What makes a surgeon excellent?

[ekimsurfer]

After seeing countless surgeries, talking with surgeons, and studying a little medicine (MSII), my question is, What makes a surgeon excellent? I believe it to be an artform which lends the question; Is it the technical/physical precision that he/she has? The firm grasp on the pathogenesis/pathophys behind the disease? What makes one surgeon more highly regarded than others among his/her peers? Another post said knowing the medicine behind the procedures and knowing when to do them and when not to...There's got to be more than that.

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[Winged Scapula]

Like most things in life, its multifactorial and what is important to one group, is not so much to others.

For example, OR staff often think they have a good idea of who is a good surgeon and who isn't. But IMHO, those decisions are based on the surgeon:

1) whom finishes on time or even early
2) whom treats the OR staff nicely
3) whom seems to be fluid and doesn't struggle
4) whom makes a nice looking wound

For colleagues (ie, other surgeons), a good surgeon is a combination of:

1) technical prowess
2) availability
3) work ethic (ie, if a case needs to be done, he/she does it rather than leave it for the next person on call)
4) knowledgeable
5) sense of "doing the right thing"

For non-surgical colleagues (ie, referring physicians), a good surgeon is one who:

1) is available (how fast can you see their patients)
2) takes insurance
3) manages complications
4) makes patients happy

Patients look for:

1) availability
2) the surgeon who takes their insurance
3) the surgeon whose office is near their home
4) a nice office staff
5) nice looking scar without lots of complications
6) prestige factor - ie, department chair, went to Harvard, etc. (important for a subgroup of patients)

I've known some surgeons who were technically good, but indecisive or had bad BS manner: I wouldn't necessarily call them good surgeons. If they were the only choice in town, that would be a different story (calling to mind the often held argument that you want the best technician not necessarily the nicest guy when it comes to your family needing an operation), but in most cases there are others who are as good or nearly as good technically but have better "other" attributes. I've also known nice guys who didn't have a lick of good clinical sense, so wouldn't necessarily call them good surgeons. And finally, I've also seen surgeons who have ascended to a high rank (ie, department chair) that seem to violate general surgical principles (marking margins, sending frozen sections, placing drains, etc.) so would not call them good surgeons...technically they may be good but they fail for mismanaging the patient.

IMHO, a good surgeon is one who exploits their strengths and works on improving their weaknesses. For example, I may be average technically but I have strengths that other surgeons do not.

 

[ekimsurfer]

Thanks...great reply...I thought I was going to have to wait for the immature remarks about treating the nurses some way...or being arrogant...etc. Thanks for the post. Now I have something to strive for.

 

[Winged Scapula]

Despite claims here and elsewhere, you do not have to be arrogant to be a surgeon.

But you also cannot be a doormat. When something goes wrong that could potentially hurt your patient, you have to address it with the person making the mistake. It can be hard, especially as a woman, to find the line btwn being assertive and being abrasive. I would expect nothing less from any physician, surgeon or no.

I had the unfortunate experience this past Friday of having to call an attending on another service to ask why he had made a decision about my patient which affected the surgical plan, which he knew, without informing ME. The answer, "I didn't have time" was unacceptable to me. I find that expressing my anger is difficult , so I have crafted a statement which I use in those situations and it allows me to express myself without using bad words or name calling, making it clear I am angry but not losing control. I apologized to those who heard my conversation with this person but sometimes being the best surgeon means doing what is right for your patient and that may mean reading the riot act to someone who is getting in the way of that.

Sorry for the digression (I am still mad about the incident...).

 

[filter07]

What makes a surgeon excellent is an unceasing drive to be the most badass mofo the world has ever known, and having the confidence to do the most badass stuff that would make everyone else's scrotum shrivel in fear. It is someone who knows more than anyone else and can do things that no one else can do, because they have read more, studied more, practiced more, and pushed the boundaries more than anyone else. There is no shortcut to being an excellent surgeon and the vast majority of surgeons fall short.

