Dr Matt Sherrer (Host 1): Welcome to the Fresh Flow Podcast, sponsored by UAB Medicine, the UAB Department of Anesthesiology and Perioperative Medicine, and the Association of Anesthesia Clinical Directors. He's Mitch, I'm Matt, and we like to talk about interesting topics in the perioperative space. Thanks for tuning in.  .

Matt Sherrer (Host 1): Mitch, what's going on, man? How are you, buddy?

Mitchell Tsai, MD (Host 2): I'm doing all right. I'm really excited about this podcast. We talk about workforce shortages, the financialization of healthcare on this side of the United States, and how academic anesthesiologists are pulled into the operating room to cover clinical workload. So, I'm coming off my overnight shift. This one's going to be special.

Host 1: Yeah. You took call last night, right? So, you're pretty much no frontal cortex right now. So, I think that means the rest of the world will probably be able to relate to you, because usually you're way above any of the rest of us. So, you're down to my level, at least today, by being up all night.

Host 2: Sounds good. Looking forward to it.

Host 1: Let's get going. Well, I'm excited about this one too. Our guest today is Chris Turner. Chris and I, how did we meet? Let's see. I was working on an article with a young lad named Stuart Hanmer. Shout out to Stu. He said, "You got to meet this guy, Chris Turner. We were talking about civility in healthcare." And he said, "Have you heard of Chris?" I said, "No." "You got to go check him out." So, I went to your website, civilitysaveslives.com, watched the TED Talk. It's incredible, I recommend it to everybody who's listening today. And I said, "I got to talk to that guy." So, you and I have chatted before and you were kind enough to come on with us today.

So, Chris Turner is an Emergency Medicine consultant in the UK. His accent makes him sound much more intelligent than Mitch and I. And so Chris, thank you for being here with us today. We appreciate it.

Chris Turner, MD: Oh, it's a massive privilege. And it is lovely to see you guys and to get the chance to chat with you. I'm delighted to be here. Thank you for the invitation.

Host 1: Thank you. Well, so just starting right off. You built and continue to maintain this platform called Civility Saves Lives. For you to take on a project like this, there's got to be a story behind it. So, can you just help us understand what led you to embark upon this endeavor?

Chris Turner, MD: Yeah. So I don't know if it works the same for you guys, but we have clinical governance structures. And the clinical governance structures look at things that have gone wrong and what we can do about them and how we might avoid them happening again. And I was a governance lead for a decade. And in that time, I tried to work out what happened to make things go wrong, and lots of different issues that came up. Emergency medicine has a lot of governance, because a lot of things go wrong.

And as I was doing that, I noticed that the organizational response to this tended to be blame-orientated. Everybody liked it when we found the bad person. We found the bad person, we all pointed the finger and said, "Yeah, it was them. It's not us and we all felt better about that," and then we stepped back off it. And we said, "We'll do a bit of education and that won't happen again." And then, it happened again, and then it happened again. And the people at the end of the line, the people who we're all pointing the fingers at, I also stopped and thought about them. They were good folks. These were good, hardworking, knowledgeable, frequently very kind individuals, exactly the sort of people that I want to look after, and I want to look after my family if we get sick. Yet, somehow we were happy to point the finger at them.

And I started to realize we must be missing something. And I had breakfast one day with a guy called Trevor Dale. Trevor is a pilot. In fact, Trevor flew Concorde just the once, but he has flown Concorde, which I think is rather cool. And Trevor and I often talk about what's going on when things go wrong? Because, you know, it's a lot of pilots in that area. And we started talking about the work of Christine Porath at Georgetown and looking at her work and Amir Erez's work. And we basically start saying, "Hang on a second. Maybe there's more to this than just people not following protocol. Maybe the protocol is a standard operating procedure. His work is imagined and the work he's done looks different to that." And we're satisfied by pointing the finger at people and saying, "Hey, you didn't follow the protocol. It's your fault." So, start thinking about what else is going on. Well, there's an environment and there's the way we treat each other. And that's how I got into it.

