“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

Sunday, February 11, 2007

I watched Greys anatomy .... Let's Operate

With shows like Grey's Anatomy glorifying the life of surgical residents, I have a feeling that the number of students who choose to go into the surgical subspecialties will increase. It will probably be like what ER did for emergency medicine and CSI did for criminalists. Not that surgery has ever needed to be promoted. It has always been seen as a great specialty but a poor life style. With the 80hr work week restrictions, it has been less intimidating from the life style stand point, and with shows like Grey's Anatomy and Dr. 90210, it is becoming more high profile. I predict the numbers of applicants will increase. In orthopaedics, we really don't need an increase in applications.

Now, with our TV knowledge of the surgical residency, an intern may expect to first assist on a complicated cardiac procedure, or in my realm, a complex spine procedure, such as a pedicle subtraction osteotomy. As the intern first assist, when my hands start to tremble, you will take over because you have read the book and looked at the pictures. Au contraire, mon frair. The development of surgical skill can not be learned like the Kreb's cycle. Surgical decision making can not always be fit into an algorithm. It is more complex than that, just because I slept at a Holiday Inn. Becoming a surgeon is a process. It takes time to develop. Your vision gets better, like a running back who can see the holes in the defense. Some develop quicker than others, some are more skilled and some less skilled. Let's talk about surgical skills development.

In an article by one of my mentors, Dr. Robert Hensinger, he describes the development of masters. In his editorial, "The Making of Masters: Some Assembly Required." (SPINE 2003; 28(18): 2046-2048), he describes the different stages of surgical development.


At this level, the learner is given rules that define the actions. The learner is told precisely how the procedure is to be performed. It is the exact formula to attain a specific goal. Unfortunately, the formula cannot predict all the variables for each instance, patient or procedure. This level requires a great deal of memorization. Because of this, the learner never reaches a level of incorporation of information.


At this level, the learner gains experience in coping with real situations and patients. The person begins to understand the problems that can occur in clinical situations. The learner begins to notice subtle variations in outcomes that occur within the same diagnostic theme. It is at this stage that the learner begins to organize the information within a frame reference. As the student incorporates more principles and rules, the teacher assumes the role as coach, evaluating and providing feedback.

This is a rule-based phase. Because, algorithms become longer and more complex, the learner can become overloaded and experience burnout.


The Competent is the level which we as educators would like to see our learners reach prior to you leaving our supervision.

This is the level when performance and expectations can be overwhelming. In prior levels, when rules didn't work, the learner rationalizes that maybe they have not been given enough or adequate rules. This is when the learner may wonder "how can this be mastered?"

Competence is more than rules based; It is problem solving. It is the ability to manage ambiguity and tolerate uncertainty, making decisions with little information. Competent physicians sort better and can compare patient patterns. They transform knowledge to fit the task. The learner becomes accountable for their actions and begins to take some responsibility for outcomes. They become emotionally invested and begin to develop a sense of remorse for their mistakes.


At this level, there is an incremental incorporation of technical skills, rules, and principles. As experience is assimilated, the rules become subliminal. Answers become intuitive. Certain findings jump out as important without the learner standing back and going through the tiresome mental process to select a plan.

Due to past experiences, the learner is able to select one of several possible options based on relating the patient's presentation to others. With this "pattern recognition", the learner needs fewer clues to develop a plan. This specific trait of "pattern recognition" is one of the most important trains in determining surgical excellence.


This is accomplished performer, the skillful practitioner. The expert sees what to do and has an immediate intuitive response. Envisioning becomes a part of the practitioners’ behavior. The ability to represent mentally the physical environment and the movement to be performed are major determinants of surgical technical performance. Specific strategies associated with this stage include imagery and mental practice. Aristotle noted that we acquire our craft from the master through observation and experience. In problem solving, experts draw on many strategies, while the student uses the same cognitive strategy.


The master has style. The master is a truly unique individual. The master loves surprises and challenges. There is a danger that the apprentice will merely become a clone of the master. Musicians have learned from this experience that those who follow one master are not as creative of a performer. Professors in the School of Music encourage association with several masters, taking bits of style from each to develop a completely unique performance.

Surgical mastery—the ability to gain knowledge, although necessary—is not sufficient to develop superior operative skill. Pure psychomotor skills and manual dexterity are not the major components that distinguish the outstanding surgical performance from the mediocre. More important are visual–spatial problem-solving abilities, for example, the capacity to rapidly analyze and organize perceptions based on multisensory information. They have the ability to distinguish essential from nonessential detail even when the signal-to-noise ratio is high. This appears to be most crucial to superior technique and correlates better with operative skill than board scores. It is essential that the surgeon manage anxiety and tolerate stress.

So, I guess we are not all trying to be masters, but our development as surgeons does go through various stages. Those who are in training or have completed training know the point where all of the sudden, they began to see clearly. We all remember when the process of seeing patients in clinic and making a plan became easier. The mental work became less. We became quicker or more efficient. Becoming a surgeon is a process, it takes time. It is not innate. Sometimes we want to force the situation before we are ready. Be patient young Padawan, your time will come.


Anonymous said...

This is really great of you to do. As a PGY2, I know that more than skills and knowledge, I lack perspective. Thanks for sharing some.

Anonymous said...

I just like the helpful info you provide to your articles.
I will bookmark your weblog and take a look at once more right here regularly.
I am fairly sure I'll learn many new stuff proper right here! Good luck for the next!
My website: Audio Visual