 

[dynx]

I've also seen surgeons who have ascended to a high rank (ie, department chair) that seem to violate general surgical principles (marking margins, sending frozen sections, placing drains, etc.)

I get your point but you lost me on the example. Why can't you place a drain?

 

[Winged Scapula]

I get your point but you lost me on the example. Why can't you place a drain?

Sorry, I meant placing a drain when you SHOULD. The point was that I have seen highly ranked physicians (ie, department chairs) not manage patients according to the standard of care.

This would include removing surgical specimens without marking the margins, not placing drains at sites of likely seroma formation, at anastomoses, etc.

I was just thinking of things I had seen which were outside of current practice and wasn't clear in my description.

 

[Winged Scapula]

C**k size.

It might make him excellent, but not necessarily as a surgeon.😉

 

[teddybear]

arrogant

Did somebody call my name???

Just kidding. Seriously though what was the statement you use to express anger? I'd like to know.

 

[teddybear]

scrotum shrivel

I thought that was your face.

 

[teddybear]

C**k size.

guess that leaves you out.

 

[radslooking]

What makes a surgeon excellent is an unceasing drive to be the most badass mofo the world has ever known, and having the confidence to do the most badass stuff that would make everyone else's scrotum shrivel in fear. It is someone who knows more than anyone else and can do things that no one else can do, because they have read more, studied more, practiced more, and pushed the boundaries more than anyone else. There is no shortcut to being an excellent surgeon and the vast majority of surgeons fall short.

you're ridiculous. you might consider the fact that some people would run roughshod over you in real life, but don't particularly care to stand in the same spot for 10 hours and not take a piss.

 

[Chronic Student]

I think he was being sarcastic.

Back to the question.

Winged Scapula hit it right on the head. I worked in the OR for a long time and we judged a surgeon solely by his/her ability in the OR and to a lesser extent by how they treated us.

Floor nurses will judge you by how much you hassle them, if you're nice, etc. It boils down to different people judging you on different merits.

Now that I work for one I see how my view was just a small view of a much larger picture. In fact, I am now judged by OR folks in the same way. I assist (not very exciting or glamorous) and so they think thats all I do. One of the techs a few months back heard me presenting a patient to my doc that I had seen in the ER while he finished an operation. I ran down the exam and findings and she wanted to know what a homonymous hemianopsia was.

I explained it to her and she was impressed (even if I wasn't). She went on to say that she never thought about what we do outside the OR. They don't realize you have to do clinic, rounds, answer calls, do paperwork, etc., but I digress.

Gestalt is the word that comes to mind when I think of what makes a surgeon excellent. I have worked with surgeons who have excellent knowledge, but it does not come through to their hands and they can't operate their way out of a wet paper bag.

I have seen others (one who stated that he just barely made it through medical school) who have an incredible gift of feel and eye and are a true joy to watch.

The ones who impress me most are the ones who give a damn about their patients, who do the right thing even if its late, they are tired or whatever it is, is inconvenient and they do it anyway. They read and know their field in-depth and have an idea about what others do. They constantly refine their skills, do not accept mediocrity, treat others with respect and communicate with families and patients.

You know how many of those I've seen. n=0.

Over the years I have seen a few who are close. The thing is you will never make everybody happy and treating patients usually involves some compromises from the patient, consultants or things beyond your control. Perfection in something as complex as medicine is something to strive for and is rarely achieved.

OK, rant over.

 

[Winged Scapula]

Did somebody call my name???

Just kidding. Seriously though what was the statement you use to express anger? I'd like to know.

It varies somewhat and is rather HOW I say the statement rather than the statement itself.

I start off by repeating the problem as I understand it. And then I ask why X happened.

As the person I am speaking to starts to give me the answer, if I decide that it is BS, then I repeat my question. Over and over. I am like that 6 year old brother who used to play copycat except that I am doing it with myself.

So in the situation from last Friday, I simply kept repeating, "That is not an acceptable answer. Now please tell me again why I was not informed of X."

Its a bit robotic and passive aggressive but I find it helps me stay on point without losing it and frankly, drives the other person a bit nuts.

