"You can train a monkey to operate"

[DrDude]

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I've heard that saying more than a few times. Usually said in good natured jest but sometimes said to put down surgery as if it takes little intellectual effort to operate versus to medically manage a patient.

IMO it takes plenty of intellectual effort to operate when it's YOU who is ULTIMATELY responsible for the operation. Sure when you're the med student who's only responsibility is to retract or the resident who still has the attending right there to carry you through if you need help it might not seem so hard, but I think it's a whole other game when you're the attending and there's nobody else in the room to make your decisions for you. It's all on you then. I'd like all the people who claim you can teach a monkey (or the other often quoted: C-average high school student) to operate to try to do the "basic" general surgery operations like an appy or choley skin-to-skin without anybody there to hold their hand through the operation, not to mention the super complex operations. Because I've seen the "routine" appy or choley throw some curve balls and the resident who has assissted on a bunch of them before looking lost until the attending ultimately bails them out so to speak.

 

[tussy]

I hate that expression and don't totally agree with it. It's intention is to say that the operating part of surgery isn't the difficult part - it's the management, deciding what operation to do, who to operate on ect.

However, some people are naturally skilled at surgery and pick it up easily, while others really suck and teaching them is next to impossible. Some people just don't have the hand-eye coordination, the understanding and ability to recognize tissue planes, and the manual dexterity to be a surgeon. My current senior resident falls into this group and I HATE having to have him in my OR!!

 

[Jackofknives]

I hate that expression and don't totally agree with it. It's intention is to say that the operating part of surgery isn't the difficult part - it's the management, deciding what operation to do, who to operate on ect.

However, some people are naturally skilled at surgery and pick it up easily, while others really suck and teaching them is next to impossible. Some people just don't have the hand-eye coordination, the understanding and ability to recognize tissue planes, and the manual dexterity to be a surgeon. My current senior resident falls into this group and I HATE having to have him in my OR!!

There is no bad student, only bad teachers. (Or is it the other way around? 🙄)

 

[tussy]

There is no bad student, only bad teachers. (Or is it the other way around? 🙄)

There are definitely bad of both!

 

[toxic-megacolon]

If operating is so much easier than medical management, than why do so many attendings watch you like a hawk in the OR, but then disappear after the last suture is cut to let you medically manage their patient until discharge. I've never see in the other way around...

 

[Winged Scapula]

If operating is so much easier than medical management, than why do so many attendings watch you like a hawk in the OR, but then disappear after the last suture is cut to let you medically manage their patient until discharge. I've never see in the other way around...

Because operative misadventures pay much more big bucks than does medical mismanagement.

 

[DrDre311]

I hate that expression and don't totally agree with it. It's intention is to say that the operating part of surgery isn't the difficult part - it's the management, deciding what operation to do, who to operate on ect.

You are correct. Regardless of popular opinion, surgeons are physicians first and our most important function is to decide when it is appropriate to operate--secondarily (and still importantly) to perform well technically and obtain a good result.

However, some people are naturally skilled at surgery and pick it up easily, while others really suck and teaching them is next to impossible. Some people just don't have the hand-eye coordination, the understanding and ability to recognize tissue planes, and the manual dexterity to be a surgeon. My current senior resident falls into this group and I HATE having to have him in my OR!!

There's a senior resident at my program who shakes like a damn tree in the wind. I've always said that if your hands ultimately do what you want them to do, then you can be a surgeon, but there are times I just want to take the instruments out of this resident's hands because I know I could do the job in a third of the time, without wrecking the tissue by pinching the hell out of it and stabbing it (again and again and again...). I've definitely seen people who don't really have the hands for the job despite a more than adequate fund of knowledge.

 

[medfriend]

I have read on this site that manual dexterity is not all that important for most operations--with exceptions like microvascular, etc. what sort of talent is needed besides developing good clinical judgement? How high does your visuospatial aptitude need to be? Can this be improved somewhat, or is it just inborn?

And is the most recent post too cynical, or right on target about malpractice fears driving division of labor decisions that may have terrible consequences for the patient?

 

[Winged Scapula]

The reason attendings watch residents much more than they used to is almost always due to med mal issues and the public outcry when it was discovered that training programs allowed residents to do cases without attendings.