And honestly, I thought it was going to be one talk. I thought I was going to give a talk about the impact of behavior on performance. I stand there and then I'd do it once. I might do it twice. And then I'd move on and learn about something else and give another talk on something else. And that was seven or eight years ago. And what happened was the very first time we talked about it, a whole bunch of people came up and wanted to talk about it afterwards. And then, I got a few more invites and then I got more invites. And this thing just snowballed.

And Joe Farmer who started it with me, Joe and I just ended up getting invited to go and talk all over the place and it turns out that this idea that behavior matters in a material way is actually something that resonates with lots of folks. And I think what's happened to an awful lot of people is, when we go into the workplace and somebody treats us in a way that feels disrespectful, not necessarily screaming and shouting at us, just leaving us feeling disrespected, that when we walk away from it, we look inside ourselves and we say, "Hey, I should be better than that. I should be able to deal with that. I should be tougher than that. And I should be able to cope with that sort of thing." And it's a personal feeling. And once you start to look at the research, you realize it's not a personal feeling. It's human beings, it's how we are. And when we treat each other negatively, people perform less well and share less information, and that is a toxic combination.

Host 2: I mean, it's obvious that across your journey or through your journey, you've dug a lot into this research. In her most recent book, Annie Duke, who's a faculty member at Wharton, points out that there's a difference between pedestals and monkeys, right? And I think a lot of what we've done in patient safety is we just keep trying to build a better pedestal, right?

I think there was a recent study by, I believe, Etheridge, JAMA Surgery, about how do you re-implement the surgical checklist, right? But one of the comments that they made was the surgical checklist doesn't ensure patient safety. It doesn't ensure civility, right? And so, going back to Duke, we can build the pedestals or we can actually do the harder part, which is training the monkey, right? So, how does civility allow us to build a better healthcare system?

Chris Turner, MD: Hey, Mitch, tell me you didn't just refer to the surgeons as monkeys.

Host 2: Oh, no. That would be Matt Sherrer at the University of Alabama.

Host 1: Fantastic.

Chris Turner, MD: All right. So, here's the deal. You want people to behave better towards each other, it's got to be meaningful. There is no point in somebody coming and telling me, "Hey, Chris, be nice to the guys in your trauma team," if I don't think that's going to result in better outcomes. I think an awful lot of people of my vintage-- And I'm older than you guys. I am 55-- A lot of people of my vintage grew up in a medical setting where treating each other like crap was just normalized. I was educated through humiliation. I used to be terrified to go on to some wards, because some of those consultants, those senior doctors, had such negative reputations that I really didn't feel able to perform well. Now, none of them were doing that to deliberately hurt me. They weren't doing that. The guys who are hostile in theatre, the guys who are hostile in the trauma call at cardiac arrest, they're not doing that to hurt other people. They're doing it, because they think that gets results.

And in my experience, and this is what the evidence says, is if you can start to talk to people about why this stuff matters, a huge number of people simply choose to change, if they believe it, if they think it resonates with them. So, the starting place is not actually, "Hey, you guys need to be nicer to each other." It's not even you guys need to start to implement the WHO checklist. It's actually, "This is why it matters. This is the impact that doing this thing." Either implementing the WHO checklist, and we're talking about change management here, or thinking about how we interact with each other, this matters.

And what comes after the because is not what matters to Mitch, not what matters to Matt and not what matters to Chris. It's what matters to the person that we're talking to. We change in response to our own values, not each other's values. And sometimes a little bit towards organizational values. But as doctors, this is a comment about doctors here for a second, doctors are broadly autonomous, have an awful lot of agency, and we tend to want to do what we want to do, because we believe it's the right thing for the patients and for the people around us.