 

[BSN2DOC]

I was working with a nurse once and there was a resident surgeon in the room checking on his post-op patient. He did a very quick exam, washed his hands, and then left the room.

She turned to me and said "he is the type of surgical resident that is going to make an amazing surgeon!" She was being dead serious, so I turned to her and asked her why. She replied with, "because he washes his hands after touching the patient." I chuckled.

So apparently to be an excellent surgeon, all you have to do is wash your hands after touching a patient.

 

[Winged Scapula]

I was working with a nurse once and there was a resident surgeon in the room checking on his post-op patient. He did a very quick exam, washed his hands, and then left the room.

She turned to me and said "he is the type of surgical resident that is going to make an amazing surgeon!" She was being dead serious, so I turned to her and asked her why. She replied with, "because he washes his hands after touching the patient." I chuckled.

So apparently to be an excellent surgeon, all you have to do is wash your hands after touching a patient.

Woot!

Then I must be a super-duper excellent surgeon because I wash my hands before AND after touching a patient!

 

[teddybear]

Its a bit robotic and passive aggressive but I find it helps me stay on point without losing it and frankly, drives the other person a bit nuts.

sweet!

 

[teddybear]

 

[Miami_med]

They keep an extra mayo stand in the OR for me to rest it on, so I think I'm good.

I want to know how you keep that thing sterile?

 

[Chronic Student]

I want to know how you keep that thing sterile?

They just wrap up his head and torso in Ioban.

 

[maceo]

What makes a surgeon excellent is an unceasing drive to be the most badass mofo the world has ever known, and having the confidence to do the most badass stuff that would make everyone else's scrotum shrivel in fear. It is someone who knows more than anyone else and can do things that no one else can do, because they have read more, studied more, practiced more, and pushed the boundaries more than anyone else. There is no shortcut to being an excellent surgeon and the vast majority of surgeons fall short.

it aint that hard dude... you are fooling yourself.. you described a world class athlete which is much harder to achieve than a surgeon

 

[roja]

WS has the right approach. Being combatitive, rude and basically acting like a tantrum throwing toddler might throw people off but it will garner little respect. If I saw WS using her line, I would have buckets more respect for her than if she started yelling and screaming.

Well respected because:
she is doing what is best for her patient, not her ego.
She is managing to find the fine art of putting someone in thier place and doing it in an elegant mature way.

From an ED standpoint, the surgeons I respect: (applys to any doctor really)
-knowledgable
-keep thier patients health/lives/etc as thier focal point, not thier ego
-recognize the importance of working with other specialties
-respect other specialists
-sense of humor


I'm sure theres more, but I need some coffee

 

[mterp45]

What makes a surgeon excellent is an unceasing drive to be the most badass mofo the world has ever known, and having the confidence to do the most badass stuff that would make everyone else's scrotum shrivel in fear. It is someone who knows more than anyone else and can do things that no one else can do, because they have read more, studied more, practiced more, and pushed the boundaries more than anyone else. There is no shortcut to being an excellent surgeon and the vast majority of surgeons fall short.

I hope to be this type of surgeon one day. 👍

 

[nonesuchgirl]

The ones who impress me most are the ones who give a damn about their patients, who do the right thing even if its late, they are tired or whatever it is, is inconvenient and they do it anyway. They read and know their field in-depth and have an idea about what others do. They constantly refine their skills, do not accept mediocrity, treat others with respect and communicate with families and patients.

You know how many of those I've seen. n=0.

Over the years I have seen a few who are close. The thing is you will never make everybody happy and treating patients usually involves some compromises from the patient, consultants or things beyond your control. Perfection in something as complex as medicine is something to strive for and is rarely achieved.

OK, rant over.

I know of one. 🙁

 

[gathaghar]

surgeon
A good surgeon is the one who knows what to cut,.............the better is the one who knows what not to cut........ the best one knows when not to cut ..................