While it may sound cynical, this is the basis for the change in autonomy in the OR. The public is either less informed about residents making medical management decisions or doesn't sense that these are as important as surgical/intra-operative decisions.

It is also unfortunate but anecdotally true that residents at programs with a large indigent population tend to have more autonomy than those with private or insured patients.

 

[logistic]

Quote:
Originally Posted by tussy
I hate that expression and don't totally agree with it. It's intention is to say that the operating part of surgery isn't the difficult part - it's the management, deciding what operation to do, who to operate on ect.

However, some people are naturally skilled at surgery and pick it up easily, while others really suck and teaching them is next to impossible. Some people just don't have the hand-eye coordination, the understanding and ability to recognize tissue planes, and the manual dexterity to be a surgeon.


This is my only hesitation as I begin the application process for gs residency. There have been hints for me in the past: from my chief resident while I was doing a continuous subcuticular: "haven't you been practicing" and from an attending as I was sowing in the mesh for a hernia repair: "it's NOT THAT HARD," not to mention that I've not been able to put in a subclavian line on two different patients. But I at first had trouble stiching in a drain, placing interrupted subcuticulars, and doing arterial lines, but do these easily now.

 

[BlondeDocteur]

Oddly enough, when I've heard this saying it's meant as a comfort, not an insult. Most people tell me that there are outliers who are either amazingly dextrous and take to surgery like a duck to water, and those who have Hands of Death, but most people fall comfortably into the "gets fine with practice" category.

I think logistic's point is a good one-- most things involving manual dexterity are tough to pick up, but quickly you become decently proficient at it. Minor procedures that were tough a year ago are fine today, and I feel confident that it will be the same in residency.

 

[Strength&Speed]

this is why I refuse to continue on in a surgical residency, because I refuse to compete with monkeys low-balling me for jobs. Damn those Borneo apes!

 

[medfriend]

Can anyone offer an opinion on the importance of 3d spatial aptitude relative to manual dexterity and clinical judgement? If someone had good clinical judgment, but had some difficulty with visualizing the surgical field how much would that affect their performance? Is this something that improves during a surgical residency and has anyone noticed an improvement after playing video games?

 

[DrDre311]

Can anyone offer an opinion on the importance of 3d spatial aptitude relative to manual dexterity and clinical judgement? If someone had good clinical judgment, but had some difficulty with visualizing the surgical field how much would that affect their performance? Is this something that improves during a surgical residency and has anyone noticed an improvement after playing video games?

I think there was a study a few years back that showed that surgeons who played video games performed better on laparoscopic simulation exercises. I don't know how video games translate to actual operative skill because button-pushing isn't really the same is training the intrinsic muscles of your hands not to be stupid, and video games don't develop your tactile sense.

As for the inborn skill question, some people definitely have better hands than others. A technically excellent plastic surgeon once told me (as I struggled a little with a tough microvascular anastomosis under the scope) that surgeons were made, not born. But I still think it's better to have magic hands in the first place. Even if you don't have magic hands, there are things you can train yourself to do to minimize tremor and stabilize your movements, but it is critical to be able to recognize tissue planes and have your hands do what you want them to do.

 

[Blade28]

I think there was a study a few years back that showed that surgeons who played video games performed better on laparoscopic simulation exercises. I don't know how video games translate to actual operative skill because button-pushing isn't really the same is training the intrinsic muscles of your hands not to be stupid, and video games don't develop your tactile sense.

That was the much-publicized 2003 study out of Beth Israel by Butch Rosser.

Residents who spent at least three hours a week playing video games had 37% fewer mistakes and were 27% faster in laparoscopic simulators.

 

[medfriend]

If you had to choose between having a high spatial aptitude and poor manual dexterity and vice versa (at the beginning of training) which would you go with? Does training itself (as opposed to video games) seem to sharpen 3d skills in those who did not start out strong in that area?

 

[DrDre311]

If you had to choose between having a high spatial aptitude and poor manual dexterity and vice versa (at the beginning of training) which would you go with? Does training itself (as opposed to video games) seem to sharpen 3d skills in those who did not start out strong in that area?

Can't really say because I've never really struggled with it other than what I would consider a normal learning curve. I would say it's probably more important to have a good innate spatial sense so you don't really screw things up.