The Invisible Gorilla Strikes Again Journal

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Inattentional blindness in anesthesiology: A gorilla is worth one thousand words

• Alessandro De Cassai,
• Sebastiano Negro,
• Federico Geraldini,
• Annalisa Boscolo,
• Nicolò Sella,
• Marina Munari,
• Paolo Navalesi

x

• Published: September 23, 2021
• https://doi.org/10.1371/journal.pone.0257508

Figures

Abstruse

Introduction

People are not able to anticipate unexpected events. Inattentional incomprehension is demonstrated to happen not only in naïve observers engaged in an unfamiliar job but also in field experts with years of training. Amazement is the perfect example of a discipline which requires a high level of attention and our aim was to evaluate if inattentional blindness can impact anesthesiologists during their daily activities.

Materials and methods

An online survey was distributed on Facebook betwixt May i, 2022 and May 31, 2021.

The survey consisted of v simulated cases with questions investigating the anesthetic management of day-case surgeries. Each case had an introduction, a chest radiography, an electrocardiogram, preoperative blood testing and the last instance had a gorilla embedded in the chest radiography.

Results

In total 699 respondents from 17 different countries were finally included in the assay.

The main outcome was to assess the incidence of inattentional incomprehension.

Only 34 (four.9%) respondents were able to spot the gorilla. No differences were constitute between anesthesiologists or residents, private or public hospitals, or betwixt medical doctors with different feel.

Give-and-take

Our findings assess that inattentional blindness is common in anesthesia, and ever-growing attention is deemed necessary to amend patient rubber; to achieve this objective several strategies should be adopted such every bit an increased use of standardized protocols, promoting automation based strategies to reduce human mistake when performing repetitive tasks and discouraging evaluation of multiple consecutive patients in the same work shifts independently of the associated complexity.

Commendation: De Cassai A, Negro S, Geraldini F, Boscolo A, Sella N, Munari M, et al. (2021) Inattentional blindness in anesthesiology: A gorilla is worth one thousand words. PLoS One 16(ix): e0257508. https://doi.org/10.1371/journal.pone.0257508

Editor: Dylan A. Mordaunt, University of Adelaide, AUSTRALIA

Received: June 22, 2021; Accustomed: September 2, 2021; Published: September 23, 2021

Copyright: © 2022 De Cassai et al. This is an open access commodity distributed nether the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in whatsoever medium, provided the original writer and source are credited.

Data Availability: All relevant data are within the paper and its Supporting information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

People are not able to conceptualize unexpected events as, past definition, they are unexpected. Despite it may appear tautological and rather ironic, this miracle, known as inattentional blindness, has been extensively studied in the past decades since information technology has several tangible consequences in daily-life, such as policemen not noticing a gun during a vehicle stop [1] or an audience non noticing a gorilla on the stage [2]. In the latter example, one-half of the viewers asked to count ball-passes in a curt video were unable to detect a man with a gorilla suit inbound the stage, turning to face up the camera, thumping its breast, and exiting after a total of nine seconds on the screen [3]. Inattentional blindness has been demonstrated to happen not only in naïve observers engaged in an unfamiliar job, simply too in field experts with years of preparation [4].

Anaesthesia is a complex bailiwick which requires a high level of attention and is characterized past periods of intense activity while managing multiple tasks at the same time and periods with a lower workload demand. The lower workload periods may occupy substantial parts of the routine cases (upwardly to xl%) being associated with lower cognitive and physical demand [5]. However, during the intense action stage, the anesthesiologist has to pay different types of attention to ensure patient safe. The required attention types are focused (due east.chiliad.vital signs alarms), divided (e.g. evaluating at the same time patient'due south vital parameters, surgical field and the equipment such as ventilator at the same time), selective (e.g. selecting and choosing the important input from the multiple parameter monitor suppressing irrelevant or distracting information) and sustained (east.m. patient undergoing emergent major surgery for several hours and requiring hemodynamic and respiratory management throughout the duration of the surgery). Necessarily this field has seen a continuous technological evolution and a progressive introduction of practice standards over the final decades with a pregnant improvement in patient rubber [6]. Still, complications still happen, and while many of them are probably unavoidable, an analysis of anesthesia claims highlighted that well-nigh half of the anesthesia agin events were preventable with additional monitoring and attentive vigilance [vii].

The aim of our written report was to evaluate if inattentional incomprehension can affect anesthesiologists during their daily activities, in detail whether anesthesiologists are able to identify an unexpected stimulus during routine preoperative examination.

Methods

Survey design

Nosotros conducted an online survey using the Google Grade spider web-instrument (https://world wide web.google.it/intl/it/forms/well-nigh/, Google, Mountain View, California, United States). The survey protocol was examined past the Institutional Review Board of Padua (Chairman: Dott. Sergi, reference 32148/2021), and a waiver of formal approval was granted considering the nature of the study.

