Episode 22

full
Published on:

21st Sep 2026

S6 Ep19 Dr. Derek Donegan on Orthopedic Trauma & Metacognition

Dr. Derek Donegan is an orthopedic trauma surgeon and Associate Professor at the University of Pennsylvania, a healthcare entrepreneur, co-founder of ORtelligence, and a national leader with the Orthopedic Trauma Association, where his work centers on well-being, moral injury, and advocacy.

Dan and Derek start with the distinction that elective joint replacement is planned, optimized, and predictable weeks out, while orthopedic trauma is a patient you've never met and can't prepare for. The two paths have the same training pipeline, same residency spots, but somewhere along the way some surgeons catch the "trauma bug" and start looking for chaos to organize instead of variables to eliminate.

From there they dig into what Derek calls his "Spidey sense", the signal that a case is turning before he could point to why, and his reputation for going quiet in the OR exactly when things get hardest. They use cognitive load theory to get at why that instinct resists being taught even when everyone in the room wants it taught.

This conversation was released in partnership with The Emergency Mind Podcast.

If you found value in this discussion, the best way to support our work and stay up to date on future episodes is to subscribe and leave us a quick rating or review. It helps us reach more people who need to hear these conversations.

Transcript
Preston:

Welcome to the Teamcast.

2

:

I'm Dr.

3

:

Preston Cline, director of the

Mission Critical Team Institute.

4

:

Here, we discuss all things

mission-critical teams.

5

:

These are teams of four to twelve people

indigenously trained and educated to

6

:

solve rapidly emerging, complex, adaptive

problem sets where the consequence of

7

:

failure is death or catastrophic loss.

8

:

With my colleagues and our guests,

we bring you insights from combat

9

:

zones to emergency rooms, dedicated to

improving the success, survivability,

10

:

and sustainability of these teams.

11

:

We grapple with how to prepare for

future events and how to develop

12

:

language and frameworks to transfer

critical, often unspoken, knowledge.

13

:

Whether you're on a mission-critical

team or not, we aim to bring you

14

:

the broadest range of topics and

guests as possible to help prepare

15

:

you to perform when it matters most.

16

:

Thank you for joining us, and

hope you enjoy the Teamcast.

17

:

Dan: Hi, folks.

18

:

I'm Dan

19

:

Dworkis.

20

:

I'm

21

:

delighted to have Derek Donegan

on the podcast with us today.

22

:

Dr.

23

:

Donegan is an orthopedic trauma surgeon.

24

:

He's the associate professor at

the University of Pennsylvania,

25

:

and he's a healthcare entrepreneur

focused on advancing surgical care,

26

:

technology, and physician well-being.

27

:

He's a co-founder of ORtelligence and

serves in the national leadership with

28

:

the Orthopedic Trauma Association,

where his work centers on well-being,

29

:

moral injury, and advocacy.

30

:

And if you're watching me read that off

the side of the screen, that's just 'cause

31

:

I wanna get all of that exactly right.

32

:

Most importantly, I think Derek

is a, a brilliant leader and a

33

:

clinician and somebody I'm proud

and happy to call a friend and

34

:

happy to have him on the podcast.

35

:

So Derek, welcome.

36

:

Derek: Thanks, Dan.

37

:

It's a pleasure to, to be here,

and it's humbling when you hear

38

:

somebody read that, so thank you.

39

:

Dan: Yeah, absolutely.

40

:

We've had, over the years, a ton

of super interesting conversations.

41

:

We've done some projects together.

42

:

We're in the middle of

doing some projects.

43

:

There's a, a lot of really interesting

ground to go over for this.

44

:

Why don't we start, if folks haven't

met you and they don't know you, can

45

:

you give us like a 30,000-foot view

or the metric system, if you prefer,

46

:

of what you do and who you are?

47

:

Derek: Sure.

48

:

As Dan said, my name's Derek Donegan.

49

:

I am a practicing orthopedic trauma

surgeon at a fairly busy level one

50

:

academic trauma center in Philadelphia

at the University of Pennsylvania.

51

:

I've been in practice, I think

I'm just starting my 15th year or

52

:

so as a, as an attending surgeon.

53

:

That role is, r- very vast,

um, a couple different hats.

54

:

Number one, obviously, is clinical care,

taking care of poly-traumatized and

55

:

trauma patients that come in through ER,

the trauma bay, who injure themselves

56

:

and come in through our clinic.

57

:

In addition, because it's an academic

center, we get to do research and

58

:

study things that can hopefully advance

our field and make things better for

59

:

our patients and for other providers.

60

:

And lastly is I get to educate.

61

:

I get to educate medical

students, residents, and fellows.

62

:

And so when you think about the ability

to have impacts on the systems and people,

63

:

this starts to really broaden the ability

to touch people in many different ways.

64

:

In addition, I'm happily married for

20 years and a proud father of four

65

:

incredible daughters that keep me very

busy outside of when I'm not working

66

:

as an orthopedic trauma surgeon.

67

:

Dan: And then as Dan also mentioned,

68

:

Derek: I have a passion for the

entrepreneurial spirit to bring kind

69

:

of more visionary things into the

healthcare space to really just to make

70

:

our jobs a little bit better and to

provide better care for our patients.

71

:

Dan: Love it, man.

72

:

I love it.

73

:

There's-- I'm thinking back of all of

the conversations we've shared over the

74

:

years, and they usually involve stealing

5 or 10 minutes in between things,

75

:

which is no surprise given the list

of the depth of what you, what you do.

76

:

I, I think it's worth starting

With what is ortho trauma?

77

:

And I think that's worth it because I'm

not sure the breakdown is the same in

78

:

other places, and it's worth defining

what it is 'cause I think it's gonna

79

:

be one of the themes we poke at is

what does it take to be a good ortho

80

:

trauma person and how do we build that

and what does a system look like that?