So if we want people to move from one position to another, to choose to move from one position to another, we have to find out what matters to them and then to wrap up the conversation in that information, not in what matters to us. So, just to elaborate on that a wee bit, if I'm talking to an executive board, the sort of stuff that I talk to with them tends to be about reputation, financial performance, and the impact, how well their team can perform at a board level. If I'm doing this with surgeons or any frontline clinicians, doctors and nurses and allied health care professionals, if I'm doing it with those guys, I tend to talk about our performance at an individual and team level and how we can get better outcomes for patients and actually also for staff if we choose to behave in certain ways, particularly as leaders. And that resonates more with people. And many of us have basically Damascian conversions as we walk along. When I discovered the way that I'd been behaving as a senior member of staff was possibly creating harm for the people around me and for patients, I had to have a long, hard look at myself in the mirror and then think, "How do I want to be? Who do I want to be to other people? And how do I need to behave in order for people to see me that way?" And I think that's a journey that many of us go on as we begin to understand that this stuff is important. How we behave has therapeutic validity.

I mean, I don't know if you guys have ever spent time talking about or reading Compassionomics. But Compassionomics is a phenomenal book about the impact of compassion on the efficacy of the treatments that we give to patients. And it's mind blowing. We just don't have a good scientific basis to explain it through, but the empirical evidence says that we treat people compassionately, they get better quicker, they have less pain. And that seems like a big deal, and I think that can drive a bit of behaviour. But it's always about what matters to the people that we're talking to. So, huge long answer, apologies. But if we want to move people, then find out what matters to them. The Robert Cialdini work out of Arizona State from a few years ago about what things help people to be persuaded to move to a different state, it's really useful around that. There's lovely videos of his work on YouTube.

Host 2: One of the business professors that I had chance learn under, it would be Warren Bennis. And one of the things that he always talked to us about was that there's a difference between being and doing, right? And most of us just do things to supposedly be something. But the other piece is that, you know, once you figure out what you want to be, then you know what to do, right? And I think those are two different frameworks that absolutely apply to what you're talking about here.

Chris Turner, MD: One of the bits of work that we end up doing with people when we're workshopping this is we talk about reputation. Everybody listening to this podcast, and all three of us, we're interpreted through our reputation. If we have a positive reputation, if people see us as being good folks, when we do things, people tend to believe those are good things that we have done. And if we do something bad, people go, "He couldn't have meant it," and they might even come and check if we're okay and our reputation. And this is doubly true when we're sending somebody an email because when you read an email interpreting some words on the page through the mood you're in at the time and the reputation of the sender.

And reputation is massively important. And a way that I think is lovely to think about this is your reputation is your theme tune. What music plays in other people's heads when Mitch walks in the door? And it's not what plays in your head, it's what plays in their heads. And actually, what music would you like to play in their head? And if you decide what music you want to play in their head, what you want your theme tune to be when you walk through the door, how do you have to behave in order for them to hear that music? And then, working on that and working on ourselves. We're all working on ourselves all the time, but working on your theme tune. Thinking about what you want it to be, and then working on it so that other people might hear that. And it doesn't matter what you want. You might want the theme tune to Jaws, which I would argue is probably a little bit negative. But if you want that, then behave in the way that terrifies people when you walk through the door. You might want something positive, where people feel able to tell you information, where they're not scared of you. Well, choose your tune and decide how you need to behave in order for people to hear that.

Host 2: I just watched Indiana Jones and the Dial of Destiny with my youngest son, so I'm going to go with the theme song from Raiders of the Lost Ark.

Host 1: I love that. I have a buddy of mine that we talk about what our walkup song would be if we were-- you know, in baseball in America, you walk up, you get to choose your song. This is going to change my perception of it. Maybe not the coolest, heaviest rift, but what do I want people to think of.

I remember when we had Alex Macario on, and as accomplished as he is in anesthesiology in the United States, we said, "What do you want to be remembered by?" And he said, "I want people to think that I was kind." That stuck with me. That was an incredibly impactful statement.

