How can you tell if a surgeon is good?

[SeaBreeze2]

I'm still a medical student (IMG), but I can easily tell how good a doctor is in non-surgical specialties. I can simply look up what they are saying and see if it makes sense.
When one of my IM teachers said "End diastolic volume decreases in systolic heart failure" and stuck with that assertion after I questioned it, I knew that I should stick to a textbook for instruction.

I'm rewatching a cell phone video of a foot amputation we got to see and I'm wondering how "correct" the surgical technique is. The surgeon is saying something about how clean the cut is affecting phantom limb pain and I see him figuring the distance to make the flap and where to saw. I have no idea if this is good surgery I'm seeing or bad. We usually have 5 minutes notice before we go see an operation so we can't read up much on it beforehand.

Generally, how can you make watching surgeries a more useful learning experience? What do you look for in a surgeon's technique?

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[OnePunchBiopsy]

If is difficult to critique a surgeon's technique without sufficient insight into the procedure being performed.

Medical students typically don't start out with sufficient knowledge to discern good from poor technique (except in instances of gross negligence). You can increase your knowledge by reading surgical texts or watching operations on youtube, but insight is typically gained through experience in the OR.

As a medical student, I would use time in surgery to reinforce anatomical relationships and learn what surgical pathology looks like to the naked eye, i.e., the difference between healthy and dead tissues, purulent vs serous drainage, discerning artery/vein/nerve.

 

[PieOHmy]

Easy: If he is fast, he is usually good. Very few fast bad surgeons.

Some surgeons you barely know they are in the room. Thast another sign.

Surgeons who dont fuss too much.

 

[kb1900]

Easy: If he is fast, he is usually good. Very few fast bad surgeons.

Some surgeons you barely know they are in the room. Thast another sign.

Surgeons who dont fuss too much.

This + the anesthesiologists typically know a lot about the different surgeons

 

[CyrilFiggis]

We always new our OR schedule for the week ahead of time. Read up on the surgical procedure. Get to the OR early and write the steps on the board. You’ll be able to understand the surgeons proficiency with regard to the science of it. The speed and smoothness of his hands with tell you his proficiency with regard to the art of surgery.

 

[Angus Avagadro]

Any surgeon who makes the operation look so easy that even YOU could do it.

 

[zero0]

The surgery rotation should be more of a humbling experience than educational in any real sense of the word. You learn how to deal with surgeons and attendings in general. They'll say things that are flat out wrong sometimes, like that amylase is a better indicator of pancreatitis than lipase 🙄 and you just kind of have to suck it up and don't argue. Just Google it real quick later to confirm you are right and move on. The only real learning in surgery happens on the floors.

My experience mostly comes from the other side of the drape but I've noticed the best surgeons don't talk as much and are generally liked. They plan for things and don't let stupid crap happen, like breaking the tip of a bovie off during an arthroscopy and losing it in the joint. You can always just ask the anesthesiologist, they'll tell you who's good and who sucks.

 

[Dr G Oogle]

Any surgeon who makes the operation look so easy that even YOU could do it.

this is pretty much it. If it you are doing Something with a surgeon and you feel like you’re the one doing it and it’s going well that’s a good surgeon. Same if there is a resident and it looks like they are doing most of the case then that is a good surgeon.

 

[efle]

Comparison to trainees was the dead giveaway. You watch the attending on the DaVinci robot and think "wow, robotics makes this surgery so smooth and easy!."

Then you watch the PGY-3 get on and fumble around a while and realize it wasn't the robot, it was a gifted surgeon.

 

[allantois]

What’s the OR staff saying about surgeon

 

[IMG69]

When they're more worried about the playlist than the surgery.

 

[ndafife]

When he or she is doing surgery on people who work at the hospital

 

[Neopolymath]

When he or she is doing surgery on people who work at the hospital in the OR

Spent several years in the OR before school and then rotated with some of the same docs. My opinion hasn't really changed even as my experience has grown. It becomes very apparent who is safe, good +- fast, who is straight up incompetent, and who is slick.

 

[anbuitachi]

ask the anesthesiologist

 

[Engrailed]

ask the anesthesiologist

can you elaborate???

