高賭注，高風險專業（如神經外科，航空和核電力管理）的技術需求都是巨大的，更複雜。因此，當前的培訓計劃已經發展以滿足這些領域的技術技能。

However, although most pilots, for example, are highly skilled and well-trained practitioners, several high-profile aviation disasters have been attributed to errors in cockpit communication or cognitive pitfalls than to the pilot’s lack of training or expertise. The civil aviation community has responded to these incidents with a steadfast dedication to training in nontechnical aspects of aviation. Similarly, it has been found that up to 43% of errors during surgery and 27% of claims against health care organizations stem from errors in communication and cognitive bias.

雖然許多這些技能在非技術培訓方案中被強調的是更大的程度，但是外科醫生和外科學員的境界的教育已經很少見。神經外科醫生和神經外科學員現在具有卓越的機會，可以在駕駛艙內使用駕駛艙中的非技術技能（NTSS）培訓的最佳實踐來使用。

One of the most used medical training and assessment tools is the Non-Technical Skills for Surgeons (NOTSS) system. It defines NTSs as “the cognitive and social skills that underpin knowledge and expertise in high-demand workplaces.” The goal of NTS education and assessment is to allow teams operating in high-stakes environments, such as surgical teams in an operating room, to develop shared mental models of rapidly changing situations and to communicate about them effectively to prevent errors and promote good outcomes. The NOTSS system defines four categories of skills with three elements each:

Arguably the most important of the NTSs, situation awareness is crucial for neurosurgeons to master, both inside and outside the operating room. Gathering, understanding, and interpreting information and then using what has been learned to predict future states underlie every aspect of medicine, including triage, history taking, physical examination, diagnosis, treatment planning, operative intervention, and postoperative care. These skills are particularly important inside the operating room, where information sources are varied and often subtle, for example, the sound and cadence of a cardiac monitor, the pulsations of blood vessels or cerebrospinal fluid spaces, and the tactile feedback given by an instrument interfacing with an unidentified structure. Successful surgeons must learn to

• 對患者，他們的同事及其樂器的信息敏感;
• be receptive to this information during both rote “autopilot” portions of a procedure and during the intense focus on the critical portion of the operation;
• triage which information sources are important to pay attention to and at which times;
• recognize their own internal biases that might prevent proper information gathering and handling; and
• use available information to create a model of what will happen in the next seconds to minutes (the next steps of the operation), hours to days (potential complications), and weeks to months (postoperative care and recovery)

Trainees might be sensitive and receptive to information during surgery but lack the experience necessary to fully interpret its significance and decide on a course of action based on it. It is crucial, therefore, for more senior surgeons to verbalize their thought processes to junior trainees at every step of an operation, erring toward more discussion of available information and its future implications.

製定術中決定是神經外科實踐中最重要但難以獲得的技能之一。盡管外科醫生和學員可以在手術前討論患者選擇和手術計劃，但手術期間做出的決定通常是直觀的，並在一定的時間表中進行，這使得難以向學員傳達他們的細微差別。由於發展史無勢判斷和決策技能的重要性，外科醫生應該盡一切努力“大聲思考”並告知他們的受訓人員和同事了解他們過去做出決定的信息，他們過去常常的任何規則或啟發式，該決定及其替代方案的影響以及適用的任何警告。

A full recounting of the rich science of human cognition and decision-making is certainly beyond the scope of this chapter, but in general, surgeons make intraoperative decisions in four ways:

• 分析：外科醫生考慮一係列選項，比較和評估它們的相對福利和風險。（“我們可以通過Pterional或Retronigmoid方法來接近這種腫瘤。這就是為什麼我認為Pterional方法可能會更好。”）
• 使用規則：外科醫生采用個人，機構或區域規則或最佳實踐，規定如何接受具體情況。（“在我們的機構，我們傾向於使用這種縫合線和這種粘合劑來修複腦脊泄漏的這種品牌。”）
• 啟發式：外科醫生直觀地使用多年來開發的啟發式磨練他們的模式識別係統來決定如何繼續。（“我知道我們在C1後拱上橫向看到的出血量增加的是，我們靠近靜脈神經叢，我們橫向暴露。”）
• Creativity: surgeons develop novel approaches to problems when limited established protocols to solve them exist. (“The only way to control this difficult aneurysm was to occlude an important vessel, so I had to design a bypass to restore perfusion to the affected area safely.”)

在做出決定並實施後，外科醫生必須收集新信息以評估他們的幹預是否有效或是否需要進一步措施來達到預期結果。這種思想過程也必須傳達給學員和同事（如手術技術人員，循環員和麻醉家），他依賴外科醫生發出他們的決策過程，同樣地做出工作。

Although both information management and decision-making involve communication, the NOTSS system specifically highlights communication and teamwork as a core NTS for surgeons and trainees to practice and master. The entire surgical team, including the surgeon, assistant, surgical technician, circulator, anesthesiologist, and others, must develop a “shared mental model” of the operation, how each of their roles fit overall, and what steps they must take at each juncture.

清晰易懂的溝通是至關重要的for each team member to understand what is happening during surgery and what he or she must do to keep the procedure running smoothly. Closed-loop communication, in which statements or requests are acknowledged clearly and audibly, ensures that messages are not lost in the often loud and “chaotic” operating theater. Trainees often require more communication than senior surgeons realize, because they might not have a wealth of experience with a given operation, and they might not yet have the skills to anticipate what is expected of them or what the next steps of the operation are. Surgeons should always err on the side of communicating more to keep their trainees and colleagues informed. Please refer to theOperating Room Etiquettechapter for more details.

Despite the ever-more team-based nature of modern medicine, complex operations require clear leadership to ensure that surgical goals are accomplished safely, thoroughly, and efficiently. Surgeons are role models for residents, medical students, visiting scholars, and all other operating room personnel. Good behaviors must be modeled consistently so that they can be mimicked and adopted by others in the future. Please refer to theLeadership Principleschapter for more details.

Surgeons must do the following:

• Set and maintain high standards: clear expectations for team performance should be outlined with specific and detailed surgical plans that are communicated to key team members before a complex operation. Feedback should be both elicited from and provided to team members. Surgeons should adhere to guidelines regarding patient safety, preoperative time-out, surgical field sterility, and other areas.
• Support each member of the surgical team:因為所需的絕對集中的外科醫生during an operation, it is often easy for them to miss errors or fail to detect impending dangerous situations.Other team members are often in a more advantageous position to notice such situations and should feel empowered by the surgeon to speak up and alert the team to a possible hazard; these types of communications should be encouraged by surgeons and never punished, even if the team member’s concern was ultimately unwarranted.
• Cope with pressure: critical portions of a surgery must be highlighted by the senior surgeon, who should advise the team to be on heightened alert for specific phases of an operation when necessary. Surgeons must lead their team calmly and effectively through any crises that arise.

Often absent from discussions of both technical skills and NTSs in medicine are the nuances of human interaction required to teach these techniques effectively and to model them for colleagues in the operating room. Although the situation has certainly improved over time, kindness and friendliness are often conspicuously lacking in neurosurgical training.

大量的研究表明，學習往往受到壓力和負麵情緒，大喊大叫，投擲樂器或給予“無聲治療”的抑製。與同伴和文明的同事和下屬與其他NTS協同作用，以提高團隊表現和享受苛刻的高賭注工作。

貢獻者：David A.磨砂，MD，PHD

DOI:https://doi.org/10.18791/nsatlas.v0.5.00