 

[Virgil]

What makes a surgeon excellent is an unceasing drive to be the most badass mofo the world has ever known, and having the confidence to do the most badass stuff that would make everyone else's scrotum shrivel in fear. It is someone who knows more than anyone else and can do things that no one else can do, because they have read more, studied more, practiced more, and pushed the boundaries more than anyone else. There is no shortcut to being an excellent surgeon and the vast majority of surgeons fall short.

Throw in a sense of humor and I think we have a winner.

 

[tri]

What makes a surgeon excellent? QUOTE]

good absite scores (>95th %ile)
😉

 

[cbass1350]

What makes a surgeon excellent is an unceasing drive to be the most badass mofo the world has ever known, and having the confidence to do the most badass stuff that would make everyone else's scrotum shrivel in fear. It is someone who knows more than anyone else and can do things that no one else can do, because they have read more, studied more, practiced more, and pushed the boundaries more than anyone else. There is no shortcut to being an excellent surgeon and the vast majority of surgeons fall short.

well said

 

[jhonny depp]

See every surgeon can perform his surgeries and go away. An excellent surgeon is a one who demonstrates the anatomy clearly. Anyone can do a gastrectomy but the best surgeons would ligate the left gastric artery after demonstarting the coeliac axis. Anyone can close a perfortaed Duodenal ulcer, the best surgeon would demonstrate the Mayo's vein.
That's just a thought

 

[mrantarctica]

Like some of you have alluded to - i think being the best at anything is about balance. this means outstanding traits in a number of different things

1) Forget all this "Well, I'm a surgeon" nonsense. First and foremost, you are a human being - only AFTER that can you say you are anything else. The point of this is to illustrate that a surgeon MUST have a good way with people, and a way to put frightened patients/family at ease very quickly.

2) A surgeon must be technically astute. This means that they must have a good foundation of knowledge that is deep in their specialty, but broad enough to care for many types of patients, with other complex problems. Their knowledge must be up-to-date. They should have a wide variety of highly refined theater skills that have come from experience, having travelled widely and seen many different techniques, and the versatility to try many different approaches based on the situation at hand.

3) It goes without saying that a good surgeon should be a good teacher to his junior colleagues. The word Doctor comes from docere - meaning to teach. And surgeons are not exempt from this very important responsibility in our profession.

4) A good surgeon should push the boundaries in his field, and strive to establish the best practise of care for his patients. Having said that, a surgeon should not be reckless. They do say, after all, that there's only one thing worse than an incompetent surgeon - that is an incompetent surgeon with an imagination.

5) The humility to accept that mistakes will be made - and to accept when they have been made, and go back and rectify them as much as possible. Surgery is a high risk part of medicine. We don't do things by half measures. If you're in , you're in all the way - and you have to have the confidence to proceed, but also the intelligence to appreciate that nothing's perfect, and to have a backup plan if things go wrong - even if you are hot stuff with a gown on.

My 2 cents.

 

[Habeed]

I have to question some of your conclusions, here. A lot of you interpret "best" as being "good at everything" or "well rounded".

Winged Scapula names a set of traits that would make different sets of people think a surgeon was excellent. Not whether the surgeon were actually excellent. Filter07 states that an excellent surgeon must always be trying to be better....but presumably, a person who is short on talent might try their whole life and never be excellent. I've also seen "sense of humor" (I guess that a person who saves people left and right but can't make a joke isn't "excellent") or "demonstrates the anatomy" (I guess that it is more important to be able to show off textbook minutae than to actually fix the patient)

But, if I were a patient, or a fellow doctor, what really matters? Everything has tradeoffs....no one can be the best in the world at more than a few things. What would the number 1 surgeon in the entire world (the best surgeon) have as a characteristic?

The answer is : results. The best surgeon in the world would choose the best possible intervention for each patient (including not operating at all), and then would carry out that intervention with perfect technical skill. No more, no less. Each patient would have the best odds for gaining the most quality years of life gained.

The best surgeon might not teach anyone, or be a terrible teacher. Yet, I argue, he would still be the best.

The best surgeon might be a complete *******, or a total pushover. But as long as he or she got the staff to do their jobs, such annoying personality traits don't change reality.