 

[anbuitachi]

can you elaborate???

anesthesiologists are the only other MD in the operating rooms with these surgeons working with them day and night week after week. anesthesiologists know which surgeons are slow, which have more complications, which surgeons do poorly under stress, etc

 

[Engrailed]

anesthesiologists are the only other MD in the operating rooms with these surgeons working with them day and night week after week. anesthesiologists know which surgeons are slow, which have more complications, which surgeons do poorly under stress, etc

Thank you!!! 😍

 

[OrthoTraumaMD]

Easy: If he is fast, he is usually good. Very few fast bad surgeons.

Some surgeons you barely know they are in the room. Thast another sign.

Surgeons who dont fuss too much.

Fast doesn’t necessarily equal good. A person could do a half-a$$ job in 30 minutes or a perfect job in an hour. A careful surgeon takes the time to get things done right.

 

[anbuitachi]

Fast doesn’t necessarily equal good. A person could do a half-a$$ job in 30 minutes or a perfect job in an hour. A careful surgeon takes the time to get things done right.

agree with this. but also depends on how long we are talking about here. spending 2x the time on a 30 min case is probably not a big deal. spending 2x the time on a 10 hour flap might be.

 

[dpmd]

Fast doesn’t necessarily equal good. A person could do a half-a$$ job in 30 minutes or a perfect job in an hour. A careful surgeon takes the time to get things done right.

This is universally going to factor in to how non surgeons rank surgeons though. Had a mentor that told me not to waste time (like struggling to use the last bit of a suture rather than opening a new one or similar) and to be cognizant that my reputation would be based partially off this early on and he was 100% right. I am not doing half ass jobs but I am fairly fast and I am considered better than my slower colleagues even though having worked with them I think they are fine surgeons. If you rely upon referrals, then trying to be quicker can be helpful (though there are of course other factors)

 

[OrthoTraumaMD]

agree with this. but also depends on how long we are talking about here. spending 2x the time on a 30 min case is probably not a big deal. spending 2x the time on a 10 hour flap might be.

I agree with that.

 

[fleetfox]

I don't know about asking the OR staff or the anesthesiologist. They might have accurate perceptions about some outlier surgeons that struggle with every case. But generally speaking, they have little to no idea what's going on during these cases.

Every surgeon will tell you that when you are just starting out as a new attending, it's a lonely feeling when you run into an intra op complication, look around the room and realize nobody besides you has a clue as to what is going on during the case.

If you're fast, confident, friendly, and don't seem to struggle regularly, they'll think you're a good surgeon. Your reductions and x-rays and outcomes can be trash and they won't have a clue.

Don't get me wrong - all else equal, it's good to be efficient and you should treat everyone decently, but it's not what makes a good surgeon.

 

[Wordead]

Seriously anesthesia? They have zero idea whats happening the vast majority of the time much less whos a good surgeon. Only reliable indicator is another surgeon in their field.

And there are a lot of fast bad surgeons.

 

[Angus Avagadro]

OR staff watch people operate for a living. If you think they have no clue what they are watching or how long a particular surgeon takes to complete a surgery, you are mistaken. They see all the revisions and complications too . Critiquing the pin placement may not be in their wheelhouse, but they absolutely know who they would want to take care of their families.

 

[Radetzky]

The idea that you as a medical student can easily tell which non-surgical doctors are good or bad is completely arrogant.

Being a good surgeon is about patient selection. Most surgeons are pretty darn good. But there are technically gifted surgeons who cause more harm than good by operating on the wrong patients and there are those who don’t stand out technically but always have exceptional judgement.

As for the technically gifted part, you can’t know unless you are also a surgeon. Ask their fellow surgeons.

 

[dpmd]

The idea that you as a medical student can easily tell which non-surgical doctors are good or bad is completely arrogant.

Being a good surgeon is about patient selection. Most surgeons are pretty darn good. But there are technically gifted surgeons who cause more harm than good by operating on the wrong patients and there are those who don’t stand out technically but always have exceptional judgement.

As for the technically gifted part, you can’t know unless you are also a surgeon. Ask their fellow surgeons.

Yeah, this sort of got glossed over but struck me as a weird thing to claim.

 

[anbuitachi]

Seriously anesthesia? They have zero idea whats happening the vast majority of the time much less whos a good surgeon. Only reliable indicator is another surgeon in their field.

