What is Surgical Skill?
What is surgical skill?
We often refer to technical, or skilled, surgeons as those with “good hands”.
I despise this phrase.
For one, it implies that surgical ability is something you either have, or don’t. Either you were blessed with ‘good hands’ (some ephemeral concept where your hands touch tissue and then just know what to do and how to do it, I guess), or you should probably go into a different field or only do technically ‘easy’ surgeries.
Laying aside the problems involved in viewing surgical skill with a fixed rather than growth mindset, this nebulous concept of ‘good hands’ puts all the focus on a surgeon’s hands—touching, feeling, moving—and ignores the other important skills that go into performing effective surgery.
If you apply any scrutiny, it’s clear that hands and their inherent traits (tactile feedback, fluidity of motion, coordination, etc) are among the least important of the many facets of surgical skill. For one, all of those qualities decline with age. So are the best surgeons the ones fresh out of graduation or those with 10-20 years of experience under their belt?
I know an older vascular surgeon that can barely feel pulses anymore, but can dissect right next to the aorta with a scalpel. I know an older transplant surgeon with a tremor who performs a great kidney transplant—but my hands move much more fluidly than his. Should he be handing off the venous anastomosis to me? Or are they using something more than just “hands” to operate? Like their eyes? Their brain? Their experience?
What about robotic surgery? Surgeons can perform masterful operations with no haptic feedback. Just their eyes and a screen. How is that possible?
I’m ranting at strawmen. I don’t think anyone would seriously argue with me that, no, they actually want the intern sewing their aorta because their hands are more sensitive and fluid than the experienced senior surgeon. We know that surgeons are made, not born. We know that surgeons don’t peak when their physical fine motor skills peak in their twenties. We know surgery is a complex cognitive-physical activity, like a sport. Talent plays some role, sure, but practice is far more important. Deliberate practice and extensive experience lead to high surgical performance, not ‘hands’.
The problem is, we don’t talk like this. I believe our sloppy vocabulary about ‘good hands’ prevents us from realizing what would otherwise be obvious—most surgeons without ‘good hands’ aren’t actually born without the capability to become a surgeon. They just have not learned how to become one yet. We haven’t successfully taught them, provided them with the tools to succeed. Yet. It’s probably not them (see our post on holding educators to a higher standard). It’s probably us. We have to learn how to teach better.
It’s not their hands. You can do some incredibly challenging, technical laparoscopic surgeries with only the motor skills required to hold onto some laparoscopic instruments and move them slightly up, down, left, or right. The key is knowing when to make these simple motor movements. Reading the tissue in front of you, seeing the plane, knowing what impact a certain movement or cut will have on the field.
And that brings me to the encouraging aspect of this whole topic. Just like I propose that the concept of ‘good hands’ has blinded us to ways in which we treat surgical skill as an inherent trait rather than something that that can be learned, it has also prevented us from seeing new ways that we might develop that skill in our trainees.
We need to move learning out of the bad OR environment, but current simulation solutions are terrible. If surgery is all about hands, then we are stuck. We can’t possibly learn how to operate without touching/doing something with our hands, right? I guess we need to wait 50 years for the perfect tissue simulator to come around before we can teach surgery effectively out of the OR.
Wrong
Surgery is so much more than hands. It is the coordinated efforts of hands, eyes, thought, judgement, experience. Forget the hands! You can teach so much about what you are seeing, what you are thinking, how you manipulate tissue with instruments all without ever touching anything. Just use effective multimedia! Pictures, videos.
How often, even in the operating room where you have a perfect “simulation” of surgery right in front of you, do you end up pointing at something you are looking at on a laparoscopic screen to make your point? Why couldn’t you teach that same point outside the OR using a video of that case?
That’s the power of surgical video. Leave dated thinking about surgical skill and good hands behind. Embrace our current technological ability to teach using videos and start thinking about how much you can communicate about the visual, cognitive, and yes, even technical aspects of surgery outside of the OR environment—where you are able to fully focus and teach it, and your learners are able to fully focus and learn it.
Very early in my surgical training, I overheard a liver transplant surgeon:
“Why do you always want to feel everything? You operate with your eyes, not your hands.”
If we can all internalize this lesson, we can revolutionize the way we teach and learn surgery.