Non-Technical Skills for Surgeons Can Be Life Savers

By Margaret Cary, MD, MBA, MPH | Published 12/3/2020 4

non-technical skills-for surgeons

center>Honing behavioral skills, such as teamwork and leadership, can help surgeons avert disasters. (Photo source: Adobe Stock Photos)

I turned the corner and there it was. The Death Star, as locals call it, because it’s star-shaped, imposing, and has a helipad on the roof. Also known as the Queen Elizabeth University Hospital in Glasgow—a state-of-the-art, 14-floor hospital completely interlinked, part of the National Health Service in Scotland—it was the site of the Non-technical Skills for Surgeons (NOTSS) Master Course I was invited to join.

In my exploration of what makes a good surgical team, I came across “Teamwork Assessment Tools in Modern Surgical Practice.” That article inspired me to write Can Surgery Teamwork Save Your Life?, describing one of the best assessments, Non-technical Skills for Surgeons (NOTSS).

Any excuse to travel is all right with me. The Royal College of Surgeons-Edinburgh offered a NOTSS Master course on a day I was available.  So I headed to Glasgow for a few days of Scottish music, single malt scotch, and museums before the course.

Training surgeons in non-technical skills

NOTSS is a program to train surgical residents (and more senior physicians) in non-technical skills. They are specifically referring to the behavioral elements of optimal surgical performance.


UK surgeons who are accepted into the Royal College are called Mr, Miss, Ms, or Mrs rather than doctor.  Mr. Simon Paterson-Brown and Mr. Simon Gibson kicked off the day with the usual medical statistics about using checklists in the operating room, or theatre, as it’s known in the UK. Routine use of checklists halves surgical mortality, from 1.5% to 0.8%

Using a checklist might have prevented Sheila Hynes death in March 2017, after her new heart valve was put in upside down. The two Simons asked us, “What goes wrong in your theatre?” Reasons for errors include the following:

      • time pressures
      • distractions
      • last-minute changes
      • inadequate preparation
      • faulty assumptions
      • inadequate help
      • incomplete information, and
      • the “system”: people, resources, and how they are dispersed.

Human factors, leadership, and communication, all included in non-technical skills, are the top three contributors to Sentinel Events. These are unexpected events in a healthcare setting that kill or harm patients and that are unrelated to the patients’ illness.

As I learned, NOTSS is not about:

      • bad guys,
      • remediation,
      • catastrophic failure,
      • blame/attribution, or
      • extraordinary events.

And there is no single vaccination for immunity.

NOTSS is about normal people, places, organizations, and systems. It’s about recognizing complexity and optimizing performance.

Other stories by this author: A Fatal Medical Error: Lack of Care or Lack of Caring?

Situational awareness

High on the list of necessary skills for effective surgeons is situational awareness. This is the state of being aware of what’s around you even as you focus on the task of surgery.

Check out this video to test your own situational awareness.

Here are some ways to enhance situational awareness:

      • Pre-task briefing
      • Sterile cockpit concept: Avoid unnecessary distractions
      • Active information gathering through scanning
      • Self-checking
      • Cross-checking: Ask other team members
      • Re-check information after interruption or distraction
      • Use open rather than leading questions
      • Encourage junior staff to speak up if concerned
      • Realize that even experts can make errors…and put a heart valve in upside down
      • Have a safe word, such as “watermelon,” which means stop. And then use it. And stop

Self-check and CUSS

I’M SAFE is the mnemonic for a self-check list at the beginning of the day and when starting new or major procedures. Are you having any negative effects from the following?

      • Illness
      • Medication (e.g., codeine for a toothache, antihistamines for a cold, coping with a runny nose behind a surgical mask)
      • Stress (personal relationships and time pressures)
      • Abuse (substance and alcohol, and its after-effects)
      • Fatigue
      • Emotion (rudeness, anger, aggression, and personal grief) and Eating (impact of hypoglycemia)

While observing surgeons, use CUSS for graded assertiveness:

      1. I’m CONCERNED about what you’re doing
      2. I don’t UNDERSTAND why you are doing what you’re doing
      3. I am SERIOUSLY worried about what you’re doing
      4. Please STOP what you are doing

In 1977, KLM Flight 4805 and Pan Am Flight 1736 collided on the runway in Tenerife. This was the deadliest airplane accident in history at that time, killing 583 people.

The pilot was Captain Veldhuyzen van Zanten, KLM’s chief of flight training and one of their most senior pilots. He took off without clearance, smashing into the other 747 on the runway.

In 2009, Captain Chesley “Sully” Sullender landed a crippled airplane on the Hudson River, with no loss of life. In the former, other crew members were reluctant to question the captain. They died. In the latter, the team concentrated on doing the right thing at the right time. They lived.

What do high-performing teams have in common?