81

:

So what is orth-

82

:

Derek: Yeah, that's a great question

actually, 'cause I think people

83

:

don't necessarily understand the

different types of orthopedics

84

:

that can be practiced, if you will.

85

:

So orthopedics in general i-

is basically being a surgeon

86

:

of the musculoskeletal system.

87

:

And, uh, most people think of that

as doing hip and knee replacements,

88

:

reconstructing ACLs on athletes, taking

care of some, you know, wrist fractures,

89

:

carpal tunnel releases, et cetera.

90

:

But when you start to dial into

orthopedics, there are multiple

91

:

specialties where people take an

extra year of training to really

92

:

hone their skills in a specific area.

93

:

One of those areas is orthopedic

traumatology, which I developed a

94

:

passion for and chose to pursue in

a little bit of a deeper dive And

95

:

what that really is taking care

of the acutely injured individual

96

:

from a musculoskeletal perspective.

97

:

Most commonly broken bones, whether

it's a femur fracture or a tibia

98

:

fracture or a wrist fracture or a

forearm or humerus or pelvis or an

99

:

acetabulum, those type of injuries.

100

:

But what kind of separates the orthopedic

trauma surgeon is when that all happens in

101

:

a very high energy mechanism in a patient

who potentially could be in extremis

102

:

when they come into the hospital, for

lack of a better term, on death's door.

103

:

And part of the reason is because of these

musculoskeletal injuries that they have.

104

:

And so you, we spend a year of

really focusing on how to manage

105

:

that person as a whole, how to manage

their injuries, and how to start

106

:

to put those people back together.

107

:

Dan: So there's a couple threads

that I wanna pull on here, and

108

:

maybe let's do it this way.

109

:

Can you describe the difference between

the setup for and maybe execution of

110

:

what somebody would do if they're, say,

replacing a knee in an elective surgery

111

:

versus if they're doing a femur repair

on somebody that was hit by a car?

112

:

Derek: Sure.

113

:

I think-- and that's a,

a really nice contrast.

114

:

Technically, doing hip and knee

replacements is, can be very

115

:

technically challenged, and our

surgeons that spend time become

116

:

experts for that are truly gifted.

117

:

But when you look at doing a, an

elective total hip or total knee

118

:

replacement, it's planned, right?

119

:

You meet the patient in the office,

you diagnose them with, say, knee

120

:

arthritis, and they've failed conservative

treatment, and the decision is to

121

:

proceed with surgical intervention in

the form of a total knee replacement.

122

:

That person is then booked for

surgery, usually four to six

123

:

weeks out, maybe even longer.

124

:

And in that time period, that

patient is able to become

125

:

medically optimized as well.

126

:

They can see their medical doctors,

they get cardiology clearance, make

127

:

sure their blood sugar's under control.

128

:

If there's any habits that might

negatively affect outcomes like smoking,

129

:

things of that nature, can start to

work on reversing or quitting those.

130

:

And then, and then their

surgery date comes.

131

:

And from a sur-surgeon's perspective,

if I'm doing hip and knee replacements

132

:

all day, my schedule is patient

A, total knee, patient B, total

133

:

hip, left versus patient C…

134

:

And it's very predictable and scheduled.

135

:

And then the case itself tends to

follow pretty specific steps with

136

:

similar, if not the same equipment

most times, in a very stepwise fashion.

137

:

And so those-- the people who do

that can-- are true wizards of

138

:

their craft and can become extremely

efficient at that surgery and really

139

:

optimize outcomes for their patients.

140

:

On the flip side- Orthopedic trauma.

141

:

Now, there are some elective cases

we get to do when trauma goes

142

:

sideways, when bones don't heal

correctly, things of that nature.

143

:

But in the acute setting, the person with,

say, the femur fracture who crashes his

144

:

motorcycle, they come into the emergency

room or the trauma bay, and they could

145

:

potentially have other injuries going on.

146

:

But from a, a, a orthopedic surgery

perspective, that patient, you know, is

147

:

added onto the OR schedule either that

day or the next day, and taken to the

148

:

operating room by an orthopedic surgeon

or traumatologist to fix their femur.

149

:

Now, an orthopedic trauma surgeon,

if it's just that one femur that

150

:

came in, that's all they're doing,

but that tends not to be the case.

151

:

Where- … my day is often fixing a femur

fracture, fixing a tibia fracture, fixing

152

:

a proximal humerus fracture, fixing a

pelvis, maybe doing a, a conversion total

153

:

hip for a failed acetabular fracture.

154

:

So my orthopedic trauma surgeon's day

is fairly unpredictable, and I would

155

:

say one of the things I personally

like about it, and I guess this

156

:

will get to my personality, is I

can go to bed, have two cases on the

157

:

schedule, and wake up and have 10.

158

:

And you just have to be able to

roll with that, think on your toes a

159

:

little bit, and be okay with planning.

160

:

You're gonna plan and prepare,

but with limited time to do so.

161

:

Dan: So when we go back to the, the

joints person, we're thinking about--

162

:

I love how much you used the word

optimize around that, and I think

163

:

there's this whole concept of like in

the OR, you're optimizing technique,

164

:

you're optimizing kits, you're getting

really familiar with what you're doing.

165

:

Your team's getting used to it.

166

:

You're getting a, a battle

rhythm of that same thing down.

167

:

And then even outside of the OR, you're

really optimizing the environment, both

168

:

of scheduling and getting the person in

there, but also of the human being, right?

169

:

You have time to work to make the

field better to play with, right?

170

:

To make the human better to work with.

171

:

Versus In your life where you

get the hand of cards that you

172

:

get, so does the patient, right?

173

:

Nobody necessarily wants

to be there, right?

