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Anaesthesia and Compounding Marginal Gains

The British Cycling Revolution: A Lesson in Marginal Gains

When Dave Brailsford was appointed Performance Director of British Cycling in 2003, he inherited a program defined by failure. The national team hadn't won Olympic gold since 1908, and no British cyclist had ever claimed victory in the Tour de France's 110-year-long history. The 39-year-old cyclist-turned-performance consultant would transform British cycling and our approach to improvement through an unexpectedly simple philosophy: the aggregation of marginal gains.

Growing up in one of the few English families in North Wales, Brailsford developed a perpetual drive to prove himself. "Somehow I always felt I did not quite fit in," he reflected. "So I always thought I must try harder than the others to be accepted, to be successful." This outsider mentality would fuel his pursuit of excellence.

At twenty, Brailsford abandoned his job to pursue cycling in France as a sponsored amateur. In between training sessions, he devoured exercise physiology and sports psychology texts and later earned a degree in sports science and psychology that laid the foundation for his revolutionary approach to British cycling.

Brailsford's approach was revolutionary in precision and scope, implementing rigorous systems for measuring cyclist performance, from power output to recovery metrics. However, the true uniqueness of his methodology was its holistic nature, relentlessly pursuing tiny, cumulative advantages across all performance domains: physical conditioning, technological innovation, psychological preparation, and even the minutiae of daily life.

Rather than pursuing dramatic overhauls, Brailsford focused on finding one percent improvements across every aspect of cycling performance. His team painted truck floors white to spot dust that might undermine bike maintenance. They had a surgeon teach hand-washing techniques to prevent illness and transported custom mattresses and bedding between hotels to ensure sleep quality. They scrutinised every detail, from wind tunnel testing for minor aerodynamic advantage to athlete nutrition and the perfect pillow for optimal recovery.

"It struck me that we should think small, not big, and adopt a philosophy of continuous improvement through the aggregation of marginal gains. Forget about perfection; focus on progression, and compound the improvements." - Sir Dave Brailsford.

The results were extraordinary. British cyclists dominated the Tour de France within the decade and amassed 16 Olympic gold medals across the 2008 Beijing and 2012 London Games, setting seven world records. By 2016, they had won two-thirds of the Olympic cycling gold in Rio. While British Cycling's success was enabled by substantial funding, the power of a marginal gains strategy transformed both the sport and our understanding of how excellence can be achieved.

The Transformative Power of Marginal Gains in Anaesthesia

Every component of anaesthetic practice is tightly coupled. Every aspect of care – from preoperative assessment to emergence and recovery, from team cohesion to workflow and handovers – influences all others. While this coupling can amplify errors, it also means improvements do not merely add up – they compound. A refined preoperative assessment enhances intraoperative management, enabling smoother emergence and better recovery. These improvements compound both vertically within each patient's care journey and horizontally across all patients. In anaesthesia, marginal gains compound geometrically.

The benefits extend beyond patient outcomes. Small improvements create ripple effects throughout the perioperative environment. When anaesthesiologists enhance even minor aspects of their practice, team dynamics improve. Better communication protocols reduce stress; streamlined workflows improve efficiency and job satisfaction; more effective patient interactions enhance professional relationships. These improvements boost anaesthetist well-being, producing a positive feedback loop where personal satisfaction can drive further advances in care quality.

There is another crucial reason to embrace continuous improvement: stagnation in anaesthetic practice is not neutral – it is regression. Medical knowledge, technology, and best practices evolve constantly. The moment we stop improving, we begin falling behind. As for a patient in intensive care, stability is not enough; we must see progress. Our clinical environment becomes more complex each year, with new therapies, devices, drugs, techniques, and patient safety requirements. Rising patient expectations and evolving healthcare standards demand continuous adaptation. Yesterday's gold standard becomes tomorrow's minimum requirement. Anything less than improvement represents decline.

Kaizen: Empowering Small Steps in Large Organisations

The Japanese concept of Kaizen, or continuous improvement, perfectly captures the marginal gains philosophy. Kaizen is not about dramatic overhaul or revolutionary change but instead empowers individuals to make small, meaningful improvements in their daily work. When consistently applied, these incremental changes drive both personal excellence and institutional advancement.