And there are a lot of fast bad surgeons.

i dont know about this. every surgeon i see seems to think they are the best surgeon which cant be all true.

like people below said, its not just about speed. the anesthesiologist is in the OR all day long, working with different surgeons all the time. sure they might not how amazing you are in clinic, but they see who has more take backs, more complications, who is slow but good , who is fast but bad, who is fast and good. furthermore, anesthesiologists and surgeons dont always have the worst relationships. they talk. residents talk as well. they might not be able to tell whos at the 60th percentile vs 70th, but they can tell you who sucks.

 

[DarkHorizon]

The idea that you as a medical student can easily tell which non-surgical doctors are good or bad is completely arrogant.

Being a good surgeon is about patient selection. Most surgeons are pretty darn good. But there are technically gifted surgeons who cause more harm than good by operating on the wrong patients and there are those who don’t stand out technically but always have exceptional judgement.

As for the technically gifted part, you can’t know unless you are also a surgeon. Ask their fellow surgeons.

Agreed, surgery is the easy part. By the time most surgeons finish training, they are pretty competent. Sure, keep getting better. But it’s the decision to operate and having the right indications that distinguishes good from mediocre. Also matters for outcomes, ultimately it doesn’t matter how quickly you did the surgery or how slick you were, a good outcome is ultimately what matters.

 

[OrthoTraumaMD]

If you're fast, confident, friendly, and don't seem to struggle regularly, they'll think you're a good surgeon. Your reductions and x-rays and outcomes can be trash and they won't have a clue.

100% true.

 

[OrthoTraumaMD]

OR staff watch people operate for a living. If you think they have no clue what they are watching or how long a particular surgeon takes to complete a surgery, you are mistaken. They see all the revisions and complications too . Critiquing the pin placement may not be in their wheelhouse, but they absolutely know who they would want to take care of their families.

Most really do have no clue what they are watching. I’ve literally done the same surgery and gotten the same questions about it from the staff as if they’d never seen it before because I changed one minuscule part of the plan.

 

[Angus Avagadro]

Most really do have no clue what they are watching. I’ve literally done the same surgery and gotten the same questions about it from the staff as if they’d never seen it before because I changed one minuscule part of the plan.

I think OPs basic question really can't be answered well in a general way. Only another surgeon can effectively judge another surgeon with respect to their work, and that is tricky too. Correct diagnosis, plan, knowing where to make the incision, efficiency of time, skill, all factor into an optimal result for the patient. My OR colleagues know of a past Ortho Chief at a top 10 program who was pleasant, fast, and obsessed with surgical time and turnover. 20 min for a first time total hip replacement. My friends noticed that orthopedist further down on the department letterhead, would end up doing the hip revisions later. So pleasant,fast, and sloppy although rare, is not always the best. More commonly, pleasant and slow occurs, placing the patient at risk for complications from anesthesia and prolonged environmental wound exposure in the OR.
To sum up,IMO, a good surgeon has the clinical acumen to .make the correct diagnosis, formulate the optimal plan, have the skill to execute the plan efficiently, and follow up with optimal post op care. This would be the surgeon I would pick for my family.

 

[Detective SnowBucket]

"End diastolic volume decreases in systolic heart failure"

If the above statement is false, and was in fact stated by an instructor, that's grounds to start double checking. Nothing about them being a bad physician.

The idea that you as a medical student can easily tell which non-surgical doctors are good or bad is completely arrogant.

 

[Isoval]

If the patient wakes up and isn't dead or otherwise has avoidable morbidity.

 

[Wordead]

OR staff watch people operate for a living. If you think they have no clue what they are watching or how long a particular surgeon takes to complete a surgery, you are mistaken. They see all the revisions and complications too . Critiquing the pin placement may not be in their wheelhouse, but they absolutely know who they would want to take care of their families.

OR Staff watch and have no idea why we're doing what we're doing. I cant count how many times our ENT anesthesiologist with 20+ years of experience (and that I would trust with any airway) or our ENT scrubs who've been there forever ask questions that demonstrate just fundamental lack of understanding of what's happening. How long a surgeon takes to do surgery is a horrible indicator - plenty of the community guys will cherry pick easy cases and send the disasteromas over. Their operative time is faster and complication rates are lower - would you count them as better surgeons? No way.

i dont know about this. every surgeon i see seems to think they are the best surgeon which cant be all true.

like people below said, its not just about speed. the anesthesiologist is in the OR all day long, working with different surgeons all the time. sure they might not how amazing you are in clinic, but they see who has more take backs, more complications, who is slow but good , who is fast but bad, who is fast and good. furthermore, anesthesiologists and surgeons dont always have the worst relationships. they talk. residents talk as well. they might not be able to tell whos at the 60th percentile vs 70th, but they can tell you who sucks.