174

:

But you all get the hand of cards you're

dealt, and then you have to figure

175

:

out how to play it with what you have.

176

:

And over the years that you and I have

known each other, I've been endlessly

177

:

fascinated by the training pipeline

that in some ways produces both of those

178

:

people from the same training pathway.

179

:

Now, obviously, there

are differences, right?

180

:

There's fellowship, and you do a

fellowship in trauma or you do a

181

:

fellowship in joints or sort of whatever.

182

:

But at the end of the day, most

of the training pipeline is all

183

:

of the orthopedic folks together

versus, say, the OBGYN folks or the

184

:

pediatrics folks or me in the ER.

185

:

And there's some pathway that takes

people that love surgery, they

186

:

love the musculoskeletal system,

and they want to be in this space.

187

:

And you train them how to think

through these problem sets, and

188

:

then they decide somewhere in

there, "Uh, I really like unordered,

189

:

unstructured, chaotic problem sets.

190

:

I wanna wake up and have 10 things

and not know what they are, and

191

:

wanna work on somebody that's not

optimized, wanna be in the, the

192

:

mess of it," versus, "You know what?

193

:

I actually want to be the world's best

at performing, like, left ACL repairs,

194

:

and I wanna be, like, so good at that,

that I wanna control all the variables

195

:

and make optimal really within my grasp."

196

:

And how does that work, right?

197

:

Like, how do you produce

one pipeline that…

198

:

Are you bringing both of those people

in pre-formed, and then they know

199

:

from the time they hit the door

that they're gonna go left or right?

200

:

Or are you seeing people that all come

in, and then somewhere along the way

201

:

they catch a spark and they're like,

"Ah, I really wanna go this way"?

202

:

'Cause I think there's an underlying

question there about, in general, how

203

:

do you train people to work in the

types of environments that you work

204

:

in where y- you have to love some

of that chaos to really get it done?

205

:

Derek: Yeah.

206

:

So I think you hit the nail on the head.

207

:

The, the training pipeline

is pretty similar, right?

208

:

Graduate college, you

get into medical school.

209

:

At some point in medical school, you

decide that orthopedic surgery or

210

:

whatever specialty is the specialty

you wanna go into, and then you

211

:

apply for that residency, right?

212

:

So whether it's an emergency medicine

residency, internal medicine,

213

:

orthopedic surgery, whatever.

214

:

So there's a selection process

that goes into that, right?

215

:

And so the people who say, "I wanna

be an orthopedic surgeon," they apply

216

:

to orthopedic surgery residencies.

217

:

I think the last time I looked at the

statistics, maybe about a year or two

218

:

ago, it was something like, I think,

20%, 23% people matched into orthopedics.

219

:

So to give you, uh, a real reference,

at University of Pennsylvania, we

220

:

have eight residents per year for

five years, so there's eight spots.

221

:

We tend to interview somewhere

around 80 people for those eight

222

:

spots out of probably about 1,000

people who apply to our program.

223

:

So that field becomes very

narrowed very quickly.

224

:

So then we get these eight people

who have decided they wanna

225

:

become orthopedic surgeons.

226

:

Some come in with…

227

:

And everyone has different reasons for it.

228

:

Some have a family member who's

an orthopedic surgeon, some people

229

:

underwent orthopedic surgery and nobody--

Some know someone who did, and they

230

:

just instantly changed their lives.

231

:

Some people just like working

with their hands and tools, right?

232

:

And so it's pretty diverse.

233

:

And some people come in and

say, "Hey, I wanna be the

234

:

best left ACL surgeon," right?

235

:

Some people come in and say, "I

have no idea what I wanna be.

236

:

I just wanna be an orthopedic surgeon."

237

:

And so I think there's both.

238

:

You have people who come in and have a

very clear identity and identity path,

239

:

and then you have people who come in,

are a little more open and a blank

240

:

canvas, if you will, and they tend to

catch that spark of whatever that may be.

241

:

And I think it's really important

can-- And sometimes it changes.

242

:

I'll give you, for example, for

me, I was a collegiate wrestler,

243

:

I was a phys ed teacher, I coached

wrestling all before going to medical

244

:

school and making that decision.

245

:

So in my mind, the most logical

thing for me to do was to be

246

:

a sports medicine surgeon.

247

:

Just made sense.

248

:

And I caught the trauma bug when I

was at PGY2 and 3 with a couple of

249

:

very specific experiences that I was

like, "Wow," like, "This, this is

250

:

what I wanna do the rest of my life."

251

:

It felt very rewarding

and very fulfilling.

252

:

And so that can happen But I also-- it

can happen where someone says, "Hey,

253

:

this fits my personality better."

254

:

And I think that's also

a really important thing.

255

:

It's something that we in the

academic environment try to, you know,

256

:

coach/mentor, whatever word you wanna use.

257

:

There's some nuance behind that.

258

:

But be it an advisor saying, "Hey,

this is what this is really," and it

259

:

becomes that immersive experience that

when you're on trauma for six weeks,

260

:

like, you're doing nothing but trauma.

261

:

You know what it's about, right?

262

:

You get to understand what that

lifestyle is for a short period

263

:

of time, and hopefully be able to

make a decision of I can do this

264

:

for the rest of my life or not.

265

:

Dan: And how does it work-- And I

will ask this, please feel free to

266

:

decline answering this, but how does

it work at the department level?

267

:

Because I, I have to imagine that

the personalities and problem-solving

268

:

tools and ways of looking at the world

between different types of orthopedic

269

:

surgeons who do or do not favor chaos

are probably a little different.

270

:

And so collectively, you all still

have to run a department together,

271

:

and you have to run a ship.

