Quoted: Question for faculty supervising surgeons

[NotAProgDirector]

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I have a sixth year (chief resident) that I recently started operating with at my off university campus hospital.
His surgical skills are not up to par with previous residents at this level. Specifically, he can't assist and seems to only be able to do a case the way he has seen it done previously. Things that seem obvious to us such as sucking blood where you are working or retracting tissue to help me see what I am doing just escape him. All I know how to do is tell him what to do a couple of times... show him how to retract, create space and visualization a couple of times and then I start getting frustrated. I don't know how to teach what seems intuitive and I can't remember how I learned to do this.

He gets flustered if I try to do a case in a way that he hasn't seen... as if it just can't be done that way. Not much that I do in the OR is something that I made up and I gleaned all my techniques from different excellent surgeons.
Like most of us, I don't want him to teach me how to do the operation the way he knows how. I do learn things from residents and try some things they occasionally suggest but after 10 years as a staff I think I have a pretty good track record of results doing it the way I know.

Although, I like him personally, he brings this negative energy, doubt, second-guessing and general buzz kill to the OR so I dread operating with him. I can do all of my operations with a tech so I don't need him from my end but I would like to be a good teacher. Honestly, I would rather operate with the 3rd year resident who will just do as I ask whether it is to cut here, suck there, retract this, etc.

I have been teaching residents for 9 years and 70% of my historical cases I have had a resident working with me. This situation has me stumped and I am interested in advice. I am thinking about just not operating with him. I work with other surgeons who are not exactly thrilled with his skills but I could use some outside anonymous help. Fish or cut bait with this guy?

Thanks

I'm not a surgeon, but I'll still see if I can help. I think the real crux of your problem is this: Do you simply not like working with him, or is he not a competent surgeon?

He's a chief resident, and many surgical chiefs are treated similarly to faculty. He may just be headstrong and want to do surgery his way. I agree that it's his loss not to learn new surgical techniques from you, as you never know when they may come in handy. Perhaps his interpersonal skills are not that great (which, present company aside, is not uncommon in some surgeons). If he doesn't want to do it your way, wants to do it his way, and his way is safe and effective, then he's just a PITA and you're best avoiding him.

On the other hand, your post suggests that it's more than this, and that in fact he might not be competent. If so, you cannot simply get out of the way. Somebody should have dealt with this a long time ago, as it will be difficult to deal with as a chief.

In any case, a conversation with his PD seems in order.

 

[Go Ducks]

I know nothing about what you should do, but I think that I might have some insight into this guy's problem. I've worked with people in the OR and one person who I worked with sounds a lot like this guy. The underlying issue, from my perspective, was that he could not ever see the big picture. To compensate for this disability, he was very protocol-oriented. If someone used a new protocol, he got flustered. If he had to assist, which requires you to look at the big picture so you can fill in where you are needed and anticipate the surgeon's needs, he got flustered. If something unexpected happened that forced him to deviate from the protocol, he got flustered. Because he was constantly following mental protocols, he hyper-focused on one thing at a time, which also didn't help his assisting skills.

How do you teach someone to see the big picture? This beats me. I used to teach math to adults, and some of my students could see the "big picture" and think outside the box to solve problems, but others could not, no matter how hard they tried and studied. Those that couldn't see the big picture had to rely entirely on memorizing practice problems (or, in a way, protocols). Thinking about it now, I can see clear similarities between the doctor and those math students.

Just to let you know, the doctor I worked with had far less experience than your resident.

 

[Doodledog]

From the OP

thank you.
I do like him personally to talk with etc. I just don't like the negativity and second guessing and inflexibility in the OR. Most other residents can express their opinion or how they have seen things done or their preferences without irritating the crap out of me.
I am sure I am not the only one to feel this way.
I feel it is almost like high school student who graduates and can't read.... people just promote them because they don't want to deal with holding them back. It is a big loss to the system if you kicked him out from a man power system.

I just don't know how to change this guys skills and thought process. He doesn't seem to know how to stop bleeding either... he doesn't comprehend getting exposure and control in that situation.

 

[Doodledog]

One last post from the OP...

BTW, I agree with Ducks, this is a common problem.

thank you ducks.
that is new and interesting perspective.
i guess I could have the big picture talk with him and gently say he needs to big picture the concept.
as the chief he is now going to be doing big cases almost daily and there is no where to hide. skill limitations are going to be exposed and it is sink or swim. I think as a junior resident you can hide defects more easily as the staff doesn't expect you to do as much.

 

[lowbudget]

Not a surgeon, but I found this thread interesting. A part of me wonders, like others above, if he is inflexible, detail oriented (in a very obscessive-compulsive personality disorder kinda way) or if this is a normal part of group dynamics (as seen when I reread the OP that said "recently started).

I remember this one concept from an organizational management class about the lifecycle of groups working together: forming, storming, norming, performing, adjourning. Pretty stupid mneumonic if you ask me, but sounds like you might be in the storming phase. At some point, with a little communication, it's possible that you two will find a middle ground (norming) and start operating well (performing). Maybe better days are ahead and you simply need some time?

That said, if it were me, I would simply address the affect. Sounds like you have a good rapport with the chief. How about: "Hey, can I ask you a question? And this is just between you and me. I've been observing how we work in the OR and noticed that there are times when you seem a little flustered or unsure. Is there something on your mind about how we operate? Is there something we're doing that's different from how you've learned it in the past?"

I think for me, as a recent grad, I would appreciate it if a mentor approached me this way (instead of my PD). Because in my mind, I may have an idea of how things should go; but my limited experience precludes my understanding of the range of acceptable approaches that in trying to figure out what's going on on the detailed step-by-step, I miss the big picture of what we're trying to accomplish. I think you'll find out quickly if this is a matter of inexperience or a matter of OCPD (which, by definition, is fixed and the person has no insight into it).

 

[dragonfly99]

I think I agree with lowbudget. I'm not a surgeon either, but I'm a medicine subspecialty fellow. I know that I'd rather be approached by a faculty member directly, hopefully in a nonconfrontational way, rather than have the PD bring up some problem that someone complained about. Once you go to the PD, you've pretty much made it a disciplinary issue where the chief is a "bad" resident and you're instigating some sort of disciplinary action against him, either unofficial or official. It seems like you don't feel that he's a total a-- in general and is OK to get along with outside the OR. You could just mention that you think it is important to learn to do operations in different ways, since now that he's higher up in the food chain he is going to have different things thrown at him that maybe he'll have to approach sometimes in nonstandard ways. Also, you could mention about the importance of "seeing the big picture" but unless you give him more specifics about how to go about "seeing the big picture", not sure how helpful that will be...do you mean seeing the whole operative field, or just integrating everything (like the patient's vitals, the progress of the operation with expected vs. unexpected findings, etc.)?

 

[azzarah]

Ophthalmology is a little different, but do you think sitting down with this chief resident to go over how you like things done in your OR maybe helpful?

When I operate with the residents, I like to sit down with them or go to the wetlab ahead of time and go over why I do things a certain way, my general thought process/approach, and what I expect from them, etc.

The other thing, I wonder if he is getting nervous around you. As a resident, there was this particular attending that for some reason made us all so nervous. He was the nicest person ever and not by any means intimidating, but every time I operated with him, my surgical skills deteriorated.

I personally think that before bringing anything up with the program director, you should have a talk with him. If his surgical skills are so horrible that you feel he should not graduate, then that's the only time I would discuss with the PD.