Communication, Teamwork and Crew Resource Management

Crew resource management (CRM) is the disciplined use of all available resources — people, equipment, information and time — to operate safely in a high-risk environment. It began in commercial aviation after two disasters in which technically excellent crews flew perfectly serviceable aircraft into catastrophe because no one felt able to challenge the captain: the runway collision at Tenerife (1977) and the controlled descent of United Airlines Flight 173 into fuel exhaustion at Portland (1978). The lesson was that a steep authority gradient combined with poor communication is lethal, and that these are trainable skills rather than character flaws. Medicine imported the lessons, beginning with anaesthesia crisis resource management in the early 1990s (Gaba and colleagues), and they now sit behind the WHO Surgical Safety Checklist and every modern theatre briefing.

Why does this belong in an orthopaedic exam? Because error is now understood to be among the leading causes of death in healthcare — estimated at over 250,000 deaths a year in the United States — 250,000+US deaths/yr from error — ranking third behind heart disease and cancer (Makary and Daniel 2016). A large share of preventable surgical harm — wrong-site surgery, retained instruments, missed allergies, unescalated deterioration — is a failure of communication and teamwork rather than of knowledge. Around a third of communication exchanges in the operating room have been classed as failures, most with a downstream effect on the patient (Lingard 2004). CRM is the framework that closes those gaps, and a fellowship examiner will expect you to discuss it as fluently as you discuss a fracture classification.

The single idea that organises everything else is this: the team is the safety net, not the individual surgeon. No amount of personal competence compensates for a team that does not share a mental model or cannot speak up. CRM is how you build and lead that net.

When an examiner asks "what are the principles of CRM?" they are listening for a structured answer, not a ramble about good communication. The competencies below are the standard set — derived from aviation CRM and codified for healthcare in the AHRQ TeamSTEPPS programme — and you should be able to name and apply each one.

James Reason's human-factors work gives the theory that ties these together: harm is rarely the result of a single catastrophic mistake. It is the Swiss cheese model — an active failure (the surgeon's slip) passes through latent failures (a tired team, a missing implant tray, a skipped briefing, an unassertive nurse) until it reaches the patient (Reason 1990). CRM is the job of putting more, and better-aligned, layers of cheese in the way. Examiners like this framing: describe CRM as threat and error management, where each competency is a defence layer that traps an error before it propagates.

For handover and telephone calls, the structured tool is ISBAR — an extension of SBAR with an Identify step — promoted by the Australian Commission on Safety and Quality in Health Care and adopted internationally. It defeats the two failure modes that wreck handover: rambling without a headline, and ending a call without a clear ask.

A call-out is the deliberate, voiced announcement of a critical event so the whole team hears it at once — "bleeding from the epidural vein," "the swab count is wrong," "we are converting to open." It forces shared awareness and forces you to act on your own words. Use a call-out when something changes, not only when something goes wrong.

The WHO Surgical Safety Checklist (2009), developed by Atul Gawande and the WHO Safer Surgery Saves Lives group, is the global standard and the single most evidence-backed CRM tool in surgery. In its eight-site international pilot it cut the surgical complication rate from 11 to 7 per cent — 7%complications after checklist — and the death rate from 1.5 to 0.8 per cent (Haynes 2009). It is built around three pauses — Sign In, Time Out and Sign Out — and each pause assigns a lead so that nothing is assumed.

Note the deliberate wording "greater than 500 millilitres" rather than a symbol — the checklist is read aloud, and clarity beats shorthand.

Around the checklist sit the broader habits of briefing and debriefing. A briefing is a short team huddle at the start of the list — who is doing what, which cases are complex, where the equipment and blood are, and what could go wrong. A debriefing is the mirror at the end: what went well, what nearly went wrong, and what the team will change next time. The debriefing is the part teams skip and the part that builds the shared memory and psychological safety that make the next list safer. Run both as standing practice, not as extras reserved for when something goes wrong.

The most dangerous failure mode in a theatre is the silent one — a team member who can see the error and does not say so. The authority gradient in medicine is real and historically steep, and it has killed patients. The defining modern case is Elaine Bromiley (2005): during elective surgery the team could not intubate and could not ventilate, became fixed on repeated airway attempts, and failed to perform a surgical airway or call for help in time. There was a trained team and the right equipment in the room; what failed was human factors — fixation, loss of situational awareness, and an inability to break out of the pattern. Her husband, an airline pilot, investigated it as an aviation accident would be investigated, and the case is now the touchstone for human factors in healthcare.

The countermeasure is psychological safety — the shared belief that it is safe to speak up — built deliberately by the leader. As the surgeon you flatten the gradient by inviting challenge, naming it aloud ("please tell me if you think I am about to operate on the wrong side"), and praising people when they do. The tools below give a junior the language to escalate without insubordination.

The two-challenge rule, also from TeamSTEPPS, backs this up: if a team member voices a safety concern twice and it is not addressed, they are empowered to escalate and, in extremis, to stop the procedure. The leader's job is to make clear, before the case begins, that this is not only allowed but expected.

A theatre team is a surgeon, an anaesthetist, a scrub nurse or practitioner, a circulating nurse, an anaesthetic assistant and a recovery team — each holding a piece of the information, and each able to prevent an error the surgeon cannot see alone. The shared mental model is the explicit, voiced agreement among all of them about what is being done, what could go wrong, and what the fallback is. You build it at the briefing, reinforce it at the Time Out, and repair it with a call-out whenever the plan changes.

The surgeon is the team leader, not the autocrat. The old "captain of the ship" doctrine — under which the surgeon was legally accountable for everyone and everything in theatre — has given way to a model of distributed responsibility, where each professional is accountable for their own domain and the leader is accountable for coordination. That shift is itself a CRM principle: the leader's value is in integrating the team, not in being the sole source of judgment. State the plan out loud, state the contingencies out loud, and ask each discipline for their concern out loud — that is what leading a team, as opposed to performing an operation, sounds like.

Examiners expect you to connect CRM to the professional and legal duties it discharges. Good communication is not a soft skill layered on top of competence — it is how the standard of care is met.

Two points deserve emphasis. First, the consent shift: under Montgomery, the question is no longer what a reasonable surgeon would disclose but what a reasonable patient would want to know — so the consent conversation, not the consent form, is where the duty lies, and a rushed or templated consent is a failure of communication with legal weight. Second, the standard of care: Bolam protects you when you act in line with a responsible body of opinion, and Bolitho adds that the body of opinion must withstand logical scrutiny — running the checklist, following the algorithm and documenting the Time Out is the practical embodiment of both.

Everything below condenses the topic for revision and viva practice — the high-yield points, the memory hooks, three worked vivas, and a one-screen cheat sheet.