272

:

So you have these people with very

different sort of mindsets, unlike,

273

:

to some degree, say, an emergency

department, where basically everybody

274

:

in an emergency department is emergency,

and we all, you know, for better or for

275

:

worse, have some of the same personality

traits, and that can, that can really

276

:

trip us sometimes or that can get us

all running in the same direction.

277

:

But how does that work from

a systems point of view?

278

:

Derek: That's a, that's

an interesting question.

279

:

I'd have to say I think it just

works, and I think the reason why

280

:

is because it takes all kinds for

the system to go around, right?

281

:

I think we need the people who need-- who

are able to focus on doing a 10-hour spine

282

:

surgery, and that's all they do, right?

283

:

'Cause there's patients

out there that need that.

284

:

Dan: Absolutely.

285

:

Derek: We need the people who are

like, "Hey, listen, I just wanna

286

:

do my total knees and total hips

because I can get that surgery done,

287

:

and my outcome's gonna be the same.

288

:

Like, I, I know what it's gonna be."

289

:

And one of our surgeons

say, "Same is same," right?

290

:

Same is same.

291

:

I'm good.

292

:

That's my lane.

293

:

And then there's people like

me and my partners who are

294

:

like, "Let's bring the chaos."

295

:

Because we need chaos organizers, right?

296

:

'Cause we're in a trauma center.

297

:

Sure.

298

:

And so I think it just works.

299

:

Hats off to my chairman, Kyle

Potter, for the one who has

300

:

to deal with all of us, right?

301

:

And be our boss, in quotes, right?

302

:

Because it's a lot of different

personalities and a lot of different egos

303

:

and all sorts of things that you have to

get people rowing in the same direction.

304

:

But it seems to work.

305

:

Dan: Love it.

306

:

Okay.

307

:

L-let's-- We, we've been so far sort

of contrasting two different styles of

308

:

orthopedic surgery, for lack of a better

word, two different directions of it.

309

:

But let's zoom into yours for a minute.

310

:

And you can't optimize the patient

before they get there 'cause you

311

:

don't know when they're coming.

312

:

You don't necessarily know

what's gonna be wrong with them.

313

:

And so you're handed, and I know this

isn't quite literally, but you're

314

:

handed a card, and the card says

you have to do this procedure on

315

:

this person basically in this way.

316

:

Derek: So

317

:

Dan: what are the control

surfaces you have over that space?

318

:

And we can-- the, the joints folks

can control all sorts of stuff.

319

:

What are the control surfaces that you

have when you-- when all of a sudden you

320

:

know you have to come in and do a thing?

321

:

Derek: Yeah, I think it

depends on time of day, right?

322

:

Mm-hmm.

323

:

And so I think we tend-- we've been very

lucky to set up a system where we can get

324

:

the majority of our work done during, I'll

call it, working daylight hours, right?

325

:

Where our teams, our surrounding cast

of characters, our circulating nurses,

326

:

scrub techs, anesthes-- x-ray techs

are, for the most part, similar, right?

327

:

Not exactly the

328

:

Dan: same every time,

329

:

Derek: but same enough where- Mm-hmm

… we can rely on some consistency there to

330

:

know that, okay, if we're taking care of

somebody's femur fracture, we're gonna

331

:

put a, an intramedullary nail in it that

they know how we like to set up the room.

332

:

They know what instruments

that we're gonna use.

333

:

Our scrub tech has some familiarity with

the instrument sets that we're gonna use.

334

:

Our anesthesia team knows that

patient needs a paralytics on board

335

:

for us to overcome the forces of the

thigh muscles to get our reduction.

336

:

And so those are, I think, the

things that are in our control.

337

:

We have no control over the fracture

type, whether it's complex, simple,

338

:

open, patient type, as you alluded to.

339

:

They could be morbidly obese.

340

:

They could have substances

on board and all sorts of

341

:

things, not an optimized host.

342

:

So I think optimizing the process

as best you can with the people

343

:

around you allows you to have an

efficient, optimized surgical process

344

:

that, regardless of the cards you're

dealt, is gonna set your-yourself

345

:

up for success as much as possible.

346

:

Dan: For all of us in medicine,

when we join a team, we modify the

347

:

environment around us, but we also

inherit from that environment, right?

348

:

Almost none of us design a

new system from the ground up.

349

:

But i-if I could give you a magic

wand for a minute, and y- you got to

350

:

completely remake a hospital, all of a

sudden, here's your brand new hospital.

351

:

It's gonna have the same sort

of input of patients and inflow

352

:

of stuff as you do right now.

353

:

What sort of systems would

you wanna change in that?

354

:

Or I guess an equivalent way of looking

at that is if you're thinking about

355

:

the system as the way to control the

surfaces that you can control What do

356

:

you look for when you're evaluating that?

357

:

Derek: Yeah, I think the biggest one is

the consistency of teams and resources.

358

:

I think that's where the wheels start

to fall off the bus a little bit-

359

:

Mm-hmm … anywhere in any system, right?

360

:

It's in our optimized environment, things

are even in unpredictable situations,

361

:

things are fairly predictable, right?

362

:

Like, you…

363

:

I, my mind, I know when a case can

start to go sideways and dial in my

364

:

senses a little differently, right?

365

:

And when it's the consistent

team members, that's something

366

:

I can specifically focus on.

367

:

When we start to get outside of that,

when, say, shift change happens and

368

:

those team members start to become

different, sometimes it works out

369

:

fine, sometimes it doesn't, just

because that's the nature of the beast.

370

:

Those other factors start to play a role

in our ability to efficiently do our job.

371

:

Let's just say for instance, we're

doing, we're taking care of someone's

372

:

femur, and person came in, they

need to get fixed, and it just

373

:

happens to be, say, 8:00 at night.

374

:

And it's a new shift of people, and

just unfortunately, the, the person

375

:

who's a scrub tech, say, has only done

that case maybe twice before, right?