They may be able to tell you who sucks but doubt they can tell who's good. See above about complications/takebacks and cherry picking easy cases.

 

[OnePunchBiopsy]

Regarding the notion of OR staff as a resource, they may not have the knowledge to provide well-rounded criticism of a surgeon's technical capabilities, but they can definitely tell you who the dinguses are.

 

[Detective SnowBucket]

OR Staff watch and have no idea why we're doing what we're doing. I cant count how many times our ENT anesthesiologist with 20+ years of experience (and that I would trust with any airway) or our ENT scrubs who've been there forever ask questions that demonstrate just fundamental lack of understanding of what's happening. How long a surgeon takes to do surgery is a horrible indicator - plenty of the community guys will cherry pick easy cases and send the disasteromas over. Their operative time is faster and complication rates are lower - would you count them as better surgeons? No way.



They may be able to tell you who sucks but doubt they can tell who's good. See above about complications/takebacks and cherry picking easy cases.

Even if they have no idea what to look for, if they work with the same group of surgeons for long enough, whats to prevent them from determining complication rate? That's a really great point about sending off difficult cases, but if they work with the same surgeons long enough, wouldn't they know who's best at one operation vs another? Not necessarily overall.

 

[Wordead]

Even if they have no idea what to look for, if they work with the same group of surgeons for long enough, whats to prevent them from determining complication rate? That's a really great point about sending off difficult cases, but if they work with the same surgeons long enough, wouldn't they know who's best at one operation vs another? Not necessarily overall.

Do you think they could tell if a surgeon took shortcuts and say left thyroid behind in a cancer case (because the radioactive iodine will take care of it), or the difference between a complete neck dissection and a half assed one that left half the nodes behind? Which do you think would be faster? Which is more likely to have complications?

 

[Dr G Oogle]

Even if they have no idea what to look for, if they work with the same group of surgeons for long enough, whats to prevent them from determining complication rate? That's a really great point about sending off difficult cases, but if they work with the same surgeons long enough, wouldn't they know who's best at one operation vs another? Not necessarily overall.

they’d only be able to see intraop complications which are pretty limited to iatrogenic injury (fairly rare with a modicum of competence) or bleeding; won’t know anything about post course not even while Patient is still in house not to mention readmits, infections, crappy reconstructive outcomes or positive margins etc. The idea that anesthesia can tell more than the most superficial assessment is similar to a surgeon saying they can judge an anesthesiologist by how quick room turnover, induction speed etc is.

 

[operaman]

I thought of a possible answer the other day:

The good surgeon is the one other surgeons - especially in the same department - ask to join them for particularly tough cases. It’s not a foolproof method, but so far seems fairly predictive.

The asshats seem to declare themselves and not get asked back quite so often.

 

[VincentAdultman]

You know.

 

[OrthoTraumaMD]

I think OPs basic question really can't be answered well in a general way. Only another surgeon can effectively judge another surgeon with respect to their work, and that is tricky too. Correct diagnosis, plan, knowing where to make the incision, efficiency of time, skill, all factor into an optimal result for the patient. My OR colleagues know of a past Ortho Chief at a top 10 program who was pleasant, fast, and obsessed with surgical time and turnover. 20 min for a first time total hip replacement. My friends noticed that orthopedist further down on the department letterhead, would end up doing the hip revisions later. So pleasant,fast, and sloppy although rare, is not always the best. More commonly, pleasant and slow occurs, placing the patient at risk for complications from anesthesia and prolonged environmental wound exposure in the OR.
To sum up,IMO, a good surgeon has the clinical acumen to .make the correct diagnosis, formulate the optimal plan, have the skill to execute the plan efficiently, and follow up with optimal post op care. This would be the surgeon I would pick for my family.

Agree with your last paragraph for sure!

 

[mehc012]

I thought of a possible answer the other day:

The good surgeon is the one other surgeons - especially in the same department - ask to join them for particularly tough cases. It’s not a foolproof method, but so far seems fairly predictive.

The asshats seem to declare themselves and not get asked back quite so often.