Patients might hate the surgeons' beside manner....doesn't change anything, this surgeon is still the best.

Hospital administrators, medical boards, the entire world might hate this surgeon....but the reality is what it is. No other definition of "best" fits the bill.

I'm trying to create an extreme case here (obviously the best surgeon wouldn't stay the best for long if he couldn't get access to top notch staff and top notch operating equipment) to show that this question has a clear answer.

And one final comment : if such a person exists, statistics might not show it. You would have to have perfect knowledge (aka viewpoint of God) to actually determine who the "best surgeon" by my definition actually is.

I'm not meaning to be inflamatory : but the whole topic reminds me of various wishy-washy stuff in a recent ethics class. If this question was rephrased : "What makes an excellent golfer?" the answer is pretty cut and dried (hits the ball as few times as possible). The person that touches the ball the least is the best. A surgeon's job is to repair patients to extend their conscious time on earth. The surgeon that averages the longest times is the best (assuming identical patients). End of story.

 

[smq123]

But, if I were a patient, or a fellow doctor, what really matters? Everything has tradeoffs....no one can be the best in the world at more than a few things. What would the number 1 surgeon in the entire world (the best surgeon) have as a characteristic?

The answer is : results. The best surgeon in the world would choose the best possible intervention for each patient (including not operating at all), and then would carry out that intervention with perfect technical skill. No more, no less. Each patient would have the best odds for gaining the most quality years of life gained.

The best surgeon might not teach anyone, or be a terrible teacher. Yet, I argue, he would still be the best.

The best surgeon might be a complete *******, or a total pushover. But as long as he or she got the staff to do their jobs, such annoying personality traits don't change reality.

Patients might hate the surgeons' beside manner....doesn't change anything, this surgeon is still the best.

Hospital administrators, medical boards, the entire world might hate this surgeon....but the reality is what it is. No other definition of "best" fits the bill.

I'm trying to create an extreme case here (obviously the best surgeon wouldn't stay the best for long if he couldn't get access to top notch staff and top notch operating equipment) to show that this question has a clear answer.

And one final comment : if such a person exists, statistics might not show it. You would have to have perfect knowledge (aka viewpoint of God) to actually determine who the "best surgeon" by my definition actually is.

I'm not meaning to be inflamatory : but the whole topic reminds me of various wishy-washy stuff in a recent ethics class. If this question was rephrased : "What makes an excellent golfer?" the answer is pretty cut and dried (hits the ball as few times as possible). The person that touches the ball the least is the best. A surgeon's job is to repair patients to extend their conscious time on earth. The surgeon that averages the longest times is the best (assuming identical patients). End of story.

This is a highly simplistic view of the field of surgery.

A surgeon that gets the best "results" (i.e. the longest lifespan after a surgery) is then simply the best technician. But surgeon's aren't JUST technicians.

Surgeons are physicians who have the skill and training to use operative solutions to fix problems. And physicians have to do a LOT more than just get good "results." If you look at the Hippocratic Oath, physicians ARE supposed to be good teachers - they're supposed to pass their skills on to the next generation of physicians. Physicians are also supposed to respect patient autonomy - which might include being willing NOT to operate, and letting the patient die in peace.

And by saying that the surgeon's ability to interact with nursing and patients is "not important," you are ignoring the vital importance of both pre-op preparation and post-operative care. The actual technical aspect of the surgery is just one part of the entire equation. You could have done the most technically perfect Whipple or liver transplant in the world....but if you have $hitty SICU nurses who don't keep a close watch on your patient, then your patient may still have a bad outcome. And while that doesn't reflect poorly on your technical skill as a surgeon, it still affects your patient's outcome.

And, obviously, none of the other definitions proposed by surgeons and surgical residents have been "cut and dry." That's because medicine, unlike golf and sports, is NOT cut and dry. If you think it is, you still have a lot to learn.

 

[Habeed]

ok, call it "best technician". I still argue that the person with the best technical skills would be "better" than someone with lesser technical skills who was good at teaching, bedside manner, and leadership.