376

:

Dan: Sure.

377

:

Derek: And so now my focus not only

is on the patient, it's also on the

378

:

scrub tech, making sure that we're

getting the right equipment at the

379

:

right time for the right reason, and

that it's functioning pro- properly.

380

:

So it just, it starts to dial your senses

or I should say dilute your senses away

381

:

from probably the most important task.

382

:

Now that being said, you do

this long enough, you start to

383

:

understand that, and you change

your style in those moments, right?

384

:

And if I think the people who have

been doing this long enough and

385

:

that are successful at it can see

that and see that coming and have

386

:

a different way of working, right?

387

:

Mm-hmm.

388

:

Can a- adapt to that environment

to still optimize outcomes.

389

:

Dan: Can you press on this?

390

:

Could you give us an example

of what, like what would you do

391

:

differently or- What type of thing

would you change in that moment?

392

:

Derek: Yeah, I think fortunate

to have a couple people in

393

:

the operating room with us.

394

:

And so if at that time, if I have

a medical sales consult for…

395

:

So for trauma and actually most of

all of orthopedics that are very

396

:

implant-dependent, the companies have

representatives that kind of bring the

397

:

implants in or are, we'll call them

set experts, for lack of a better term.

398

:

If I have somebody that I, that

I trust on that end, I can have a

399

:

conversation with them ahead of the

case, like, "Hey, this, our scrub tech

400

:

is a little new, like newer to this,

has only done this a couple times.

401

:

I need you to be like super engaged.

402

:

Need to make sure that like you're

guiding them through this is the right…

403

:

When I ask for a guide wire,

the correct guide wire.

404

:

When I ask for a drill bit,

this is the correct drill bit."

405

:

And so those are things you can

start to dial in a little bit.

406

:

Additionally, being in an academic

teaching center, it's, we have a

407

:

obligation to teach our residents to be

able to do these procedures as w- as well.

408

:

And if there's certain variables that

I can't control, then Those are the

409

:

parts of the cases that I need to

make sure that maybe I'm doing, right?

410

:

Because the, the instruments are in

my hands because it's just one more

411

:

variable that I c- I can't control, right?

412

:

Yeah.

413

:

And so I think bringing in as

much of that you can control in

414

:

this situation is, is helpful.

415

:

Dan: There's a-- I don't know that

there's a good word for it, but

416

:

there's a sense, and I literally

mean that sight or touch or whatever.

417

:

There, there's a sense that people

who work in this space develop about

418

:

the moment to moment feeling of the

uncertainty that's around them, right?

419

:

And there's a way that you can

just feel what that is, and I

420

:

think you're describing some

version of that right now, right?

421

:

There's-- the uncertainty

is bounded, right?

422

:

You know you're gonna be working

on an orthopedic problem.

423

:

It's unlikely anybody's gonna call you

over to the CT sur-surgery side of the

424

:

room and have you work on somebody's

heart, or you're not gonna be intubating

425

:

with me down in the ER, right?

426

:

You have a sense like, "I don't know

what's coming in, but I know it's gonna be

427

:

somewhere in this field," and that allows

me to deploy experience and repetition

428

:

to within these spaces and to get a

sense of what right looks and feels like.

429

:

And then I can start feeling the quality

of the uncertainty that's in there.

430

:

A lot of the work from Gary Klein's team,

the naturalistic decision-making world,

431

:

starts feeling about this like what is

your sense of normal and how do you know

432

:

when something's drifting from that?

433

:

But I, I think it's interesting

to describe that idea that there's

434

:

a systems layer to that and a

personal layer to that, right?

435

:

So you're describing the systems layer

of what is the experience of this

436

:

team in this operation in this space,

and then there's a person layer to

437

:

it where y- you're, you're like meta

watching your own attention and where

438

:

it's going, and you're adjusting that,

that control surface inside of you.

439

:

I have a billion directions to

go from that, but I'm curious

440

:

what-- does that match what you're

feeling on the inside there?

441

:

How does that sound to you?

442

:

Derek: 100%.

443

:

I think that's, that's

said very appropriately.

444

:

I think this kind of, what do

we call it, the tacit knowledge

445

:

transfer problem, right?

446

:

This is just experience.

447

:

It's one of those things, and it--

no matter how hard I think we try

448

:

to teach it, it's a matter of you

d- almost just have to do it and be

449

:

there and experience it enough times

for that, I call it my Spidey sense.

450

:

My Spidey sense is up.

451

:

It's just, it's a feeling.

452

:

It's a gut.

453

:

It's like, okay, hey, this is like

really the critical part of the case.

454

:

I'm gonna do it because if something

goes sideways here in this current

455

:

environment- It could drastically

change the outcome, right?

456

:

And so it's just one of those things

where you're like, uh, you- yeah,

457

:

it's a sixth sense, if you will.

458

:

But it's also one of those

things that's really important

459

:

for us to try to teach, right?

460

:

Where it's like-

461

:

Dan: Absolutely.

462

:

Derek: And so we're fortunate enough,

we get to work with residents through

463

:

all first year through fifth year.

464

:

And so when our chiefs are with

us, it's one of those things where

465

:

even if, you know, i- if you can

call it out at the time They can

466

:

hopefully start to pick it up, right?

467

:

"Hey, I'm gonna do this

right now because…"

468

:

And you just give like a very brief

two-second whatever, and hopefully they

469

:

can start to pick some of that stuff up.

470

:

Dan: It, it's interesting the way

you said that, that, uh, for sure

471

:

there's tacit knowledge here that

it's very hard to transmit because

472

:

we don't have the language for it and

we don't have the structure for it.

473

:

But I think that it's easy

to lump a lot of stuff under

474

:

tacit and to not poke at it.