Clear guidelines to design a survey do not exist, still, we followed general recommendations to blueprint and conduct high-quality surveys [viii, nine].

A member of the research team performed a bibliographic search in lodge to identify validated surveys on inattentional incomprehension in anesthesiology and the terms "inattentional blindness", "survey", "anesthesiology", "anesthesiologist" were used in dissimilar combinations on the following literature database: Scopus, Pubmed, Fundamental.

Yet, no pre-existing surveys or survey questions were found.

Therefore, we designed the survey items following Peterson's acronym BRUSO: brief, relevant, unambiguous, specific, and objective [10].

In order to achieve this objective we congenital our questionnaire keeping both the questionnaire and each question every bit brusque equally possible in order to reduce the rate of partially completed questionnaires, we tried to avoid misleading or cryptic terms and we asked simply relevant questions.

The survey consisted of 5 fake cases with single-choice, multiple-choice, and open-concluded questions investigating the coldhearted direction of day-case surgeries. Each case had an introduction (medical history, medications, proposed surgery), a chest radiography, an electrocardiogram and preoperative claret testing. Laboratory tests, chest radiography and electrocardiogram were the same for each example, without pathological findings. However, in the terminal case, a gorilla face was embedded inside the cardiac shadow (Fig 1).

Each case proposed a healthy patient or 1 with minor health problems undergoing non-major general surgery which did not present whatever item business organization or challenge related to the anesthetic management. Given the higher up, we would like to highlight that at that place cannot be a universally accepted correct answer past the respondents (e.g. spinal anesthesia compared to full general anesthesia).

We decided to focus our survey on these simple cases in order to both increase respondent conviction with patient management irrespective of the personal feel gained as anesthesiologists and to investigate inattentional blindness during routine piece of work.

For each instance, participants were asked to choose the best anesthesia technique and to highlight remarkable findings in the case. For the chief objective of this study, the question "Whatsoever comment on Patient 5?" was used to summate the gorilla detection rate. All the same, we decided to consider the identification successful also if the doc incorrectly named the animal or labelled the cardiac shadow in the chest radiograph as "not normal".

The total list of questions is available for consultation (S1 File).

Pretesting

Survey underwent four stages of pretesting. Commencement, the survey was reviewed by the enquiry team to evaluate the developed survey with particular attention to the questions to avoid "skip" or "branch" logic. 2nd, the survey was forwarded to 30 anesthesiology residents at the Padua University Hospital request to evaluate text fluency and to report any typos and time required to complete the survey. In this phase, the time required to complete the survey was estimated to be lower than v minutes for all the participants. Third, in social club to investigate the visibility of the embedded gorilla in the chest radiography nosotros showed the embedded image to an audience of twenty residents. The prototype had an initial transparency of 100% (gorilla not visible at all), then the transparency was progressively lowered by 1%. At 15% all participants reported the gorilla. Fourth, hypothesizing that responders could use the mobile phone to respond to the survey, we assessed its visibility on different mobile phone screens. Twenty residents, uninvolved in the previous pre-testing phase, were able to conspicuously see the gorilla on phones with screens between 4.seven to 6.v inches. All residents were able to identify the gorilla both on four.vii and half dozen.5 inches screens.

Population of interest and survey distribution plan

Population of interest are worldwide anesthesiologists.

We spread the survey on unlike groups for anesthesiologists on Facebook (Facebook, Inc., Menlo Park, California, United States) retrieved by searching groups using the following keywords: "anesthesia", "amazement", "anesthesiology", "anaesthesiology", "critical care", "ICU".

Nosotros spread an invite to the survey on 1st May 2022 and we ended collecting responses on the 31 May 2021.

A reminder was sent a week after the initial invitation.

Participants were invited to forrard the survey to other anesthesiology groups and fifty-fifty to colleagues outside the Facebook platform.

Statistical analysis

Variables are expressed as percentages and compared between groups using the chi-square test or Fisher'due south exact exam when appropriate.

All statistical analyses were conducted using R version 3.iv.0 (2017-04-21), statistical significance was set up at p-values <0.05.

Results

In full, 734 respondents completed the form. Of them, 35 were neither anesthesiologists or resident in anesthesia and therefore were excluded from the assay leaving 699 respondents in the final assay. Nosotros received completed forms from 17 countries and the geographical distribution of the centers is depicted in figure (Fig ii).

Characteristics of respondents are shown in Table 1, while raw data are available as S2 File.

In our survey, only 34 (four.ix%) respondents were able to spot the gorilla.

Discussion

Our piece of work demonstrates that inattentional blindness exists in the anesthesia field and may be far more mutual than generally thought.

In our report anesthesiologists were asked to plan anesthesia management for v imitation cases. The proposed cases did not pose any particular challenge to the respondents considering patients were good for you or with only minor wellness issues. About patients undergoing anesthesia for minor surgery practice not pose item concerns to anesthesiologists, however the repetitive chore of evaluating these patients could pb to lower attention threshold if the anesthesiologist is required to evaluate several of these patients consecutively in a brief fourth dimension.

