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Shifting Perspective. The key to successful interview

22 September 2014

We don't like to think of doctors as people who make mistakes.  That is a problem, because doctors are human.  Martin Bromiley didn't like to think about it either, until the death of his wife in a completely avoidable error by three of Britain’s top surgeons.  They told him that her death was caused by an unavoidable, unforeseeable event and it appeared that at the time the surgeons genuinely believed this was the case.  But when one of the nurses in passing said, “It’s terrible.  I just can’t believe that happened” he became much more interested.

Bromiley pushed for a review of the operation, and the findings make for an interesting case study. Effectively 2 minutes into the operation his wife’s airway collapsed and the anaesthetist tried to force an air tube down her throat, but was unable get the airway open. The 3 surgeons each tried and failed because of an unknown blockage. This is a common problem and it is routine policy that an emergency tracheotomy be performed.  However, in this case, 20 minutes later the surgeons were still attempting to force the tube down the patient’s throat. During this time the following occurred:

  • Monitors and alarms started sounding which the surgeons heard
  • The patient’s skin turned blue.
  • Her oxygen-starved brain caused her arms to spasm, blocking their access to her body.
  • A nurse presented an emergency tracheotomy set, silently, to one of the surgeons.  He pushed it away.
  • Another nurse phoned the intensive care unit, telling them to expect the imminent arrival of a patient who had been too long without oxygen.  Upon advising them of what she had done they looked at her and shook their heads.

The 3 surgeons all later estimated the time the patient spent without oxygen as 2-3 minutes, not 20.  The key factor here was a fixation on one particular problem above all others.  This is an example of what is commonly called fixation error.

(The synopsis is based on an article by Ian Leslie in The New Statesman - May/June 2014:  "How MIstakes Can Save LIves.  One Man's mission to combat human error in the NHS - by studying plane crashes".  Martin Bromley has since gone on to form the Clinical Human Factors Group - - in an effort to alter the way medical teams behave.) 

The one practical Human Skill the surgeons could have used at that moment was to shift perspective. 

Perspective shifting is the hardest of all human skills because we are wired to see the world from our point of view, but it is something that can be practised. 

Deliberate questions to help shift perspective would be:

  • If that nurse thinks we need a tracheotomy kit, why don’t I think that?
  • If that nurse thinks this patient will need intensive care, why don’t I think that?
  • What am I thinking right now?  How is that different to what they think?

Fixation error actually happens quite a lot in interviews.  My favourite anecdote is from an immigration officer who had just joined the department.  He was observing an interview with a man who had made an application for Asylum.  All he could think was:  This person owns an I-phone.  Refugees don't own I-Phones.  Therefore this person cannot be a refugee.  Luckily the officer had a strong mentor, who demonstrated the importance of knowing clearly the purpose of the interview, and having a valid map of obejctives, otherwise he would have been struggling to manage that ensuing Bias.

Some critical-thinking questions we have used successfully in interview are: 

  • Why would a rational and reasonable person do that?
  • Is it possible that there might be an alternative explanation here?
  • If I think I know what is going on, How do I know?
  • Is this a fact?  or is this my story?

The key to shifting perspective is to value the views of others and to be prepared to examine your own actions in light of that.  The process should lead you  back to an examination of your own performance.  Of course, if you recognise Bias, you've then got to do something about it.  It is easy to know the right thing to do.  It is not always easy to do the right thing.


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