475

:

And I'm not saying that accusatorily

because you and I have had these

476

:

conversations a bunch, right?

477

:

But it's interesting what you said

a second ago was your reasoning for

478

:

it, which was, "I'm gonna take over

because I know if this thing happens in

479

:

this situation with this environment,

it could produce these outcomes."

480

:

So it-- there's some sense in there

where what you're, the data streams

481

:

that you're melding together are what

the normal case looks like, what the

482

:

environment looks like, what fu- the

cone of future possibilities looks like,

483

:

and you're comparing that against some

sort of a risk surface or a risk map.

484

:

And that's, if, if you had to explain it,

those are some of the data streams and

485

:

sort of operations that I'd put in your

mouth as you're describing it, right?

486

:

But what else would you

put in there if you…

487

:

And I'm gonna give you an

impossible challenge, right?

488

:

Literally an impossible one, which

is, all right, you gotta train

489

:

a robot to do this or you gotta

train an AI system to do this.

490

:

What else would you put in there if-

491

:

Derek: Yeah, no, it's interesting, Dan.

492

:

I-- this is my argument for why I

don't think AI will take over all

493

:

aspects of surgery, 'cause there is

a component of feel and experience

494

:

that I think is really important.

495

:

It might say the right thing in

this situation is to do X, but if

496

:

you can't do X, like you're not

physically capable of doing X, then

497

:

X probably isn't the right answer.

498

:

Now, a robot might be able to physically

be capable of doing X, so that

499

:

might eliminate that conversation.

500

:

But you have to use your experience

of what you know you can do and what

501

:

you can do safely to help that patient

at that time versus not, right?

502

:

I should not be exposing and

decompressing somebody's spine.

503

:

That's just not me.

504

:

It's not in my wheelhouse.

505

:

As my-

506

:

Dan: Shouldn't be either, let's be clear.

507

:

Yeah.

508

:

Derek: Yeah.

509

:

My internist probably shouldn't

be fixing a femur fracture, right?

510

:

But he probably doesn't want

to m- read, me reading an EKG.

511

:

That's, it's fair, right?

512

:

It's all good.

513

:

We have our kind of areas of expertise.

514

:

I think the, the interesting thing

is that the There is a way to, I

515

:

think, verbalize it and call it out.

516

:

And as I think you do that more, I think

the, the knowledge transfer becomes

517

:

more, it can become explicit, right?

518

:

You can develop the words behind

it, even if it's just, "Hey, it's a

519

:

feeling, and this is what I'm seeing."

520

:

And so I think that allows it to

hopefully come across a little bit.

521

:

But I think there are situations

where it's, it is an ex- an experience

522

:

thing that's really important.

523

:

It's hard to replicate.

524

:

Dan: Yeah.

525

:

There's, there's an internal component

to it that requires you as the expert

526

:

to pay attention to what you're

feeling and to surface those signals.

527

:

And then there's a guide translator

component to it where you have to be

528

:

willing and interested to verbalize

out loud, "Look, I don't know how

529

:

to explain it, but I'm just, I

don't like the way this feels."

530

:

And then there's a learning component

to it where the learners have to pick

531

:

up on that and understand that's as much

signal as you're gonna get, and you have

532

:

to figure out what to do with that space.

533

:

And I think that it's hard to reduce

that to language, and I'm using

534

:

language really broadly here, right?

535

:

Just anything that we would do to

explore it or, you know, that we could

536

:

transmit knowledge in some sense with.

537

:

And I know there's a ton of work that,

that, you know, on the mission critical

538

:

side about the tacit knowledge transfer

problem that we've talked about.

539

:

But I think it's interesting to think

through, like what are the edges of that?

540

:

What are the data streams?

541

:

What are the control surfaces?

542

:

I'm not trying to make it all machines,

but if we lean into that, what do we

543

:

learn about ourselves by doing it?

544

:

Derek: Yeah, no, I think it's interesting.

545

:

It's definitely different

from person to person as well.

546

:

I think it's part of who

you are, your personality,

547

:

things, things of that nature.

548

:

I do think, I've known, right?

549

:

My reputation is when things

get hard, I get quiet.

550

:

Like, when I get quiet in the OR

and just start doing, things- are

551

:

probably more challenging, or things

are starting to head in a different

552

:

direction than what we want.

553

:

It's taken a lot of work for

me to recognize that myself, to

554

:

then- Mm … be able to openly

talk about it in the moment.

555

:

Sometimes I don't, depends

on what's going on, right?

556

:

But I think because my, the people

I'm training kinda know that about

557

:

me, the ones who are curious, I'll put

it that way, afterwards will be like,

558

:

"Hey, what was going through your mind?

559

:

Why were you doing that?

560

:

What happened?

561

:

What did you see?"

562

:

Not all of them are that

insightful, but some are.

563

:

Mm-hmm.

564

:

And so you're able to verbalize it then.

565

:

So I've been trying to be better

at verbalizing in the moment, but

566

:

sometimes, as you said, the moment

doesn't call for that, right?

567

:

The moment calls for work to be done.

568

:

It needs to get done, and it

needs to get done quickly.

569

:

And- Yeah … and right.

570

:

Yeah.

571

:

Dan: Yeah.

572

:

There's a tension between, in

our limited wet brains, right?

573

:

There's a tension between the

amount of bandwidth we can devote to

574

:

metacognition, thinking and teaching,

versus the amount of bandwidth we

575

:

need to devote to executing and saving

a person's life or limb or whatever

576

:

the equivalent is in another space.

577

:

And there's a, a, a mirror of that

layer of tension if we zoom out at

578

:

the systems level that says, hey,

we have to be prepared to operate in

579

:

these ways at these periods of time,

and we need to balance the amount of

580

:

staff we have and the training and

experience and all of the things.

