We Do It the Same Way Every Time

Once he’s finished positioning the retractor just perfectly, he has a pristine view and is ready to start the meticulous work of the anastomosis. He silently reaches out his hand and the scrub tech hands him the loaded suture that every other attending in the department uses for the outer layer, but as this surgeon starts to throw his first stitch, he throws the driver back onto the Mayo and growls.

As close as he can come to screaming without having a report filed, he says again, “I do it the same way every time!” It’s followed by the typical contradictory admonitions and demands (“Anyone can do this! Get someone in here who knows what they’re doing!”) and presumably rhetorical questions (“Why can’t you get this right? How hard can it be to hand me something?”). The resident stays silent.

There’s plenty to dissect, plenty to recognize as horrible about this response, and plenty that’s been said about the benefits of appropriate professional behavior in the OR.¹ However, there’s another assumption underlying this common interaction that’s rarely explored: why do it the same way every time? What if it’s different from everyone else? What if you don’t have access to that suture, that stapler, that mesh?

Undoubtedly, a benefit to decreased personal variation is practiced repetition with the goal of perfection. It’s reasonable to believe that procedure after procedure done the same way improves the surgeon’s comfort and thus ability with the technique. It’s similarly reasonable, though, to acknowledge that some—probably most—of those techniques have drawbacks, or they would be the techniques everybody uses every time. And it’s very likely that every technique has some situation in which it isn’t the best.

Surgeons aren’t technicians. Surgeons must improvise and adapt to the situation at hand, to anatomic variations, to resource limitations, to the unexpected and the unknown. Academic surgeons must additionally adapt to learner needs. Trainees won’t see it the same way every time, and that’s a benefit; they learn pros and cons of different approaches, find those that are the most amenable to the most situations, those that work when others fail, and those that are utterly unusable. Why, then, would an academic surgeon limit themselves to one way?

This isn’t limited to the operating theater. Patient care need not be—indeed, should not be—by rote. Algorithms work wonderfully for a great many cases of a great many diseases. The role of the surgeon is to recognize and understand when the algorithm won’t work, when the specifics of the circumstance belie the assumptions of the guideline, when the patient hasn’t read the textbook. One way to enhance this understanding in the academic arena is a practice introduced to me by one of my mentors, Amalia Cochran, in a recent conversation:

If a plan is reasonable and is unlikely to result in patient harm, even if it’s not what I would have done I am willing to let residents try it. My reasoning is twofold:

They learn if it doesn’t work.

I learn if it does.

There’s more than one way to do it. As surgeons, we should of course practice to achieve excellence. As surgeons, we should also know and practice alternatives. As surgical educators, additionally, we must know not only what many other ways are, but why we do it the way we do, how to do it other ways in case the balance of risk and benefit changes, and—perhaps most difficult at all—how to teach with poise and restraint when those we’re supervising choose a different way.

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