to switch sooner in managing the delivery and not fixate on one maneuver

References:

  1. Gardner R. Introduction to debriefing. InSeminars in perinatology 2013 Jun 1 (Vol. 37, No. 3, pp. 166-174). WB Saunders.
  2. Van De Ridder JM, Stokking KM, McGaghie WC, Ten Cate OT. What is feedback in clinical education?. Medical education. 2008 Feb;42(2):189-97.
  3. Mitchell JT. When disaster strikes: The critical incident stress debriefing process. InJournal of emergency medical services 1983 (pp. 36-39).
  4. Pulcrano M, Evans SRT, Sosin M. Quality of Life and Burnout Rates Across Surgical Specialties: A Systematic Review. JAMA Surg.2016;151(10):970–978. doi:10.1001/jamasurg.2016.1647
  5. Sawyer T, Eppich W, Brett-Fleegler M, Grant V, Cheng A. More Than One Way to Debrief: A Critical Review of Healthcare Simulation Debriefing Methods. Simul Healthc. 2016 Jun;11(3):209-17. [Abstract]
  6. Klair MB. The mediated debrief of problem flights. Facilitation and debriefing in aviation training and operations. Aldershot: Ashgate. 2000:72-92.
Adrienne Nicole Cobb, MD

Adrienne Nicole Cobb, MD

In fall of 2022 Dr. Cobb joined the faculty at the Medical College of Wisconsin in the Department of Surgery – Division of Surgical Oncology. Her clinical practice focuses on breast cancer, benign breast diseases, and patients who are at increased risk for developing breast cancer. Dr. Cobb’s research interests include surgical outcomes, breast cancer disparities and healthy equity.
Adrienne Nicole Cobb, MD

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