581

:

And there's some meta…

582

:

Whatever the word for

metacognition is for a system.

583

:

I don't know if there…

584

:

I'm not sure if there's a word for that.

585

:

I don't

586

:

Derek: know.

587

:

Dan: But like the system thinking

about how the system operates.

588

:

Meta operations?

589

:

I don't know.

590

:

Somebody will- It is … somebody

listening to this will provide

591

:

me with the answer of that.

592

:

But- We'll,

593

:

Derek: we'll know in due time.

594

:

Dan: Yeah, exactly.

595

:

So meta operations or whatever,

versus operations that the system

596

:

has to just execute versus improve.

597

:

And we all have limited bandwidths.

598

:

And to build resilient people and

resilient systems that can operate

599

:

in uncertain environments, w- we

have to ride that edge a bunch.

600

:

I don't know that I have a

question about that, but man, is

601

:

that interesting to think about.

602

:

Derek: Yeah, and I just, what it made

me think of, which I think is important,

603

:

a- a- and I don't know where this…

604

:

Not, and I don't wanna say this in

the fact that people don't think this,

605

:

because I think they do, but they

don't understand what it really means.

606

:

What we do is hard.

607

:

It's supposed to be hard, right?

608

:

And there's real consequences

to when things don't go well.

609

:

Dan: Yeah.

610

:

Derek: And that can weigh

a lot on a person, right?

611

:

And- Yeah … and again, I don't

think there's any way to…

612

:

You can, we, I could have that

conversation with you a million times,

613

:

but until you experienced the hard-

And that falls on your shoulders.

614

:

It's hard for that person to

truly grasp what that means.

615

:

That, just that it makes any sense.

616

:

So I think the important thing is to

realize that, like all these things

617

:

take, number one, time to figure

it out and to develop your thing.

618

:

But number two is that it's hard,

and it's supposed to be hard.

619

:

And so if you come in thinking like,

"Hey, I'm just gonna put a bunch of

620

:

screws in people and things are gonna be

fine," maybe, but probably not, right?

621

:

There's a component to it that's

gonna be, I need to know my stuff,

622

:

I need to learn my anatomy, I

need to learn my technical skills.

623

:

I, my, I…

624

:

We, the residents joke sometimes, "Hey,

like those tools are like a- an ex-

625

:

like just an extension of your hands."

626

:

I'm like, "Yeah."

627

:

I'm like, "That's what they should be."

628

:

Like, these are the tools of your trade.

629

:

You should know them better than anybody

else in the room, and should be able

630

:

to use them better than anybody else

in the room, because that's what the

631

:

person asleep is expecting of you.

632

:

And so I think to- the things to control,

to go back to our previous conversation-

633

:

Mm-hmm … I think you need to s-

do everything in your power to set

634

:

yourself up for success as well, right?

635

:

When you're in the middle of that

case, like you shouldn't be really

636

:

thinking or learning of how to use

a drill for the first time, right?

637

:

That really needs to be

second nature by that point.

638

:

Dan: Yeah, it- that's

super interesting, right?

639

:

So we can go back to a cognitive

load theory point of view, right?

640

:

And be like, all right, there's

the intrinsic load, the mental

641

:

energy it takes to do the task.

642

:

The extraneous load, which is

the mental energy to buffer noise

643

:

and chaos and all other stuff.

644

:

And then the germane load, which is

the inwardly directed energy about-

645

:

learning and sort of forming ways

of thought about what you're doing.

646

:

And there is a lot of the surface area

of what we do where I totally agree with

647

:

you, where you should be, you should be

second nature about what you're doing on

648

:

it, and you shouldn't be hesitating, and

you should just be running into it, right?

649

:

In our world, it's usually a

little more simple than that.

650

:

The amount of stuff we do for

that is, yeah, it's put your

651

:

hand in the bleeding spot, right?

652

:

Hold the protect the airway,

do this stuff, right?

653

:

Move forward towards the patient

unless they're covered in

654

:

toxic goo or whatever it is.

655

:

But there's also a lot of stuff that

we do where that's impossible, right?

656

:

There's just not enough time or repetition

to truly develop that sense of it, right?

657

:

And I think the-- I don't know if

this is a correct fact, but I'm

658

:

gonna say it anyway, so asterisks.

659

:

Most ER doctors on the civilian

side do one emergency crike in

660

:

the course of their whole career.

661

:

One, right?

662

:

But you never know what day it is.

663

:

You never know when it's gonna come.

664

:

That person needs you to be skilled at it,

and you will do one in your entire career.

665

:

S- And just by the sort of the, the law

of randomness and exposure surfaces,

666

:

there's stuff that I've never done

that I might be called on to do.

667

:

There's stuff that the person

next to me has never done that

668

:

they might be called upon to do.

669

:

So th- there's some spaces where

that can't be the answer, right?

670

:

A- and I know that we've been talking

about bounded uncertainty, but what, what

671

:

does that space look like for you all?

672

:

And how do you carry those things over

from, "Hey, I wanna be the best I can at

673

:

what I do," to, "I wanna be the best I can

at what I do, but I've never done this"?

674

:

Or, "Hey, here's a new-- there's a-- we

invented a new tool, and it's amazing,

675

:

but it's your first time using it."

676

:

Or I don't know what the, I don't know

what, what the right parallel is there.

677

:

Derek: I think that's a similar one.

678

:

I think there's- Mm-hmm … new

technologies coming out all the time

679

:

that for especially being in an academic

center and often the first time or first

680

:

few times using it is in our hands.

681

:

I would just say, I think there's

just a basic loved skill set

682

:

that one develops over time.

683

:

Mm-hmm.

684

:

And your ability to apply those skill

sets to new environments, I think,

685

:

is how you carry over that, right?

