It is subtle. It is stealthy. And it can be lethal to patients and surgical careers.

Complacency is always a concern in high-reliability organizations, professional and especially surgical endeavors. As far back as 1751, Samuel Johnson, the English writer, essayist and lexicographer, eloquently described a caution in the relationship of success and complacency:

“It frequently happens that applause abates diligence … He whom success has made confident of his abilities quickly claims the privilege of negligence … ”¹

In surgical care, the impact of complacency is readily concerning in clinical errors. It is also a problem and no less impactful in interpersonal and training situations. The unfortunate consequences have been described this way:

“Regrettably, when complacency becomes the norm for a surgeon, poor clinical judgment, with unwanted consequences for the patient, and anguish for the doctor can easily follow.”²

Examples of complacent behavior witnessed in the OR include:

• inappropriate use or lack of protective equipment;
• failure to change masks between procedures;
• sporadic or absent accounting of materials and supplies;
• improper or absent verification of medications;
• food or drink in theater;
• failure to close or secure doorways; and
• other inappropriate actions or ignored procedural requirements.³

So, what is the etiology of a complacent attitude and, more importantly, what can be done by surgeons to prevent it?

There are at least three sources of complacency: that which is innate and predates a surgical career; that which is learned over the course of a surgical career; and that which is situational and imposed by the nature of a surgical career and the healthcare environment.

Some individuals bring to their career an excessive ego or self-absorption. Whether innate in their temperament or learned in developmental years, these individuals arrive with attitudes that already discount the need for constant vigilance and respect for rules, regulations and procedures.

Complacency can also develop or be learned during training and in practice. As Johnson pointed out, success can decrease diligence and promote negligence. Related to this, and as a dangerous twist on what should be the expertise from experience, too much experience can lead to inflated confidence and complacency. This has been called the “disease of expertise.”⁴

Typical comments that might belie this attitude include⁵:

1. “I have performed a hundred of these without a problem.”
2. “I don’t have to worry because the risk is low.”
3. “I can’t believe the statistics because the study has flaws.”
4. “I use advanced techniques that prevent the problem.”

Interestingly, this last statement represents what has been termed “automation-induced complacency,” the invalid belief that technology obviates the need for diligence.⁶

At the other extreme, a quiet uneventful career can lead to false comfort and expectations about the “routineness” of procedures. The old saying, “If you hear hoofbeats in the parking lot, think horses and not zebras” may be a useful and generally accurate heuristic. But it can easily become an excuse for complacency in diagnostics and procedures.

In the training experience, observing complacent behavior can affect trainees in several ways, all sowing seeds for their own complacency. There can be confusion at the failure to respect procedures. There can be disillusionment and questioning of purpose and value of precautions when they are ignored. And there can be harm done to progress and development with poor or absent detailed instruction and monitoring.³

Finally, situational influences of surgical practice and the modern healthcare environment can lead to complacency. Stress, fatigue and time pressures can become distractions that sap the energy needed for vigilance and motivation for attention to detail. Certainly burnout, depression, substance abuse and similar problems are hallmarked by behavior that can contribute to or parade as complacency and can produce untoward outcomes.

What, then, might be done to combat complacency? What are the countermeasures? Strategies include:

1. The topic of complacency, and more importantly, combating complacency needs to be discussed, reinforced and kept in the surgeon’s and perioperative team’s awareness repetitively, if not constantly. Complacency-mitigating discussions at practice meetings, clinical reviews, procedure pre-briefs and any other appropriate time should be incorporated into the agendas. There can never be too much emphasis, but varying how the cautions and strategies are presented will help prevent the message from becoming old, stale, boring and ignored. An emphasis on maintaining awareness of threats to quality (like complacency) is often seen as the hallmark of a high-reliability organization.
2. The maintenance of humility in this awareness is critical. Excessive self-importance and smugness need recognition, self-recognition and tempering. There should be acknowledgment that no one is ever fully trained or experienced—that one is always developing and improving and, therefore, contentment and satisfaction, while perhaps deserved, should at best be brief.
3. Consistent and frequent training is essential. Integrated with training should be reminders and the practice of vigilance, safety procedures and situational awareness that will combat complacency. Procedures that highlight complacency and focus on its mitigation, such as checklists, need to be trained with a respect for and emphasis on their importance.

