Revealing the Truth Behind Surgeon Psychology and Culture

The surgeon above all else is a soldier. For this healer greets every day as “a day of battle” (Schwartzbart 1982, p 22)

Over centuries, the surgeons have set the standards of ethical and humane practice. In many ways they are the few super heroes that still exist.

They are called in the middle of the night, jump out of bed, and fly to the hospital.

A surgeon immediately inserts order into chaos and somehow brings back life when all hope is lost.

My father was a general surgeon and I was on track to become one until my interests in business took me away from medical school.

Although I have shifted professions, I remain a scientist at heart. Im fascinated with psychology and how people turn thought into action.

So what makes up surgeon psychology? Here's what I uncovered on their history, culture, and psychology.

Uneducated Nomads

Historically rising from humble roots as lower-class, uneducated, nomadic barbers, surgeons were often brought through the back door of a home to do some cutting for a physician.

Physicians tended to be academics, working in universities, and mostly dealt with patients as an observer or a consultant. They considered surgery to be beneath them.

As they gained more notoriety, they took pride in their art and told their former medical superiors to refer to them as "Mister" when addressed.

No wonder surgeons and internists have a rivalry.

Over time, the profession has evolved into one of the most prestigious in America, one that utilizes the most sophisticated technologies in medicine.

Surgeons have become heroes that seek to cure by scalpel and arrest disease if not vanquish it.

They see themselves not just as healers, but as curers.

Alec Baldwin as Dr. Jed Hill in "Malice"

Surgeons have nonetheless retained many aspects of their historical culture, such as their proclivity for quick decisions, surgical "cures," and their detachment and aloofness from patients and other physicians.

Getting into the Mind of a Surgeon

Photo Courtesy of The British Psychological Society

In 1999, medical anthropologist Dr. Pearl Katz conducted a study on surgeon's when a university hospital received numerous complaints from residents that house staff was not spending enough time teaching them surgical techniques.

Her book, The Scalpel's Edge: The Culture of Surgeons, explored how their thinking is often non-scientific, how they make decisions, and how they keep secrets from patients and colleagues. 

Katz analyzes how a myriad of often unrecognized cultural factors can influence surgical decision making.

These include factors related to the culture of surgery, hospital culture, patient culture, and others.

She focuses on a cognitive bias that she calls "active posture" of surgeons - a cultural bias toward valuing action.

Her research provides valuable insight for the medical device world to embrace.

Surgeons prize individualism and you can see that in their history.

New clinical reps who spend a month with a surgeon quickly see that compared to other physicians they’re less inhibited, more excitable, aggressive, and often strained.

Surgeon Culture's Influence on Decision-Making

Over time, Katz developed a number of keen insights about “surgeon culture,” including the fact that while they act jovial and gregarious in the company of their colleagues, surgeons tend to carefully protect “information.

What kind of information? Information that is:

• About themselves
• Their Patients
• Their operating processes
• Operative techniques
• Referral sources
• Levels of specific knowledge
• Specific expertise (particularly deficits in knowledge and expertise)
• Income
• Doubts and concerns about medical decisions

In other words, anything that would give another surgeon the upper hand in dealings with them.

Surgeons have a stronger sense of competition with each other than any sense of collegiality and collaboration.

You can see this in their history.

Some rivalries were so good they even made national headlines. (If you're in the cardiac space, you must know about this rivalry)

This was one underlying feature of surgeon culture that was a critical piece in explaining a major issue.

Katz found this as one reason why residents felt that hospital staff surgeons were not spending adequate time training them for their jobs as surgeons.

Each surgical generation perpetuates the culture and passes it on by recruiting residents who seem to resemble them and then training these residents to emulate their thinking and behavior.

Did you ever notice that orthopedic surgeons all seem to be like the high school quarterback that everyone loves, or how you often find that neurosurgeons are into things like sci-fi and hobbies involving engineering?

Going with their Gut

The analysis of clinical cases indicates that surgeons obscure the decision-making processes in a variety of ways. This includes:

A. Denying that they were making a decision

B. Denying that they had the option of making a decision

C. Embedding decisions in irrelevant information

D. Making a series of small decisions which led to major decisions

E. Passing the decision-making buck

F.  Representing complex decisions as simple ones

G. Representing simple decisions as complex ones

When obscured, decisions are made based on non-medical criteria. This is why surgical training is incredibly rigorous. The best surgeons have developed a skill that can only be matched by technology; intuition.

The Love For Action

The surgical literature emphasizes the active posture of decision-making.

It is a primary skill to that surgeons look to master.

In the Bulletin of the American College of Surgeons, an article identifies three basic skills that surgeons must possess (Spencer, 1978: 9):

1. Capacity for deductive reasoning and decision-making
2. Emotional Characteristics
3. Dexterity

The article emphasized that

“a surgeon must have the capacity to make consecutive decisions under stress”.

Surgeons make a large number of decisions throughout the day.

Although they place a high value on the ability to make decisions, their perspective of their actual decision-making activities is limited.

The problem is that most medical literature emphasizes exclusive medical grounds for making medical decisions.

The focus upon the medical auspices for decision-making neglects the examination of the multiple conditions under which physicians actually make decisions.

It ignores social and cultural bases and contexts which influence decision-making, the consequences of the decision-making process on patients, and the implications of the decision-making process for the practice of the profession.

Now say what you want about surgeons. I will, however, defend them.

Even Katz cited that she entered with her own culture and bias, but after spending a few weeks the surgical environment shaped her views in a similar fashion to the surgeons.

Dominant themes of surgical culture are action, heroism, certainty, and optimism.

Although these present as barriers to identification and communication with patients, they are often the reason why surgeons cannot only heal but cure.

The healthcare companies that will truly become “trusted advisors” to surgeons will be the ones that understand the history and culture that they embrace, upon which they find ways to empower surgeons through their technology.

Technology should not aim to replace the surgeon. Rather, it should look to allow any surgeon to