In hospitals that embrace Kaizen, every staff member – from porters to doctors – is empowered to identify and implement improvements to their daily work. This democratisation of improvement has profound effects: it raises morale by giving staff agency over their work, creates a culture where questioning current practice becomes the norm rather than the exception, and, most importantly, it recognises that those who do the work are best placed to improve the work. The beauty of Kaizen is its sustainability. Unlike grand transformation projects that may get bogged down by politicking and implementation frictions, small daily improvements become woven into the fabric of everyday practice.

Implementing Marginal Gains in Your Practice

Begin by examining the unexplored corners of your practice – these often hide the most significant potential for improvement. The seemingly minor aspects of your daily routine, experienced by you, your team, and your patients, involve large patient surface areas. In their sheer frequency, these delightfully ordinary moments become critical targets because small things scale.

Small improvements create significant cumulative impact when consistently applied across hundreds of cases. Each enhancement, however minor, multiplies these benefits across every patient you treat.

Technical skills

Start with fundamental technical skills: consider how you might enhance even the most routine procedures. Could routine subcutaneous local anaesthetic before cannulation improve your patients' experience? When applied consistently, such minor refinements in technique can strengthen the quality of routine procedures.

Communication

Non-technical skills offer another rich opportunity for marginal gains. Implementing structured handover tools like SBAR might appear modest, yet it demonstrably improves communication clarity and patient safety. Refining preoperative patient communications can significantly reduce anxiety and improve satisfaction. Regular preoperative team meetings and post-operative debriefings create opportunities for continuous performance enhancement.

Patient experience

The patient journey offers numerous opportunities for marginal gains. Regular post-operative visits improve patient satisfaction and provide valuable feedback for improvement. Systematic patient surveys can reveal patterns indicating where small changes yield significant impact.

Personal well-being

Personal development deserves equal attention when pursuing marginal gains. Establish regular reflection time through journaling or collegiate discussion. Commit to reading one new journal article weekly, focusing on areas for growth. Simple mindfulness practices or brief exercise routines contribute to performance and well-being – even five minutes of focused breathing before starting your list can enhance both.

Remember that improvement does not require perfect conditions. On challenging days, focus on maintaining established gains. Every small step forward contributes to long-term progress.

Begin by identifying the smallest areas that you can improve. Managing your practice without seeking improvement is like wearing the same underwear for a week – technically possible, increasingly uncomfortable, and eventually, someone will notice and call you out on it. It's better to make small, regular changes before things get embarrassing.

Summing it up

Excellence in anaesthesia emerges not from revolutionary breakthroughs but from consistent, small improvements compounding over time. Each enhancement — in knowledge, technical skill, communication, or patient interaction — builds toward better patient outcomes: reduced complications, improved recovery times, enhanced patient experience, and more robust team performance.

The impact of marginal gains cascades beyond individual improvements. Like British cycling's transformation under Brailsford, our collective commitment to continuous enhancement can elevate both our individual practice and the entire field of anaesthesia. The question is not whether to pursue improvement — the question is which small enhancement you will tackle today.

References

The Power of Kindness in Anaesthesia

Kindness is the foundation of positive human relationships. Kindness is also the foundation of quality anaesthesia, framing not just the goals of care but the paths we tread to reach them: kindness to our patients, kindness to one's team, and kindness to oneself. Kindness is the oxygen that sustains our practice.

"[Kindness is] helpfulness towards someone in need, not in return for anything, nor for the advantage of the helper himself, but for that of the person helped." – Aristotle, Book II of Rhetoric

Like many anaesthetists, I often fixate on outcomes. Yet, the journey usually matters as much for patients as the destination. While modern medicine makes successful outcomes the lowest bar, the hospital experience shapes the patient's entire perception of care, sometimes turning a medical success into a perceived failure. When we centre our practice on kindness, we elevate both process and outcome, giving them equal weight.

Too often, we equate quality anaesthesia with technical excellence: precise techniques, rapid turnover, stable vitals, and adherence to best practices. We audit hard markers like pain scores and discharge times. Yet this reductionist approach misses the cornerstone of healthcare: kindness.

When we view our practice through the lens of kindness – not empathy, for it helps no one for the anaesthetist to experience the same pains and fears as their patient – we reorient our decisions around "how can I help this person?" with a clarity of purpose unburdened by personal gain. This perspective expands our care to embrace the whole person under our care. For instance, taking a few extra minutes to explain the procedure to an anxious patient or keeping a family informed and reassured are acts of kindness that impact a patient's experience.