4. The words and terms used in team communication influence attitudes and behaviors. Words are powerful. They give direction and reveal mindsets of performance expectations. Elite military units eschew the word “try” related to effort and mission. “Try” is seen as a weak and incomplete word. ”Doing one’s best,” which sets a standard for maximal personal effort, is preferred terminology, reflecting and molding attitude and behavior. Parallel applications exist in surgical communication.
5. Each surgeon and team member should strive to develop an excellence and counter-complacency mindset. It is normal to have a day, or periods during a day, when seeing another patient or doing another procedure becomes wearisome. Therefore, it is helpful to mentally prepare for each day, and indeed each patient encounter.⁷ Much as an athlete will “psych up” or mentally prepare before a game, it is desirable for each surgeon and team member to develop a routine that becomes the signal that they are moving from a personal to a professional and performance mindset. This helps promote the high level of concentration and commitment needed in providing surgical care. Walking through the doors of the OR suite (and probably some point before that) should trigger a performance mindset, like throwing a switch, to start an enhanced state of performance and responsibility.
6. Related to the mindset is using performance imagery or mentally rehearsing techniques and possible actions prior to commencing an operation.⁸ Part of this mental rehearsal should be a focus on developing and maintaining high awareness and high alertness to counteract complacency.

7. Affirmations can be used to combat complacency as well. Affirmations are positive statements about ourselves that we make to ourselves that highlight our strengths. They are typically stated in “I” form and in the present tense. An example might be: “I am a dedicated and determined surgeon.” Included among affirmations should be statements that counter complacency, such as: “I am actively aware at all times in providing care to my patients” or “Detailed preparation is emblematic of the surgical care I provide.”
8. Finally, countermeasures to complacency need to be promoted by everyone in the surgical setting and not just surgeons and not just personally. Mutual support reminders about complacency should be a regular part of interactions. The use of greetings like “stay sharp” is an excellent example of continuously calling attention to the essential task of combating complacency.

Writer and motivational speaker Og Mandino has said: “I will not allow yesterday’s success to lull me into today’s complacency, for this is the great foundation of failure.”⁹

In surgical practice, it also represents safety, quality, satisfaction, and ethical and performance excellence. So, stay sharp.

References

1. Johnson S. www.samueljohnson.com
2. Posnick J. Is your BS detector getting rusty? J Oral Maxillofac Surg. 2022;80(2):209-210.
3. Preceptor complacency in the OR. The struggle is real. www.ast.org/uploadedFiles/Main_Site/Content/Educators/PreceptorComplacencyintheOR.pdf
4. Gonzales L. Deep Survival. W.W. Norton; 2003.
5. Rosenfield L. Complacency, conscience and complications. Plast Reconstr Surg. 2018;141(6):1603-1604.
6. Singh I, Molloy R, Parasuraman R. Automation-induced complacency: development of a complacency-potential rating scale. International Journal of Aviation Psychology. 1993;3(2):111-122.
7. Asken M, Yang H. Aboushi R, et al. Prepping for surgery: surgeon prepare thyself. Am J Surg. 2020;221(4):775-776.
8. Asken M, Yang H. SIM, The Surgeon’s Imagery Mindset: Performance Enhancing Mental Imagery and the Optimization of Surgical Skill. Amazon E-Books; 2021.
9. Mandino O. www.quotationspage.com. https://safestart.com/news/4-signs-youre-under-the-influence-of-complacency/

Dr. Asken is the senior organizational performance consultant, Department of Surgery, UPMC Pinnacle Hospitals, in Harrisburg, Pa. Dr. Owens is a urological surgeon and the chairperson, Department of Surgery, UPMC Pinnacle Hospitals. Dr. Ladie is a transplant surgeon and the assistant chairperson, Department of Surgery, UPMC Pinnacle Hospitals.