All right, Chris. So, you know, you've talked a lot about getting people on board and getting people to see the value. And you've talked about the data. I know this stuff is kind of ingrained in your mind. You go out and talk about it all the time. I love your infographics page here on the civilitysaveslives.com website. And there's infographics that anybody's free to come and take and post in your workspace. Of course, my favorite is, "Leading through incivility is like breaking wind in a lift. You may feel better, but everyone else feels and performs worse. So, just a reflection of who's driving the website there.

Chris Turner, MD: I'm particularly proud of that.

Host 1: That's a great one, want it in all our operating rooms at UAB. But there's lots of data. And I've said for a while, "Hey, you know, we all want to be evidence-based physicians," but it's hard to admit that healthcare is not a team sport. And so if we're going to understand and be evidence-based physicians, then we all have to understand the evidence behind teamwork and incivility, et cetera. So, you know, a lot of that data, it's kind of near and dear to your heart. So just briefly, can you tell us, what does incivility do to us?

Chris Turner, MD: So before I say what incivility does to us, I'm going to tell you something different. It's about what is the single most important factor determining the quality of decisions that teams make. And it's information sharing. It's not how smart Mitch is, Matt is or Chris is. And I'll tell you why it's not how smart we are. It's because in every team that we work in, there are people in that team who know things that we do not know. And unless we know about it, unless they share it with us, we cannot take it into account. We can't let our wonderful leadership brains take it into account when we're making the next decision.

So, the key factor here is what's helping a team to share information? And what does help people to share information? It's feeling valued and respected. When the people around us feel valued and respected, we turn on the flow of information. We share information. If we don't feel valued and respected-- I mean, this is psychological safety, it's all in there. If we don't feel valued and respected, we turn off our flow of information. We don't share information. And when somebody doesn't share information with me in a trauma call, there's every chance I won't know what's in their head. And then, I make my next decision. And It might be a really poor one, because I've starved myself of the oxygen of wisdom, which is information.

So, what happens when we treat each other in an uncivil fashion, and when I'm talking about incivility here, I am not talking about the screaming and shouting. I'm talking about the mild to moderate incivility, the eye rolling when you speak, the tutting when you speak, the people who correct your English halfway through the sentence or finish your sentence off for you when they couldn't possibly know what you're about to say. And the evidence on this is that in the moment, it squeezes our bandwidth. It stops us thinking so well. And there's about a 61% reduction in our cognitive ability when somebody treats us in a negative way. Now, that lasts for a varying length of time. For some people, it's just a few seconds, but for many of us it's a lot longer and with a tail.

And if you witness incivility between other people not directed at you, there's about a 20% reduction in your cognitive ability just being around it. And I suspect that the mechanism that's going on here is that incivility is the very thin end of the threat wedge. Threat can come at an overt level where somebody's standing in front of you and they're pulling their fist back and they're about to hit you and it's pretty clear that you're in trouble. So, we have a fairly extreme physiological response to that. But at the other end of threat is the stuff that we don't know if it's meant to be offensive, but it makes us uncomfortable. And we think, "Well, if they're okay with treating me like that, how else are they going to be okay with treating me?" And I think that's what we're measuring with a mild to moderate incivility. It's the thin end of the wedge of threat. And that means that a couple of things happen. If I treat the guys in my team in a negative way, the first thing is I make them less smart. They're not wonderful, smart human beings. I squeeze their brains down and make them a shadow of themselves. So, that's the first thing. But the second thing is that they are now less likely to share information. So I've got a double whammy on my hands. Less likely to talk, and even if you do talk, you're not going to be as bright as you were before, and that is a disaster for my decision-making. And that's the mechanism that I think is going on when this happens, and that's from pulling together lots of different sources.

There's tons of other data. I mean, you mentioned a few minutes ago and I've forgotten the chap's name, but you said he wanted to be remembered for being kind.

Host 1: Alex Macario.