Patient fears before anaesthesia and surgery become just as essential to address as the technical aspects of care. Technique choices are no longer made for the convenience of the anaesthetist or hospital but rather for the needs of the patient. Perioperative care rooted in kindness recognises the interconnection between patient experience and patient outcomes – the two factors that truly matter to those under our care.

This practice of kindness extends beyond the patient. It reshapes and reorients our engagement with our team and ourselves. Kindness is a glue that binds a team together, encouraging a sense of unity and shared purpose.

Kindness to our team means fostering a culture of supportive communication: listening to concerns, acknowledging contributions, and responding to mistakes with constructive compassion. How often do you thank your assistant and surgical team at the end of a list?

Kindness becomes even more critical in moments of crisis. Everyone in the room likely shares your stress and looks to you for professional and emotional leadership. Maintaining calm, staying composed, and offering reassurance transform a team's performance under pressure. In a crisis, anger is a poison that corrodes collective resilience. Kindness, on the other hand, is a powerful tool that can reassure and instil confidence in the team, transforming both the atmosphere and the outcome of the crisis.

Kindness to oneself may be the most challenging form of kindness to practice. In a field where expectations are high, self-compassion is essential as we struggle to accept imperfect outcomes or personal errors. We must see mistakes not as failures but as opportunities for growth. The long hours, the high-intensity work, a sometimes-capricious health system, and the unpredictability of anaesthesia all contribute to burnout. Getting lost in our vocation can be easy and insidious, but we must recognise that life cannot be all work. Our families, our friendships, and our health must take priority. Kindness to ourselves is not indulgence; it is self-preservation. By practising self-kindness, we acknowledge our own value and well-being, prevent burnout and ensure we can continue providing the best care to our patients and team.

In our demanding profession, perhaps the best advice is simple:

"Be a little kinder than you have to." – Emily Jenkins.

When we practice kindness – to our patients, our team, and ourselves – we create an environment where care is more than just a technical exercise. We cultivate a virtuous cycle: supported team members provide better patient care, and well-cared-for patients make our work more fulfilling. Kindness in anaesthesia can lead to improved patient outcomes, enhanced team dynamics, and a more satisfying professional experience for all involved.

When we are kind to ourselves, we have the emotional resources to extend that kindness to others. In anaesthesia, as in life, kindness is not just a virtue – it's the vital sign reflecting our practice's health. Kindness is an act of compassion that elevates routine care, benefiting everyone involved.

COVID research mid-year round up

We are now two and a half years into the COVID pandemic, and just beginning to see yet another case surge with the arrival of the BA.5 Omicron sub-variant. The good news just keeps coming! 😉

Along with new variants, 30 months has also given us a lot of research and data. Metajournal alone has indexed almost 39,000 COVID-related publications relevant to anaesthesia, pain, critical care and emergency medicine.

Of course that's a crazy volume of research to manage, with a pretty low signal-to-noise ratio. Sifting through that for quality and relevant studies is exactly what metajournal was designed for.

Here's a quick round-up of interesting COVID-related research...

RAT tests & infectiousness

As good quality, locally validated RAT tests become increasingly available, we are also collecting more data showing they are a good indicator of individual infectiousness at the moment in time the test is performed.

The article collection 'Does a COVID RAT-negative result mean non-infectious?' explores several of these studies, suggesting that a negative RAT is likely a reliable indicator of being non-infectious.

The bottom line...

A correctly-performed adequately-validated RAT, is likely a sensitive indictor of individual infectiousness at that specific moment in time. The reliability of a negative RAT will be improved if using the same manufacturer and technique as a previously positive test, and more so if there are several subsequent negative RATs.

Return to exercise after COVID?

A recent J Sci Med Sport editorial (Hughes 2022) from Australian elite sport, exercise medicine and sports cardiology experts, provides reassuring encouragement when returning to exercise after COVID recovery.

Read on for more on exercise after COVID...

Does doctor gender impact patient outcome?

A very interesting study in JAMA Surgery from Wallis et al. received a lot of press coverage. The research team showed that female patients treated by male surgeons not only more commonly experienced post-operative complications, but also suffered a higher mortality, than when treated by female surgeons.

