“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Saturday, May 19, 2007

When you have experience you need less exposure...

“I am enough of an artist to draw freely upon my imagination. Imagination is more important than knowledge. Knowledge is limited. Imagination encircles the world.”

~Albert Einstein

One day when I was an intern, I had one of the general surgery attendings say to me, "when you have experience you need less exposure." I had no idea what he was talking about, but I did smile and nodded as your suppose to do. As I matured as a physician/surgeon, the meaning of this statement became more evident and I was astounded at the immense wisdom in such a simple statement. It is something that our medical counterparts will never truly understand.

Today, we had a wonderful lecture from one if the greats in orthopaedics, specifically total knee arthroplasty, Dr. Booth. Why was the lecture so good? Because even though I do not do TKA's, it helped me with my understanding of changes in philosophies and implants that have occurred over the last few decades and what the future holds. What was of particular interest to me was his references to medicine as the art of medicine and the performance of surgery.

He made several references to artist/sculptor Michelangelo Buonarroti. Michelangelo was extremely technically gifted and through his work you can see his maturation and his development of his own style. The Pietà which was one of Michelangelo's fist major works. It took him 2 years to complete. During this time, he studied anatomy extensively verifying that everything was perfect. He did all of the work from beginning to end, including the final polishing. It has been noted to be highly finished and showed that he had mastered anatomy and the disposition of drapery and had solved the problem of the representation of a full-grown man stretched out nearly horizontally on the lap of a woman. This is regarded as one of his most famous works. When you look at one of his later sculptures, such as the Moses, in it's creation, he saw what he wanted to carve in the single block of marble and carved it. He did not need to study the anatomy or revisit the models or paintings. It was done all from memory, from what he envisioned in his mind's eye. He could see what needed to be done without seeing. With his experience, he needed less external input to get a wonderful result. The comparisons of surgery to art is amazing including the differences in styles or the phenomenon of how the second side of a bilateral procedure is quicker; like Michelangelo when he painted the Sistine Chapel, the second half was done much quicker.

I thought this correlation with surgical techniques was wonderful. It illuminates the fact that in a technical craft you must have an understanding of the concepts and be able to perform the techniques. The technical skill comes with time and aptitude. Dr. Booth pointed out that when he had residents, only about 1 in 3 could immediately visualize things in three dimensions. It is not something that can not be taught. Some people have it and some don't. I do believe it can be eventually learned. The ability of seeing something without seeing takes the experience of seeing. So, what is happening with todays surgical fields? We are going to more minimally invasive techniques which do not give our learners the experience of seeing the anatomy as in the past.

I can look at my own practice. I have seen the change of styles and the increase in residents dependence on fluoroscopy. I watch during surgery the need for a learner to gather more input. "What is this structure?" Immediately the finger goes into the wound to touch it, gathering more information from another sensory source. "Why do you need to put you finger in the wound?" This is really a rhetorical question. I know the answer. They don't yet have the vision to see what I see. I realize now that the time to develop this vision is increasing. Why, you may ask? Most of what we do now is done minimally invasively. We do scopes and percutaneous procedures. We use the new technology to make smaller incisions for a more aesthetic result. So, what skill or vision that many in the past developed doing open procedures is lost. The ability to visualize what is under the skin without seeing is being replaced by technology.

Dr. Booth reference several articles that where proponents computer aided total joint arthroplasty. He review their results and made the point that the amount of error in the non computer aided total joints may have been a result of inexperience with doing non-computer aided surgery or increasing dependence on the computer and decrease experience on relying on anatomical landmarks. He pointed out that no matter how good the computer gets, it can not duplicate or correct for some of the things that an individual surgeon develops over time. He noted that every time he has watched a demonstration of the computer aided techniques, the surgeon ends up making multiple cuts in the femur or tibia to appease the computer. That is the exact opposite of the old mantra, "measure twice, cut once." He pointed out that technology is improving orthopaedic surgery and will continue to help improve it, but the human factor must always be present and that it is hard to put a value on experience.

As generations come and technology evolves, things will change; it is the nature of living. Medicine is an art and the scalpel is the surgeons brush. We all approach things base on our experience and the techniques of our masters. We evolve over the years of practice developing out own flare and styles. Some of us paint with oils and others with water colors; we carve wood or chisel marble. We become comfortable with what we know. How will technology change our art? I am not sure, but it will be fun to watch the future unfold. Now we don't have the exposure, when will we develop the experience?

“In art the hand can never execute anything higher than the heart can inspire”

~Ralph Waldo Emerson


Midwife with a Knife said...

Operative gynecology is putting more and more emphasis on minimally invasive surgeries. This may be somewhat different from orthopedics. But, although you don't see the anatomy in the same way through a laparoscope looking into the pelvis, you see it a whole new way. And you can teach residents to identify the pelvic vessels and ureters and nerves laparoscopically as well as grossly.

As a resident, for the most part, I felt like laparotomies and laparoscopies were different skill sets. Then, as I really learned to identify tissue planes laparoscopically better, I realized that we use the same planes for a massive lysis of adhesions for severe endometriosis or pelvic inflammatory disease. And having seen these planes up close and magnified, I then realized I knew where they were even without the scope during a laparotomy.

And then, after having been requested (or forced?) by a well meaning gynecologic oncologist to do digital blind lysis of adhesions in the deep recesses of the pelvis ("Oh, you can't see in there anyway" he says), somehow the synthesis of laparoscopy, laparotomy, and even the feel of different tissues it all clicked.

The moment when I knew I wouldn't have to be afraid in the operating room as an attending (or, maybe since I'm a fellow, I'm really just a pretending) was late in my last year of residency, I was doing a complex laparotomy/oophorectomy/lysis of adhesions for chronic pelvic pain, and I just knew exactly where and how to get the ovaries off of the bowel and off of the ureters and the bowel off of the bowel and the ovaries out of the sidewall without causing any injury, did it successfully while my attending watched me and smiled and made pleasant jokes.

I think that all of these skills, at least in the pelvis, come together, provided the trainee gets enough experience with each technique.

I miss real surgery sometimes, sorry for the long comment.

Someonetc said...

i really have now problem with minimally invasive surgery. the problem i see is most of these concepts come from doing open surgery. there is no question the arthroscopic surgery (in your case laproscopic) was a needed advancement in orthopaedics. the visualization is so much better etc.

we are now into the minimally invasive hip, knee, and spine surgery. well, you have to understand the three dimensional anatomy to grasp the concept of the techniques. what open surgery does is helps you understand it better.

the hardest thing for me to teach percutaneous procedures, because you have to be able to see the anatomy in your head without actually seeing with your eyes. they eventually get it.

many of my residents wonder how when not scrubbed, i can look at them and tell them that their hand is too high or too low. i don't know how i know, i just do :)