This is a good metric. I don't think it weeds out asshats as well as you'd think, though. We've definitely called in experts who stopped by the OR and salvaged a bad situation...while literally throwing instruments and being pretty jerk-y.

 

[dpmd]

This is a good metric. I don't think it weeds out asshats as well as you'd think, though. We've definitely called in experts who stopped by the OR and salvaged a bad situation...while literally throwing instruments and being pretty jerk-y.

The incompetent asshats get weeded out. The ones who do a good job I would prefer over the pleasant incompetent surgeon

 

[mehc012]

The incompetent asshats get weeded out. The ones who do a good job I would prefer over the pleasant incompetent surgeon

Fortunately, it IS possible to find socially AND surgically competent humans. #lifegoals

 

[dpmd]

Fortunately, it IS possible to find socially AND surgically competent humans. #lifegoals

I like to think I fit that.

 

[anbuitachi]

OR Staff watch and have no idea why we're doing what we're doing. I cant count how many times our ENT anesthesiologist with 20+ years of experience (and that I would trust with any airway) or our ENT scrubs who've been there forever ask questions that demonstrate just fundamental lack of understanding of what's happening. How long a surgeon takes to do surgery is a horrible indicator - plenty of the community guys will cherry pick easy cases and send the disasteromas over. Their operative time is faster and complication rates are lower - would you count them as better surgeons? No way.



They may be able to tell you who sucks but doubt they can tell who's good. See above about complications/takebacks and cherry picking easy cases.

Examples of stupid questions that lack fundamental understanding? I came from a huge hospital that does frequent flaps that last 8 to 12 hours. Few years ago I changed hospitals and the ent flaps regularly last 15 to 24 hours with frequent takebacks. I get everything not in your field should be taken with a grain of salt but at least it's a bad sign to me. It's also why I said talking to residents in the field who work with all their surgeons is a good way. In this case I talked to the ent chief resident who said he is just very slow. Plus the fact that he has take backs leads me to not want to go to him when I get my flap

 

[operaman]

Examples of stupid questions that lack fundamental understanding? I came from a huge hospital that does frequent flaps that last 8 to 12 hours. Few years ago I changed hospitals and the ent flaps regularly last 15 to 24 hours with frequent takebacks. I get everything not in your field should be taken with a grain of salt but at least it's a bad sign to me. It's also why I said talking to residents in the field who work with all their surgeons is a good way. In this case I talked to the ent chief resident who said he is just very slow. Plus the fact that he has take backs leads me to not want to go to him when I get my flap

The takeback rate may be relatively good indicator but the timing may not.

For example, in free flaps much depends on the infrastructure as well as the flap choice. We commonly do free flaps in under 6- 8 hours but that’s only on certain cases with certain flaps and with 2 surgeons so one raises while the other resects. Take the same surgeons and make it something like a scapula flap where you can’t raise simultaneously and now you’ve nearly doubled your time. We are able to do a lot of forearms that would usually need scaps or fibulas because we have an Ortho hand guy harvest the bone and he can take ridiculously long segments. Lots of random things like that can have a big impact on times. I think our attendings are great and fast but drop one in a less optimized environment and their times would be much longer.

That said, 24 hour flaps should be rare. I just can’t imagine what you’re doing during that time unless you’ve had a tenuous or failed flap, the worst chasing margins ever, or the most ocd person ever doing the inset. If someone is regularly that far outside the box it can be a powerful indicator.

 

[dpmd]

The takeback rate may be relatively good indicator but the timing may not.

For example, in free flaps much depends on the infrastructure as well as the flap choice. We commonly do free flaps in under 6- 8 hours but that’s only on certain cases with certain flaps and with 2 surgeons so one raises while the other resects. Take the same surgeons and make it something like a scapula flap where you can’t raise simultaneously and now you’ve nearly doubled your time. We are able to do a lot of forearms that would usually need scaps or fibulas because we have an Ortho hand guy harvest the bone and he can take ridiculously long segments. Lots of random things like that can have a big impact on times. I think our attendings are great and fast but drop one in a less optimized environment and their times would be much longer.

That said, 24 hour flaps should be rare. I just can’t imagine what you’re doing during that time unless you’ve had a tenuous or failed flap, the worst chasing margins ever, or the most ocd person ever doing the inset. If someone is regularly that far outside the box it can be a powerful indicator.