Contrary to common belief, perception is not a uncomplicated chore where all the elements available to our senses are hands recognized and correctly interpreted. Indeed, for data to exist correctly elaborated, it has to be perceived, understood, and finally analyzed for its possible future implications. This concept represents the three levels of situational sensation, defined as "the perception of elements of the surroundings within a volume of time and space, the comprehension of their pregnant and the projection of their status in the well-nigh future" [xi]. However, in sure situations, even being able to correctly gather and elaborate of import information can potentially not be enough. For example, while working in a squad, the shared situational awareness requires a common understanding of the situation as well every bit organized and timely communication. Ideally information is gathered, elaborated and shared within the team without filibuster, but actually this process is subject to potential failure on whatsoever level of the situational sensation concatenation [11]. Incorrectly gathered information could consequence from both a lack of detectability (i.e., concrete barrier, equipment failure) or the inability to process the bachelor information for various reasons.

Expanding the concept of inattentional blindness, the broader term of "inattentional insensitivity", defined equally "the inability to detect the sensation of a salient stimulus while performing a chore within a congruent sensory modality" [12], warrants consideration and can exist practical to both medical and non medical situations. Undetected salient stimuli can exist visual, as shown in this article, simply the same miracle has been recognized for auditory [13] and tactile [12] stimuli. Inattentional incomprehension is a reality and information technology is not something to exist ashamed of, because it is part of homo beingness and it is not exclusive to a particular professional person surroundings. Several examples of inattentional blindness are available in both medical (gynecology [14], general surgery [15] and cardiac surgery [16]) and non medical literature (driving vehicles [17] and aviation [eighteen]).

This is non the beginning study evaluating inattentional blindness in anesthesiologists, with Ho et al [nineteen] demonstrating that anesthesiologists were able to find hypotension (90%) but non primal venous line disconnection (23%) or caput motion (42%) while watching a video of a major abdominal surgery. In our survey, the percentage of responders able to identify the unexpected event was even lower (4.nine%) than in Ho et al. However, while in Ho's paper [19] participants were direct asked to search for abnormalities and these abnormalities are realistic and plausible in clinical practice (head movement and key venous catheter disconnection), we focused participants' attention on some other task (preoperative evaluation) considering information technology is a sine qua non for inattentional blindness. Moreover our stimulus was not predictable.

In our report anesthesiologists with more than years of feel were as likely to spot the gorilla compared to younger colleagues, plainly in contrast with Graham and Shush's study, which found that incomprehension for an unexpected event is greater for older adults than younger ones [20]. However, we did not directly investigate the age of the participants, only only their years of feel as anesthesiologists. While a correlation between age and years of feel surely exists, it represents but a surrogate of age, leaving the possibility of young anesthesiologists with more than years of experience or older anesthesiologists with just few years of experience. Moreover, other potential confounders exist, such as years of residency, and different digital support used to reply to the survey (mobile telephone vs pc).

In anesthesia exercise inattentional blindness deserves particular attending because it could accept important safety implications, as an example, it has been reported that during anesthesia administration drug recording error is as high equally 1 every eight administration [21], with error frequency increasing with a higher cerebral load [22]. Therefore, awareness of this phenomenon is of paramount importance to limit its dangerous consequences and guarantee patient condom. Anesthesia exercise has made dandy strides in this management, such as double checks earlier drugs assistants is a common adept clinical practices to avoid similarly looking vials or ampoule, implementation of checklists prior to any medical or surgical procedure reducing the human being component, gas cylinder having a particular pin configuration for each medical gas on the yoke of the amazement machine in club to avoid gas cylinder commutation [22] and so on.

Our written report has some limitations that we would similar to discuss. First, we practice non know the total number of anesthesiologists that received the invite to complete the survey and this prevents u.s.a. from calculating non respondent charge per unit and to model their characteristics using a moving ridge analysis. For this reason, while the aim of our paper to investigate the presence of inattentional blindness in anesthesiology practise was achieved, we recognize that the true incidence could have been over- or nether-estimated.

2nd, the time in which the anesthesiologist looked at the image was not standardized. It could exist argued that the gorilla would somewhen be noticed with more visualization time. However, it has been proved that even though subjects have more opportunity to detect the unexpected object the longer it remains on-screen, the vast majority of noticing events occur in the offset 1.v seconds or non at all [23].

Third, we recognize that given the nature of the study (a survey distributed via social network) it is non possible to determine how seriously the respondents assessed each case.

Conclusions

Inattentional blindness is a common and unavoidable miracle in anesthesia. An ever-growing attention is deemed necessary to better patient safety; to accomplish this objective several strategies should be adopted such as an increased use of standardized protocols, promoting automation based strategies to reduce human being error when performing repetitive tasks and discouraging evaluation of multiple consecutive patients in the same work shifts independently of the associated complexity.

Supporting information

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Source: https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0257508

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