Chris Turner, MD: Yeah, Alex Macario. So, I think that is a wonderful thing to want to be remembered for. But witnessing incivility literally makes us less kind. If you witness incivility not directed at you, just witnessing it, you get up and you go around the corner and somebody asks you for help, you're a full 50% less likely to help that person. It makes us less kind, it primes us in the negative. And. That just seems like a really bad idea in my head, because most of the time at work I'm relying on people being kind to me, helping me, because I am constantly, as I'm sure you guys are, constantly in workaround mode, trying to make things happen in a system that feels like it's fighting against us sometimes, where we're trying to put a patient first, and it doesn't always feel like the system wants to do that as well. So, we work with other people, we have workarounds, but they rely upon other people being willing to help us to be kind.

Host 2: Thanks, Chris. You know, Matt and I, we've had the opportunity to toss around a few ideas with Jaideep Pandit who was on our podcast earlier. And he's at the NHS as well, he's the Editor-in-Chief for Anesthesia Analgesia, but you know, Matt is definitely a proponent of team-based care, right? That's important for how we deliver care here in the United States. The interesting thing for us is as residents, very few programs train you to learn how to work with a team, right? And our residents here are taught how to run a team. And what I teach the residents is that communications up and down and down and up. And what you want is you want to have a team of people that surround you that at 2:00 in the morning when you're on overnight call, that somebody's going to feel comfortable enough to tell you that, "Hey, did you think about this?" Right? To have that communication open is going to save a patient one day. And I think that's really, really important.

Chris Turner, MD: This guy called Michael West and I suspect you've not come across Michael West. But can I commend him to you with my whole heart? Michael West is the Professor of Leadership at Lancaster University in the UK and at the King's Fund in the UK. And he talks about the evidence base behind highly performing individual teams and organizations in the system I work in, in the NHS. But most of this won't be any different to you guys. And you can show how highly performing teams share certain characteristics. There's not usually more than eight or nine people. Once you get beyond eight or nine people, it's actually hard for everybody to be heard. When you're in these mega teams, only some voices get heard and we have to work hard to give people voices in those settings. He can also show that the best teams have away days every three to six months. They go away and they talk about what it means to work here and the strategizing of where we're going and how we want to be treating each other.

He talks about other stuff as well. And one of the things he talks about is this, if you cannot do the whole thing on your own, if you can't go into theatre and do the operation, be the scrub assistant, do the anaesthetic, do all the rest of it, if you cannot do it all on your own, then the minimum unit of performance is the team. It is not the individual. And boy, did I not like that when I first heard it. Every bit of me pushed against, this because our entire education in healthcare tends to be about personal mastery. It's about me. How good am I? What do I know? How can I work out things? And we do it all in exams on our own. So, it's all about personal mastery. But when it comes to us functioning in teams, If we have people who aren't able to perform well within that team, you actually can't really compensate for some of those jobs. So, the minimum unit of performance becomes the team, and that means how we treat each other really matters, because that has an impact on performance at an individual level.

Host 1: I've kind of maintained for a while, we do a great job in this country of turning out outstanding clinical anesthesiologists who then the very next day, when they take their job, are doing something completely and totally different because they're managing teams, right?

And so that brings me to another topic that's near and dear to your heart. And you mentioned this last time we chatted and we haven't gotten to go into it. And that's the, one of your passions is teaching wisdom. Can you expound a little bit more upon that? Because I think that's part of this. We're saying, "Hey, again, when you go out there, there's one way to do things in your mind." there's lots of other ways to do things that people might want to try. How do you handle that? And that kind of comes more down to wisdom. So, explain what that means to you.

Chris Turner, MD: Just for a start, I would say what you've just described about what happens to anesthesiologists in the States is exactly what happens to emergency medicine consultants in the UK. You're seeing patients, you're in the front line one day, and the next day, you're running a department and organizing people, and that's a wildly different way of functioning.

Anyhow, back to wisdom. Wisdom's fascinating. So, that's why I research. I researched the

development of wisdom in doctors. And it's properly esoteric. You try and hold it and it slips through your fingers and everyone says, "What's wisdom? What does that mean?" And all this sort of hard academics are uncomfortable with it, because it's hard to pin down. The thing is, what do we want to do as clinicians, as doctors, as nurses, allied healthcare professionals, and as administrators? What do we want to do? We want to make wise decisions.