I wonder if the resection of the complex tumor plus radical neck dissection followed by a break where the team changes to the flap folks is the culprit for the length.

 

[Wordead]

Examples of stupid questions that lack fundamental understanding? I came from a huge hospital that does frequent flaps that last 8 to 12 hours. Few years ago I changed hospitals and the ent flaps regularly last 15 to 24 hours with frequent takebacks. I get everything not in your field should be taken with a grain of salt but at least it's a bad sign to me. It's also why I said talking to residents in the field who work with all their surgeons is a good way. In this case I talked to the ent chief resident who said he is just very slow. Plus the fact that he has take backs leads me to not want to go to him when I get my flap

As stated above there's a fair bit of variance. If we whack out a big mass in the neck and throw some soft tissue up there sure we can be done in sub 8 hours. If we end up doing bony work with a difficult inset it can take 16 or 24 or whatever. At our county hospital there's a lot more vasculopaths and bombed out necks than at the mothership. I do think most of our H+N guys at main campus are better but I dont think it's an apples to apples comparison and going by timeline you'd be judging the wrong things. At the county hospital also we have inconsistent scrubs so whereas at main campus all the equipment is set and the circulator knows exactly what positioning needs are, our head and neck anesthesiologist gets them under fast and keeps them down, we waste a ton of time at county because we are missing 30 pieces of equipment every case, we dont roll into the room until 30 mins past start time, the scrub is trying to hand you some crazy ass instrument from like an ortho tray, and the patient is getting off the table half the case cuz anesthesia sucks. It all adds up. It's not that the surgeon is terrible.

Also at the county hospital residents have greater autonomy. Yes, it takes me probably an hour longer than my attendings to do a neck dissection. Probably 30 mins longer to isolate vessels for anastamosis. I screw up a lot more often. But I can do a case skin to skin at county vs at main Im just doing parts with the attending guiding everything so it's substantially faster.

So again, you may have a lot of experience but you really dont have a grasp of subtleties. It's not a knock on anesthesia itself, just that it's not possible for someone outside the field to really understand.

 

[anbuitachi]

As stated above there's a fair bit of variance. If we whack out a big mass in the neck and throw some soft tissue up there sure we can be done in sub 8 hours. If we end up doing bony work with a difficult inset it can take 16 or 24 or whatever. At our county hospital there's a lot more vasculopaths and bombed out necks than at the mothership. I do think most of our H+N guys at main campus are better but I dont think it's an apples to apples comparison and going by timeline you'd be judging the wrong things. At the county hospital also we have inconsistent scrubs so whereas at main campus all the equipment is set and the circulator knows exactly what positioning needs are, our head and neck anesthesiologist gets them under fast and keeps them down, we waste a ton of time at county because we are missing 30 pieces of equipment every case, we dont roll into the room until 30 mins past start time, the scrub is trying to hand you some crazy ass instrument from like an ortho tray, and the patient is getting off the table half the case cuz anesthesia sucks. It all adds up. It's not that the surgeon is terrible.

Also at the county hospital residents have greater autonomy. Yes, it takes me probably an hour longer than my attendings to do a neck dissection. Probably 30 mins longer to isolate vessels for anastamosis. I screw up a lot more often. But I can do a case skin to skin at county vs at main Im just doing parts with the attending guiding everything so it's substantially faster.

So again, you may have a lot of experience but you really dont have a grasp of subtleties. It's not a knock on anesthesia itself, just that it's not possible for someone outside the field to really understand.

none of those are subtleties. no one is judging from one surgery or from one experience. and no one is saying we are 100% absolutely certain about a surgeon sucking. i would argue that some of what you mentioned reminds me of a surgeon mentality that i often hear. "my patients are sicker", "i take more complicated cases" , 'my equipment sucks'. as if those things do not happen in other hospitals.

not having equipments causing delay in starting the case doesnt even count since thats not surgical time.

and i was just using flaps as an example. maybe it wasn't the best example since its a complicated surgery. but the point is anesthesiologists often have a pretty good idea of which surgeon sucks because they are in the OR way more than any of you, and they work with every surgeon and they are also MD so they aren't as dumb as surgeons think they are. you can use your subtleties argument in a n=1 scenario but when the n is large, and a surgeon tries to justify their crappiness with their patients are super sick and complicated and the equipment sucks, most of the time i call BS