686

:

Like in your example is emergency

crike, like you understand airways.

687

:

You understand how to use a scalpel.

688

:

You understand its basic

tenants of to do this.

689

:

You understand anatomy.

690

:

It's stressful, I imagine

more than anything.

691

:

But you put that together

and use it, right?

692

:

And so I think there's a, a

basic level of skills that you

693

:

need to continue to develop.

694

:

And I can't remember if I heard this or

was reading this or just thought about it

695

:

on my own, but the idea that you need to

have a plan and you need to be prepared.

696

:

And chances are that noth- nothing

that you, that it's an emergency

697

:

situation or in a chaotic environment,

nothing's gonna go to as you planned.

698

:

But hopefully it's in the

realm of how you've prepared.

699

:

And so I think you can't have some,

have an answer for every iteration

700

:

of whatever you're about to- Yeah

701

:

encounter, but hopefully you're able

to utilize your skill sets to expand

702

:

that at the time when it's needed.

703

:

Dan: That's really…

704

:

I like that a lot, right?

705

:

I think we talk on the podcast a lot about

bounded versus unbounded uncertainty,

706

:

and looking at stuff that feels like

it's pure chaos and finding the islands

707

:

in the middle of it that are more

predictable or more understandable, and

708

:

understanding that your job isn't to solve

the whole problem necessarily, but it's

709

:

to go island to island as you're moving

your way through it, which is a, a lot

710

:

of the instruction that I would give,

say, a junior ER doctor who's running

711

:

a cardiac arrest for the first time.

712

:

Don't solve everything.

713

:

Just go island to island and

work your way through it.

714

:

But if you prepare ahead of time,

"Hey, here are the things that I know

715

:

how to do, and I, I'm gonna create

the constellation on the fly with

716

:

it," like, that makes a lot of sense.

717

:

Darren-

718

:

Derek: And you might not

get it right at first.

719

:

Like, you might- Yeah

720

:

have to go from plan A to plan

B to C to maybe Z and then back

721

:

to D again, and that's okay.

722

:

And you just have to be okay with that.

723

:

Dan: Yeah.

724

:

Yeah.

725

:

Absolutely.

726

:

That, that not only can that happen, but

that it will happen Requires the- The

727

:

obvious movement of back and forth there.

728

:

All right, Derek, this is awesome.

729

:

Thank you so much.

730

:

Man, I feel like we covered just

a huge amount of ground in terms

731

:

of how do you train, how do you

think, and how do you operate.

732

:

We invented some words maybe,

which we'll figure out afterwards.

733

:

But before we jump off, I wanna give you

a chance to challenge people listening

734

:

to this with something you want them

to do differently on their next shift

735

:

or their next mode of operation.

736

:

To give you a second to think

that through, I'm gonna do our

737

:

normal disclaimer, which is that

nothing we do here on the Emergency

738

:

Mind podcast is medical advice.

739

:

Our only job is to take the best of what

everybody else has already figured out

740

:

about applying knowledge under pressure

and bring it out to the forefront.

741

:

Nothing that we say represents

anybody that we work for or with.

742

:

It's just us out here in the universe

trying to make it a better place.

743

:

And I'll add to that, if you are

listening to this and you have ideas

744

:

of people that would make great

guests, please reach out to me.

745

:

I'd love to hear it.

746

:

You can find me at dan@emergencymind.com.

747

:

All right, Derek, what's the challenge?

748

:

What are people doing?

749

:

Derek: All right, I think

a coup- so couple things.

750

:

So I think the challenge is this.

751

:

I think the challenge, I've been reading

this book lately about four assumptions,

752

:

and I think the four assumptions, which

I've been trying to kind of recreate in my

753

:

mind, and so this is my challenge for you,

is number one, be impeccable to your word.

754

:

So mean what you say.

755

:

Number two, don't take anything personal.

756

:

Number three, don't make assumptions.

757

:

And number four, be your best self.

758

:

So that's my challenge to the audience.

759

:

Dan: I love it.

760

:

Derek, thank you so much for

joining the podcast, man.

761

:

It's an honor to have you.

762

:

Derek: Yeah, thank you, Dan.

763

:

This was fun

764

:

Preston: Thank you again for

listening to our Teamcast.

765

:

If you found value in this discussion,

the best way to support our work

766

:

and ensure you don't miss future

episodes is to subscribe and

767

:

leave us a quick rating or review.

768

:

That'll help us reach more people

who need to hear these conversations.

769

:

For more on Mission Critical Team

Institute, including all of our episodes

770

:

and show notes, visit missioncti.com.

771

:

You can also connect with us on LinkedIn.

772

:

And if you're a mission-critical

team looking to learn more about

773

:

our programs, reach out directly

to our director of operations, Ms.

774

:

Janese Jackson, at janese@missioncti.com.

775

:

That's J-A-N-E-S-E@missioncti.com.

776

:

Until next time, thanks.

All Episodes Previous Episode

Listen for free

Show artwork for Teamcast

About the Podcast

Teamcast
Mission Critical Team Institute Teamcast
Dr. Preston Cline, Dr. Dan Dworkis, Dr. Art Finch and Harry Moffit of the Mission Critical Team Institute share research and explore the questions vexing the most elite teams in the world, from Special Operations soldiers to Firefighters, from Trauma Medics to Professional Athletes, and from Astronauts to Tactical Law Enforcement.

About your hosts

Coleman Ruiz

Profile picture for Coleman Ruiz
Co-Founder and Director of Performance, Mission Critical Team Institute

Preston Cline

Profile picture for Preston Cline
Co-founder and Director of Research and Education at the Mission Critical Team Institute
Senior Fellow, Center for Leadership and Change Management, The Wharton School, University of Pennsylvania