And, okay, so I am about to say something incredibly grandiose, and it's this: I think pretty much everybody who researches wisdom has got it wrong. And I'll tell you why Pretty much everybody who researches wisdom looks at the decision-making process that goes on between our ears when we're making a decision. And I can describe this to you in terms of Aristotelian virtue ethics and the Nicomachean ethics and the primacy of phrenesis over the other ethical decision-making processes. And If I'm honest, I think it's a wee bit of nonsense. I think we like it, and we spent the equivalent of $1.5 million researching this. And this is why I think it's a bit of nonsense. I don't think it's all rubbish. I think it's useful to be able to deconstruct thinking. But I think most people will make good decisions when given the right information. And here's the gig. You ask people at an undergraduate level, what does a wise doctor do? We're talking about doctors here for a second or two. What does a wise doctor do? Well, they say, "Well, the wise doctor makes a great decision." And what they then do is they assume that they make that great decision because they've got all this wonderful information inside them and they use it and they come off and get the great decision. But that's not what's happening, in my opinion. And actually, this is what the evidence says, that people who become great leaders and make wise decisions, they don't just have the answer. It isn't just there in their head. What they do is they behave differently.

Now, when we move into leadership positions, and this is true for many, many of us, we move into leadership positions. We have a little bit of imposter syndrome. We thought we knew how to do the job. We move up a level and go, "Holy crap, there's quite a lot of stuff up here that nobody appears to have told me about." Then, we start learning about it. We have imposter syndrome. Our natural reaction to that is to move into command and control mode where we try and get grip of the situation, and we feel a bit more comfortable when we've got some control. And then, we start micromanaging people because we're in our comfort zone when we're micromanaging people who are doing something we know how to do.

And what we know, and this is actually back to Michael West's stuff, what we know is that people who behave that way don't get good outcomes. They don't make what are retrospectively regard as being wise decisions. But people who do make wise decisions from leadership positions move into what Edgar Schein who died just a few months ago. Edgar Schein would call asking not telling. They move into a different leadership mode instead of command and control, it's asking not telling. And what they do is people who make wise decisions start asking people around them what they think. And you see this in cardiac arrest, you see this in things that go horribly wrong in theatre, you see it in trauma calls, that often for the first few moments, it's very command and control, but only for the first few moments. And then, it becomes collegiate. You get a bunch of people who are talking to each other, who are sharing information, and they're working together towards a shared goal, which is usually resuscitation in these settings, but they're doing it by sharing information. And that asking not telling is a really interesting way of changing the dynamic so that we are effectively giving ourselves more and more information so that our wonderful brains can make better decisions.

And I think that wise decision-making is a function of getting the best information from the people around us, which is a function of our behavior, so that we can then process that information. And if you really want to make your decision wise, you can do something else afterwards. Once you've made your decision, tell the people who you're working with, what your decision is, and why you made that decision, because you Instantly provide yourself with a feedback loop. If they feel able to say things, they go, "Yeah, but did you realize that there's another knife sticking in his back or something like that?" so that you can then take that piece of information into account. And when we describe our decision making processes, what happens is that other people are let into our thought process and they sometimes feel able to contribute more to help us to make an even better decision. So, there you go, that's $1.5 million in seven years of work wrapped up and me telling you, "I think we missed the point and actually this is probably better."

Host 1: I got to use the term a wee bit of nonsense more in my daily vernacular. I'm incorporating that one in, a wee bit of nonsense. Doesn't sound as good when I say it as when you say it.

Host 2: Chris, I just wanted to add that I'm going to have to call Kenneth Sharp and Barry Shwartz who wrote Practical Wisdom on this side, and then there's a section in there in Medicine & Healthcare that the book is bonk. I don't have any problems doing that.

Chris Turner, MD: Don't do that. Barry Shwartz is a god.

