Mandatory training for rare anaesthetic events or mandatory safety preparedness – the beatings will continue until morale improves, or is it time for a carrot and not a stick?

Abstract

Nathanson et al. [1], supported by Kane et al. in a subsequent letter [2], call for mandatory standards of training for rare anaesthetic events and mandatory safety preparedness. Their implicit assumption is that, with more training, anaesthetists will become less error-prone, performance will improve and, therefore, outcomes from uncommon, life-threatening peri-operative events will also improve. I believe this assumption merits challenge.

Mandatory training for rare peri-operative events and safety preparedness is an integral part of anaesthesia training delivered through various methods including didactic sessions; formal and informal education; scientific meetings; literature review; and simulation laboratories. It is a key component of the curriculum for the Fellowship of the Royal College of Anaesthetists. Ongoing regular training and education in all aspects of anaesthesia is also a fundamental part of clinical practice. So perhaps it is more accurate to call for different training in the management of rare peri-operative events, begging the question ‘will this make things better?’

Time for ongoing training must be utilised wisely. Is it possible to show that suboptimal management of rare events can be ameliorated through participation in a revised and different mandatory training programme? This proof might be elusive, since a tendency towards failure to perform perfectly (especially at times of high stress, pressure, complexity and surprise) is a fundamental part of the human condition. What makes us human also makes us error-prone and while this may be modifiable it is fundamentally ineradicable and cannot be dissipated by the setting of an inhuman standard.

Introduced in 2009, ‘Never Events’ aimed to reduce preventable errors in healthcare. An editorial argued that labelling them as such was ineffective and highlighted the issues with negative framing [3]. Despite this, these events persist. Nathanson et al. liken fatal unrecognised oesophageal intubation to a never event, estimating its annual occurrence at < 1. As long as anaesthetists are humans, this number may never reach zero, no matter how much mandatory training we are required to complete.

Is it necessary to establish a new standard requiring training completion, with implicit sanctions for non-compliance? We adhere to both imposed professional standards, like those set by the General Medical Council, and moral and personal performance standards. It is contentious to suggest that implementation of a new explicit standard (and corresponding sanction) will bring about the desired improvement in human performance.

Nathanson et al. call for a paradigm shift, and I would echo this, albeit a different one. The seven completed National Audit Projects highlight deficiencies in human performance and suggest areas for improvement. An alternative approach could focus solely on successful anaesthetic management, promoting the sharing of best practices. Learning from our successes may offer more valuable lessons and provide incentives for future performance improvements, rather than penalties for shortcomings.

Before embarking on a medical career, I completed a degree in philosophy, during which I learnt about the theory of utilitarianism [4]. This has sometimes been described as achievement of the maximum amount of good for the largest number of individuals. If one were to apply this framework to the current argument – which is ‘what is the best and fairest way of optimising the performance of error-prone humans that deliver anaesthetic management to a patient population?’ – then one might end up considering carefully the fair use of incentives and, possibly, penalties to achieve the desired outcome. In such a utilitarian assessment, it is essential to consider the needs of our patients as a priority. Additionally, we should consider our own needs and morale, which may be affected adversely if we are misunderstood or treated unfairly.