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Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.

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Develop a Game Plan to Educate and Prepare Residents for an Intraoperative Crisis

Sophia K. McKinley MD, EdM; John T. Mullen, MD, FACS; and Roy Phitayakorn, MD, MHPE, FACS

July 1, 2019

An unanticipated crisis may occur during any operation. Once an intraoperative crisis occurs, the situation has many similarities to military combat. During combat or an operative crisis, anxiety levels increase, communication becomes ineffective, and “the fog of war” may result in poor decision making. The military has developed a framework by which it can educationally capitalize on these events to prevent them in the future or mitigate damage should they occur again. In this manuscript, we have adapted this approach to the occurrence of an intraoperative crisis.

In this article, we present a repeating educational cycle drawn from the military framework of combat operations. The article begins with the preparatory phase of “war games,” during which the residents articulate their anticipated actions and develop contingency plans should a crisis occur. During the crisis, verbalization of the leader’s thought process informs the surgical team of anticipated next steps and helps educate the surgical resident. The next phase is a formal after-action review or debriefing, in which the resident and the attending surgeon each self-identify opportunities for improvement and how to achieve them in the future. The cycle is then completed by incorporating the lessons learned during the after-action review into the next cycle of war games.

War Games

The military describes “war gaming” as the process of systematically visualizing the flow of an anticipated battle. The basic process follows these steps: If I do this, the enemy will do that. If the enemy does something different, I will react in this way. To be effective, a commander must thoroughly understand all possible actions available as well as potential repercussions of those actions.1

Young and associates2,3 coined the term “war games” to describe the adaptation of this method by incorporation of clinical scenarios into a daily teaching sign-out session. During these war games, residents are put in the position of the “command surgeon”4 and are required to work their way through a series of high-risk clinical decisions. The focus is on integrated decision-making and critical-thinking skills, rather than regurgitation of isolated facts.

When conducting a war game, the attending surgeon provides a basic clinical scenario. Through a series of open-ended questions, the resident is required to articulate their actions and their rationale for these actions. The attending surgeon should only ask a single question at a time in a neutral, non-leading manner. These questions must follow a logical sequence and the resident should not be interrupted or corrected. The purpose is to allow the resident to make errors, determine for themselves that they made an error, and figure out how to recover from them. Using this method, the attending surgeon needs to be aware of the superficial learner who uses buzzwords but lacks in-depth knowledge. By asking learners to articulate the basis for their decisions, these superficial learners typically identify themselves.

This method has the advantages of developing contingency plans for actual patients who are currently on the service, allowing freedom for residents to make mistakes without any patient risk, and creating a context for integration into the daily work flow. The educational benefits of this type of mental rehearsal have been well-documented.5

In our experience, forewarning the residents that these are interactive games designed to best prepare them to face a future crisis or oral board examination lessens their anxiety. As a daily event, the residents come to understand this is a low-stakes, formative educational experience rather than a punitive one.

The Intraoperative Crisis

During the crisis, attention is appropriately focused on patient well-being. Effective communication between the command surgeon and the team is of paramount importance for solving the crisis. Effective verbal communication also has educational benefits. In his book Team of Teams: New Rules of Engagement for a Complex World,6 General Stanley McChrystal, former commander of the Joint Special Operations Command, stresses the need to develop subordinates through the active verbal engagement between all levels of command. The goal is to promote transparency and develop a culture of shared consciousness so that in future battles, everyone is on the same page. Surgeons can achieve the same development of residents by verbalizing their thoughts during a crisis. Hoff and colleagues demonstrated improved performance during trauma resuscitations when a “command surgeon was identified and effectively communicated the next steps of the resuscitation.”4

After-Action Review

Performing an after-action review or debriefing also follows a military framework7 and may be the most important element in solidifying resident education. There are three areas of focus for this type of review. First is the comparison of the actions and how they match up with current performance standards. The second is to empower the resident to self-identify what happened, why it happened, what they did well, and areas for improvement. Third, the attending surgeon should be a role model and perform the same self-reflective critique that is asked of the resident.

The U.S. Army utilizes a specific format7 for an after-action review that can be easily modified for use after an intraoperative crisis. When leading this review, the attending surgeon begins by creating a respectful environment focused on education—not placement of blame—and establishes the ground rules for the discussion. Next, the attending presents a brief, chronological summary of the events. Following this summary, each person who played a role in the management of the crisis is asked the same series of questions:

  • What went well?
  • What should be improved on?
  • How should we improve identified areas of weakness?

The attending surgeon leading the discussion should ask open-ended questions that promote self-critique by the resident. It is important to allow the residents to express their thoughts without being interrupted. At the conclusion of the review, the attending should summarize the key points of the discussion. This type of review is an example of a formative evaluation and therefore should be considered low-stakes. If the resident feels that participation will result in a poor end-of-rotation evaluation, the self-critique will not be robust.

Completing the Cycle

To complete the cycle, lessons learned during the after-action review should be incorporated into the next session of war games. In this way, residents who were not present in the operating room may benefit from the experience.

Repeating the cycle of mentally rehearsing before the event occurs, verbalizing the command surgeon’s thought process during the crisis, standardizing after-action review, and incorporating lessons learned into the next set of war games is easy to accomplish. This method can also be applied to any other type of medical emergency.


  1. Kretchik WE. The Manual Wargaming Process: Does Our Current Methodology Give Us the Optimum Solution? Fort Leavenworth, KS: School of Advanced Military Studies. United States Command and General Staff College; 1991-9292, AD-A258 094. Accessed on May 31, 2019 at https://apps.dtic.mil/dtic/tr/fulltext/u2/a258094.pdf.
  2. Young JS, Dubose JE, Hedrick TL, Conaway MR, Nolley B. The use of "war games" to evaluate performance of students and residents in basic clinical scenarios: a disturbing analysis. J Trauma. 2007 Sep;63(3):556-564.
  3. Hedrick TL, Young JS. The use of “war games” to enhance high-risk clinical decision-making in students and residents. Am J Surg. 2008 Jun;195(6):843-849.
  4. Hoff WS, Reilly PM, Rotondo MF, DiGiacomo JC, Schwab CW. The importance of the command-physician in trauma resuscitation. J Trauma. 1997 Nov;43(5):772-777.
  5. Rao A, Tait I, Alijani A. Systematic review and meta-analysis of the role of mental training in the acquisition of technical skills in surgery. Am J Surg. 2015 Sep;210(3):545-53
  6. McChrystal S, Collins T, Silverman, D, Fussel C. Team of Teams: New Rules of Engagement for a Complex World. New York, NY: Penguin Publishing Group; 2015.
  7. United States Army. Army Training Circular 25-20: Leader's Guide to After-Action Reviews. Fort Leavenworth, KS: United States. Department of the Army; 1993. https://www.hsdl.org/?abstract&did=775082. Accessed on June 19, 2019.

About the Authors

Sophia K. McKinley MD, EdM, is a resident physician and surgical education research fellow in the department of surgery, Massachusetts General Hospital, Boston, MA.

John T. Mullen, MD, FACS, is associate professor and general surgery residency program director, department of surgery, Massachusetts General Hospital, Boston, MA.

Roy Phitayakorn, MD, MHPE, FACS, is associate professor, department of surgery, Massachusetts General Hospital, Boston, MA.