Host 1: Mitchelltsai@uvm.com.

Host 2: I know Kenneth Sharp. He's a good guy. You know, what you've said is that one of the things that Steve Sample, who was the President of the USC for the longest, for a while, he passed away a couple years ago. But he wrote a book and it's called The Contrarian's Guide to Leadership, right? And one of the chapters or one of the themes is to think gray. Not black and white, right? And the longer you can stay in the gray, the better decision that you're going to make because you're always taking in information. And just in terms of wisdom, you know, in my travels as an anesthesiologist who's still trying to figure out what he wants to do with the rest of his life, I still think that leadership, education, entrepreneurship, design thinking all have that same common theme of your job is to get there and get as much information as you possibly can as quickly as possible,

Chris Turner, MD: I love that. Think gray. A thing I see panning out regularly in hospital is I have a sick patient in rescus. I have a sick patient and this patient might go surgically or they might go medically. And I invite the medical doctor and the surgical doctor who may be taking this patient to come down and see the patient. And for the first few seconds, they have conversation about the patient, then pretty quickly the patient is pushed out of it and I have the medical guy and the surgical guy and they're basically going toe to toe. They're going toe to toe, and the purpose of this conversation for them is to be right. And we mistake being right for doing the right thing. Being right is black and white, it's dichotomous. I win, you lose. It's about my ego. Doing the right thing sits somewhere in the middle. And I think a lot of the time for people that I see at work who get into a lot of conflict that it's really important to them to be right and stepping away from that, and Instead of being right saying, "Well, what's the right thing here," is something that wise senior decision makers frequently do you see that you see them coming in. These senior guys, these doctors, these nurses, these senior people, they come in and they talk about the patient and they pull the patient back into the conversation, and they discuss what the right thing to do is. And it's always somewhere in the middle, and it always involves the team that doesn't take them on to the ward, committing to consulting with the patient on a regular basis, rather than going, "That's your problem, not my problem." and I think we mistake being right for doing the right thing, and they are absolutely different in most complicated and complex situations.

Host 1: I hope that husbands are listening to this too, right? That's a marriage counseling one on one right there. How important is you to be right? We have taken this podcast to an entirely new discipline now. So, thank you for that, Chris.

Host 2: I was actually going to argue that it's sort of the continuation of crew resource management and civility within the cockpit, rigHt? And if you look at checklists in the aviation industry, all of them at the bottom, they all say fly the plane. Ultimately, our job is to take care of the patient. So, I love that.

You're the second individual we've had on the podcast from across the pond. And given the recent resident strikes in the NHS, we can all agree that trying to figure out what to do with the healthcare systems on either side of the country. And it's interesting that both the NHS and sort of the United States healthcare system evolved after World War II. Very different circumstances in England than they were in America. But healthcare system, trying to figure out what to do, it's a wicked problem. From where you sit, how would you approach making the system better? I mean, given everything that we've talked about today.

Chris Turner, MD: I think we do a lot of harm to a lot of people, because we don't have some conversations. And conversation that we don't have most often is what do you want us to do towards the end of your life? And there's a massive cultural component to this. So, I'm going to use a really broad brush on it.

My wife is Bangladeshi. My wife is Muslim. I am the only non-Muslim in my family, which is a fascinating place to be. And her family are great. They're just lovely people. But nobody in her family dies without being on intensive care with a tube coming out of every single orifice and machines pinging all around them. Now, I am a Scottish Presbyterian by birth. And in my family, it's not a good death if you die with machines on you. In my family, good death happens quietly with your family around you, either at home or in a hospital, but not hooked up to everything. And that's because there's a cultural expectation around that. And that's the cultural part of this. But what we don't do is we don't have conversations with patients and their relatives about support somebody we would want at the end of their life. And instead, we get trapped in this we-want-to-keep-people-alive-forever, often causing them more pain and distress at the end of their life than I personally feel comfortable with.