What did they do?

This big-data study covered 12 years of the 20-most-common surgical procedures performed in Ontario, Canada. Wallis and team investigated how patient-surgeon sex discordance correlated to a composite for adverse postoperative outcomes. (A deeper investigation of the earlier Wallis 2017 study).

And they found?

While ~15% of all patients experienced an adverse post-operative outcome, female patients treated by a male surgeon experienced significantly higher odds of a composite of adverse events (OR 1.15 [1.10-1.20]), 30-day complications (OR 1.16 [1.11-1.22]), readmissions (OR 1.11 [1.04-1.19]), and death (OR 1.32 [1.14-1.54]) compared to when treated by female surgeons.

Yet male patients treated by female surgeons experienced either lower odds (death 0.87 [0.78-0.97]) or statistically-similar odds of complications (composite end-point, readmission or post-op complications).

The hot-take

Women once again receive the metaphorical short-end of the medical-stick. Whether societal or elsewhere in the health industry value-chain, long established gender inequity reveals itself in worse surgical outcomes for female patients.

Hang on a sec…

But this cannot just be written off as a consequence of existing social gender inequity, but rather a disquieting causal loop between this as a cause and the result then perpetuating further inequity.

If some part of a surgeon’s ’professional success’ is wrapped-up in the ability to achieve positive outcomes for patients while minimising the adverse, then male surgeons are failing their female patients when compared to either female surgeons, or to the care they provide their male patients.

And yet the same discordance cost is not true for female surgeons.

Read on for the take-home & more medical-gender influences...

Only one compromise

In anaesthesia, sitting at the point where the ideal meets reality, is compromise.

Compromise is the practical, real-world necessity that allows a health system to function in the face of competing demands. Every point of care in a hospital is a balance of compromises, frequently between safety and the many other flavours of medical quality.

For anaesthesiology the most common compromise is balancing safety with the quality of the patient experience: pain, distress, cost, delays, efficiency, levels of intervention, seniority of care… (Though let’s acknowledge, suffering injury because of a safety compromise is also a pretty poor patient experience.)

In a dynamic world of external stressors (<cough>pandemic<cough>) compromise becomes both more important and more fraught. How do we balance conflict between the needs and priorities of care? Compromises are then a pragmatic necessity, recognising the fractal complexity of patients and hospitals that the inherently reductive nature of best practice and theory struggles to accomodate.

A great example of this is found within the Zero Harm safety movement, aspiring to the worthy (though naive) goal of reducing healthcare staff & patient injury to zero. Zero Harm’s mistake is to build an entire ideology upon an unachievable goal, for as Thomas points out in 'The harms of promoting Zero Harm':

“...some harms are inevitable and impossible to eliminate.”
– Thomas (2020)

Zero Harm is itself a compromise, deprioritising other components of care in service to absolute safety. Only by recognising the natural compromises at every level of the health system can we make informed decisions about the risk-price we are willing to pay for compromise.

Many years ago as a junior resident, a senior colleague dropped some wisdom about compromise that sticks with me today. He made the observation in the setting of one of the commonest and discrete medical interventions: intravenous cannulation. Sometimes you have a cannula that is smaller or not flowing as well as you would prefer. Depending on the circumstance, this is often tolerable and we grudgingly accept it.

"But beware”, he said, “never allow more than one compromise.”

Although imperfect intravenous access may be a small compromise, it represents an increased-risk point of failure. Perhaps you now feel compelled to accept a ‘minor’ airway compromise (LMA over an ETT?), or a fasting compromise, or location, or the presence (or not) of a parent at induction? While each step may be justifiable, stacking compromises increases points of failure and risk in a non-linear way.

Stacked compromises increase risk geometrically.

Stacked compromises are fragile.

While there may be no true hard rules in anaesthesia, we need to appreciate that risk exists on a dynamic spectrum. The adolescent ideology of Zero Harm may have near Zero Place in anaesthesia, yet the primacy of risk management and harm minimisation always requires considering how our compromises interact and compound to alter the risk profile of the care we provide. Our goal in managing risk in complex systems should be to reduce risk where we can, and build resilience where we cannot.

You may still feel it necessary to stack your compromises, but by the Gods of Anaesthesia, if you do then you better make sure you know the price being paid – and who is ultimately paying it.


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