How much of surgical skill can be attributed to tremor?

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Perzt

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I have seen some threads here from MS that wonder how their tremor would affect a potential surgical career. It seems that some surgeon point out microvascular and vascular surgery are not something to consider if having tremors.

Lately I've had some surgical experience and have seen surgeons with unbelievable steady hands and surgeons with shaky hands. One thing that caught my interest a bit was a transplantation surgeon doing pediatric pancreas transplant, and had very unstable hands. However, he managed to make the anastomoses without any problems. Also, he did a liver transplant and the anesthesiologst was impressed by how fast he worked through the case. And when I say shaky hands in this case, I mean really shaky. maybe 1 cm amplitude. I asked him after the case if he ever had used betablockers or something to overcome the tremor and he just answered "You just don't need to reduce the tremor if you understand how to anastomose it the right way".

The cases he did I would call delicate surgery at times, at least the vascular part of it. But when you ask other surgeon they say that steady hands is very very important in order to make a anastomosis.

Are there several aspects on surgical performance? It feels that if your hands don't shake your anastomoses for example will be perfect, but it seems that it is just a small part of actually getting a anastomosis right, understanding and having a good 3D-view of everything seems to be very important too.

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Probably easier if you have steady hands, but obviously from your experience its possible with a tremor. Either way if your anastomosis is leaking you would fix it prior to leaving the OR.
 
I've had no experience with microsurgery yet, but it says something in terms of "If you have mild tremor, you could exclude microsurgery, periorbital surgery in the scope of plastic surgery" in some threads here on SDN.

Here is a movie from a famous plastic surgeon. Would this guy be able to perform microsurgery or would he be limited of what you see to less delicate work only? He seems to have a relatively significant physiological tremor from time to time during the surgery. http://journals.lww.com/plasreconsurg/pages/videogallery.aspx?videoId=261&autoPlay=true
 
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Of course surgical "performance" is multi-factorial. Conventional wisdom holds that the physical skills are less important than the intellectual (ie, "I can teach a monkey to operate"). Learning to operate with a physical disability will make things, including surgical anastomoses, more challenging but humans can compensate for such things. It may also be the case that the surgeon you watched developed the tremor after having trained and worked for many years, or that his tremor was a resting rather than intention tremor.

Finally, OP please let me know if you are a medical student or pre-med so I can move this to the appropriate forum for you.
 
Tremor is one thing. Hand finesse, proprioception and spatial reasoning are very important.
 
Tremor is one thing. Hand finesse, proprioception and spatial reasoning are very important.
Although I would be very wary of 1cm oscillations for anything microsurgery.
 
Thanks for your answers. Let me put this way: when one is considering different specialties (maybe especially surgical vs non-surgical field) should one reason like
1) I like a non-surgical/surgical specialty -> I will choose it.
2) I like a surgical specialty -> next step is to figure out if one has the hands for it -> I will choose it (or not choose).

Some seem to be reasoning "I'm interested in surgery, if I will encounter any problem later in residency/career I will try to solve them then"..

When I've looked at youtube at surgery everyone seems to have a slight tremor. For example an UCLA vasc surgeon 0:56->. Would that tremor be OK? Or would attendings remark on it? I would say I have slightly less tremor than he has from 0:56 and onwards.

Baah.. Hate to start reasoning like this, have never been like this before. It's now for the first time when I have found out I really enjoy surgery and can't think of another career I have started getting these d*mn thoughts. At the beginning of surgery I wasn't dead set on it so I actually got nice evaluations from my attending for my technical ability (got to ligate all vessels, suture the deep fascia etc) first time in the OR.

Now though when I really enjoy it I feel it hard to put aside I seem to have developed a small tremor since then and I just feel that I will have to exclude specific areas (microsurgery etc). The thing is that I can't recall myself having a tremor, and now I have it even when no one is looking at my hands. I think I just want everything to be perfect, I can't stand to watch my hands shake just even a little. Especially when I stretch out my fingers..

Has anyone else had this problem?
 
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There are so many threads about this that it's clear a lot of people think about it. I wonder if it would be a good idea to get some informal data on tremor-- there are several apps that measure tremor with your phone's accelerometer. For example there is a free app called ParkinsonMeter that does this. We could have people average a couple of their readings, set up a poll and get some feedback. It'd also be cool to see if/how much tremor decreases throughout residency. Just an idea. Not that I'd go to all this trouble :), but maybe someone else would? Nice thread.
 