According to TeamSTEPPS, they

      • Are responsible for ensuring that team members are sharing information, monitoring situational cues, resolving conflicts, and helping each other when needed
      • Manage resources to ensure the team’s performance
      • Facilitate team actions by communicating through information exchange sessions, such as after-action reviews
      • Develop norms for information sharing; and
      • Ensure that team members are aware of situational changes to plans

Good quality operating room leadership leads to decreased errors, reduced costs, improved safety, and increased compliance with standard operating procedures (SOPs).

Despite that, 47% of surgeons believe the decisions of the “leader” should not be questioned. So did the crew members of Captain van Zanten. And, contrast that with the present time where only 7% of pilots have that belief, a smaller percentage after changes were implemented following the Tenerife crash.

The bottom line when it comes to non-technical skills for surgeons

One solution is to send your surgeons abroad for NOTSS training. Another is for them to take the course at the annual American College of Surgeons meeting.  This is where there is often a workshop on this topic.

The book, Enhancing Surgical Performance: A Primer in Non-technical Skills,* offers a detailed road map for “structuring observation, rating, and feedback of surgeons’ behaviors in the operating theatre.”

Anyone involved in surgery—surgeons, nurses, residents, students—will learn what to look for and how to perform to increase staff well-being and decrease patients’ deaths and errors in the surgical suite.

I use this assessment with my surgeon coaching clients as I observe them in the operating room with their teams. The experience changes how they approach the surgery process. Becoming adept at non-technical skills literally changes lives for the better—patients’ lives.

As the great sage, Yoda said,

“Do. Or do not. There is no try.”


1.NOTSS Website:
2. Industrial Psychology Research Centre, University of Aberdeen (all handbooks)
3. Intercollegiate Surgical Curriculum Project (NOTSS handbook)

*Indicate an affiliate link. We may make a small commission if you purchase this book using this link. It will not affect your price, but it does help us do our work.

Published 6/3/17. Reviewed and updated 12/3/20.

Margaret Cary, MD, MBA, MPH


Margaret Cary, MD, MBA, MPH AKA Dr. Maggi, graduated from the University of California, Santa Barbara with a degree in zoology and a minor in polo. She exercised up to 23 polo ponies/day to put herself through college. Her MD is from Baylor College of Medicine, her Master’s in Public Health (MPH) from UCLA, and her Master’s in Business Administration from the University of Colorado, Denver. She completed her Family Medicine residency in Santa Rosa, through UCSF.

From an emergency room physician in a ski resort, Dr. Maggi has worked in nearly every aspect of health care, landing at her current post as CEO of The Cary Group Global. The Cary Group Global provides executive and leadership coaching and consulting to executives in health care and film and television production.

Dr. Maggi graduated from Georgetown University’s Leadership Coaching program and holds a Professional Certified Coach (PCC) credential from the International Coach Federation. Her clients include

• Mayo Clinic,

• AMIA (American Medical Informatics Association),

• University of Massachusetts Medical School,

• Bon Secours Health System,

• Yale School of Medicine

• Weill Cornell College of Medicine,

• Georgetown University School of Medicine,

• Dubai Medical College,

• and other academic medical centers and research organizations.

Dr. Maggi is an expert at facilitating others’ learning, from medical students to health system CEOs. Her client base consists of C-suite executives to VPs and department chairs, both new and experienced. She developed and led the Community of Champions, the national physician leadership development initiative at the Veterans Health Administration.

She has held many executive posts and practiced medicine in Santa Rosa and Mammoth Lakes, California; Denver, Colorado; London; and Kendal, UK.

Her research for Telemedicine and Telehealth: Principles, Policies, Performance, and Pitfalls (The Lancet’s review) led her to the realization it’s all about the people, the relationships, and asking questions. Her passion project is A Whole New Doctor, a leadership development and coaching program for medical students, staffed entirely with volunteers. A Whole New Doctor serves medical students from Georgetown University School of Medicine, Penn State College of Medicine, University of Nevada, Las Vegas School of Medicine, University of Virginia School of Medicine, Howard University College of Medicine and Hofstra Northwell School of Medicine.

Dr. Maggi is adjunct faculty at Georgetown University School of Medicine and has taught at the Harvard Macy Institute. She coaches TED Fellows and Global Good Fund Fellows and leads nonfiction writing workshops.

In addition to being a contributing author for The Doctor Weighs In, Dr. Cary also serves on the TDWI Editorial Board, where she medically reviews articles submitted for publication.

She is intellectually curious about nearly everything, a lifelong learner, animal lover, gardener, and always ready for adventure.


  • Thank you for writing this, Maggi! This would be so useful in medical education as a preparatory course not only for the Surgery clerkship, but also for clinical clerkships, in general. If we medical students learned about effective intra-team communication and situational awareness before we step onto the wards, the transition would be a lot smoother!

    • Thank you, Jack. Intra-team communication and situational awareness DOES save patient lives, in all specialties. Many mistakes are made at hand-offs, usually because lack of effective communication.

  • Thanks Maggi. Great to have you on the course and well done producing this summary of the day. Keep in touch

    • Thank you, Simon. Great fun! I hope to learn more. See the comment below from Jack Penner, co-founder (with me) of A Whole New Doctor.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Comment will held for moderation