Let me rephrase : if a surgeon had the best technical skills but was merely adequate or even below average in these other traits, that surgeon would be the most "excellent" surgeon in the world.

 

[Winged Scapula]

ok, call it "best technician". I still argue that the person with the best technical skills would be "better" than someone with lesser technical skills who was good at teaching, bedside manner, and leadership.

And I would argue the exact oppposite.

smq gets it. Surgeons are more than technicians. We spend a lot of time training how to be good surgeons and that includes not only technical skills, but problem solving, peri-operative management and yes, just all around good physician skills.

Technical skills, by and large, do not vary widely. Its a bell curve with very few practitioners at either end; thus give me the technically good surgeon who is skilled at teaching, bedside, manner, problem solving and leadership over the skewed to the right surgeon who has none of those qualities.

The flaw in your argument is that you fail to realize, as smq notes, that a technically perfect operation may fail because of issues outside of your control.

An additional flaw in your argument is that there is NO evidence that a "technically perfect" operation results in less morbidity and mortality.

So is the surgeon who is perhaps more technically skilled a better surgeon if his outcomes are no different than the average surgeon? The human body doesn't always need perfect...as a matter of fact, a common saying is "the enemy of good is better". Attempts to make things perfect often result in complications.

 

[Habeed]

WS : actually, I based this whole premise on an article by Atul Gawande on the bell curve. The data seems to show that surgeons exist who are on the far edge of it who get significantly better results.

And again, the most excellent surgeon might have a "technically perfect operation fail because of issues outside of his or her control". That isn't the point : the best surgeon has the LOWEST chance of this happening.

Finally, re-read my post : there doesn't have to be statistically significant evidence that a technically perfect surgeon has lower M&M. It just has to be the truth. Hence my "viewpoint of God" quote. From the perspective of God (or a god, this isn't a religious argument) it can be determined who actually gets the best surgical results, assuming identical patients. I think that it is obvious that someone out there exists who embodies this.

The marginal difference could be arbitrarily small...in principle, the world's best surgeon might be 0.00000001% better. But he or she IS better.

 

[Winged Scapula]

WS : actually, I based this whole premise on an article by Atul Gawande on the bell curve. The data seems to show that surgeons exist who are on the far edge of it who get significantly better results.

Ughh...quoting Gawande will win you no points here. He's not as universally loved as the pre med and general public seem to think (although I do enjoy the paragraph where he talks about sitting next to another surgeon at a meeting who turns out to be my partner's uncle).

And again, the most excellent surgeon might have a "technically perfect operation fail because of issues outside of his or her control". That isn't the point : the best surgeon has the LOWEST chance of this happening.

How is that the case? Nearly every case needs the same amount of skill. Therefore, having skill at the far end of the bell curve adds nothing to the outcome for the vast majority of cases. Thus the "best surgeon" and the "average surgeon" will get indentical outcomes based on skill.

Neither surgeon has control over quality of nursing, environmental issues, human error, etc. Therefore, those will be randomly assorted across both the "best surgeons" and the "average surgeon" once again leaving them with identical outcomes.

Finally, re-read my post : there doesn't have to be statistically significant evidence that a technically perfect surgeon has lower M&M. It just has to be the truth. Hence my "viewpoint of God" quote. From the perspective of God (or a god, this isn't a religious argument) it can be determined who actually gets the best surgical results, assuming identical patients. I think that it is obvious that someone out there exists who embodies this.

Ok. There is no "truth" that a technically perfect surgeon has a lower M&M.

And the "best surgical results" aren't always the property of surgical skill but rather patient contribution, disease process, allied health care, luck and or assistance from God/what have you.

The marginal difference could be arbitrarily small...in principle, the world's best surgeon might be 0.00000001% better. But he or she IS better.

Eh...angels on the head of a pin. Besides, you're still focusing on your belief that the best surgeon is the one who has 0.00000001% better skill than those around him. Most of us here seem to disagree with you that technical skill is the sine qua non of an excellent surgeon. There's much more to it than that.