So, I think there's a conversation about what do we do, what's the kindest thing that we can do? And that might be on a machine with all the stuff going on around you, but it might be quietly in a side room with your family around you. And if we don't have the conversation and we don't think about how to have the conversation, what we will keep doing is expending huge amounts of healthcare resources on people in the last few weeks of their lives at tremendous opportunity cost to the patient who is unconscious in intensive care when, actually, we might be able to find more valuable time for them to have with the people that they love.

Now, it's hugely, hugely messy and it's individual and it's about individuals and what they would want and what families would want. But I think for me, the starting place, weirdly, is the end of life. Talking about what the right thing to do for people at the end of life is. Within the UK, we have a form called a Respect Form, and it evolved from a Do Not Resuscitate Form, and it is a much more sophisticated beast than Do Not Resuscitate Form. It has elements of advanced planning. It talks about what people value, what they most want, what they most want to avoid. And it includes a narrative around this human being and what's important to them. So for me, I'm straight into the difficult stuff, like, let's start to think about how we have difficult conversations about what we do with people towards the end of their life on a meta level. I'm all about socialized healthcare, and I realize how many people will just be turned off by that in that statement. But I am all about socialized healthcare. I want to know that when I have myocardial infarction, and I'm a 55-year-old squat Scottish man, let's face it guys, I mean, the clock is ticking. And when I have it, I want to know that I can pitch up at the hospital and it doesn't matter which hospital I pitch up at, that nobody is going to ask me for insurance, nobody's going to have a discussion with me about whether or not it's okay for me to do this, and nobody's going to be bankrupted by it. And that's how it works in the UK.

So, I was thinking about this earlier today, I love that I work in that system, the system just asked me to do my best and deal with the patient in front of you. And there's no phone calls to insurance companies. There's nothing. Nothing like that happens. But of course, the system has to be resourced and that's another political football. So for me, the end-of-life stuff becomes incredibly important. Thinking about how we can be most effective as individuals and teams is important. And then, there's the political stuff where I don't think anybody should lose their house because they had to have a kidney transplant.

Host 1: Man, we could talk forever. Mitch, I told you it's going to be fun. We could go hours and keep on going. I'm going to actually let the listener in here as we kind of close up. So, the listeners can't see what's going on here, but I have this keen ability to see both of the guys I'm talking to on the screen, and there's this tension that you guys can't see, right? So, Chris is drinking out of an AC/DC mug, right? I know Mitch though, Parker has a Fender guitar and a Fender amp, right? So, let's settle this once and for all, British guitar tone versus American guitar tone? I will point out, and I'm saying this as an American, when Nigel Tufnel points to the amp and says, "This thing goes to 11," what's he pointing to? He's pointing to a Marshall amp, right? It's a British guitar tone. So Chris, you're here, you have the opportunity. Do we settle this once and for all? Do we strike some sort of balance? Where do you want to go with this?

Chris Turner, MD: It's all in the gray. Mitch told us that earlier. It's all in the gray.

Host 1: Man, answer. What an answer.

Chris Turner, MD: And as long as it goes up to 11, once it gets to 11, I'm pretty certain that our middle ear and our inner ear can't really tell the difference. And for me, it's Marshall. But anything that sounds like J. Mascis rocks my world. So, there you go, for people who know who J. Mascis is.

Host 1: Awesome. Chris, man, thank you so much. This has been a blast, and I'm sure you'll be getting hit up by both Mitch and me later on to continue discussions. But thank you so much for doing this. This is the first time we've ventured outside of the perioperative space, although I will say that civility is certainly pertinent to the perioperative space. But this is the first time we've had a non-anesthesiologist on, and I think you've given us tremendous perspective. So, thank you so much for being here, man. This has been awesome.

Chris Turner, MD: Thanks, guys. A complete privilege.

Host 2: Thanks, Chris.

Dr Matt Sherrer (Host 1): Thanks for tuning in to the Fresh Flow Podcast. We hope you found it interesting and hope you'll tune in next time.