There are so many threads about this that it's clear a lot of people think about it. I wonder if it would be a good idea to get some informal data on tremor-- there are several apps that measure tremor with your phone's accelerometer. For example there is a free app called ParkinsonMeter that does this. We could have people average a couple of their readings, set up a poll and get some feedback. It'd also be cool to see if/how much tremor decreases throughout residency. Just an idea. Not that I'd go to all this trouble :), but maybe someone else would? Nice thread.

Best way to test tremors is by playing flappy bird!
 
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Everyone has a tremor. The amount of tremor has little correlation to the competency of the surgeon.

I have worked with surgeons with minimal tremor under scope who were absolutely incompetent.

I have worked with surgeons under scope who shook like an earthquake who performed a beautiful surgery.

What it comes down to, is knowing how to operate. What to do, when, how to do it, and how you, as a surgeon, are able to do that. While I have never asked any of my tremulous mentors regarding their tremor, nor have I asked do they think the would be better surgeons without a tremor, I do think the general populous is wrong to think that steady hands makes a good surgeon. This is bull****. A phenomenal understanding of anatomy, surgical procedures, and triage makes a good surgeon. Good hands are just a nice addition to boot.
 
A lot of learning how to compensate for normal physiologic tremor is ergonomics. If you sewing or dissecting with your arms doing some prolonged isometric postures, then everyone will noticeably tremor after a while.

To minimize tremor you will try to keep you arms adducted (in towards your trunk) as much as possible and support you lower arms on the patient. I think a lot of the people you think have the steadiest hands are doing this and you not appreciating it. The other tricks of the trade have to do with avoiding caffeine before surgery and limiting weight lifting (ie. wrist and bicep curls)

I disagree with some of the comments that you can be a safe surgeon on the more precise procedures with significant tremor. (I don't consider CEA to be a particularly precise surgery BTW, and I didn't think that surgeon's tremor was bad in that video). You would have a lot of trouble doing microsurgery, cardiac, & eye surgery with any significant tremor.
 
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To minimize tremor you will try to keep you arms adducted (in towards your trunk) as much as possible and support you lower arms on the patient. I think a lot of the people you think have the steadiest hands are doing this and you not appreciating it. The other tricks of the trade have to do with avoiding caffeine before surgery and limiting weight lifting (ie. wrist and bicep curls)


Why is weightlifting( of the arms) bad? The exercises you mention target forearms and arms.
 
A lot of people will get more of a tremor from increased resting muscle tone in their arm (bicep, deltoid, or tricep). It only bothers me personally when I was trying to work out with weights early before work. I normally don't have a tremor at all, but it would get hard to do anything requiring finesse when I would do that during residency.

For most students and residents, it's pretty easy to minimize it by stabilizing your arms better as I mentioned. There are some people that are hopeless though and really would never be able to compensate for it.
 
A lot of learning how to compensate for normal physiologic tremor is ergonomics. If you sewing or dissecting with your arms doing some prolonged isometric postures, then everyone will noticeably tremor after a while.

To minimize tremor you will try to keep you arms adducted (in towards your trunk) as much as possible and support you lower arms on the patient. I think a lot of the people you think have the steadiest hands are doing this and you not appreciating it. The other tricks of the trade have to do with avoiding caffeine before surgery and limiting weight lifting (ie. wrist and bicep curls)

I disagree with some of the comments that you can be a safe surgeon on the more precise procedures with significant tremor. (I don't consider CEA to be a particularly precise surgery BTW, and I didn't think that surgeon's tremor was bad in that video). You would have a lot of trouble doing microsurgery, cardiac, & eye surgery with any significant tremor.
as a wannabee orthopaedist I will have to disagree with that, the stronger your muscles are the less tremor they will likely have under static load. of course if you are training the day before and you have muscle recovering from exercise it will make tremor worse, but in the long run, it can only make it better.
 
as a wannabee orthopaedist I will have to disagree with that, the stronger your muscles are the less tremor they will likely have under static load. of course if you are training the day before and you have muscle recovering from exercise it will make tremor worse, but in the long run, it can only make it better.
isn't that what the esteemed @droliver is saying here? No lifting right before a case?
 
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