Where the Music Lives: Surgeon Performance Explained.

What is surgeon performance? The first time I got asked this question, I paused as I wanted to reflect while surveying my colleagues around the world. What did I think it meant and what did they? Occasionally, (very few), measured this through speed of surgery. However, those with enough experience felt speed was a vanity metric. What the experienced clinician valued most were patient outcomes (I agreed). Having speed with optimal patient outcomes is the unicorn we all chase. ?So, if outcomes are valued so heavily, how do we improve/measure surgeon performance? As I reflected on my own educational journey, these are my thoughts. ?

Surgeon performance starts when a patient walks in the room. The details of the history, which questions to ask, and interpreting the answers in the context of body language and behaviours begin to colour your thoughts. This is followed by a physical exam, during which time one will pay attention to subtle nuances. Your mind starts to build a framework leading you to order the imaging you need to verify the above. Once reviewed, you begin to map the entire story of what you heard, saw, and felt during the history and physical examination and confirm it with your imaging findings. Surgery may be an option, and on occasion, it is not. Assuming surgery is chosen, you create a decision tree in your mind of the possible options and prepare yourself (and your patient) for an informed discussion. Then, you must be ready to execute. But beware, the execution is not always straightforward…

On the day of surgery, there are many variables to consider. In its most simplified form, you:

1. know (ahead of time) you may need a few special tools or instruments to carry out your plan.

2. patient set up to optimize positioning and avoid pressure sores

3. appropriate draping so you can see and protect

4. appropriate incision length and location

5. deep knowledge of anatomy

6. safe dissection with appropriate retractors and hemostasis

7. a clear view of the target area and then addressing it to either remove, repair, or reconstruct.

8. extrapolating what you see during surgery and connecting it to the imaging (either before or even during the surgery).

9. Once complete you close skin, decide on a rehabilitation pathway and then wait…..

My personal approach (learned from my mentors) has been to clearly document my thoughts, conversation, and observations in my clinical notes. I add content which I think may impact my surgical and post operative plan. I review those notes the night before surgery and review them with the patient in the preoperative holding area. During surgery, I maintain mental models of the imaging in my head while executing the plan and rehabilitate based on what I know about the patient and what was done during surgery. And like every other surgeon, I follow up with the patient on a regular cadence. ?

Only weeks or months later, will I know how I “performed”. For those of us who have played any instrument, the outcome is adjacent to the action. For surgeons, this outcome is temporally disconnected which makes our job as educators and learners very challenging. Not only do we need a vast and varying amount of exposure to patients, but we also require some connection to the patient outcomes and what we observed when the patient walked into room.

This topic is a massive undertaking and there is much to discuss. So, in answer to the original question, what is surgical performance? ?In brief, it’s a series of observations, interpretations and actions that are realized in some distant future.? With time, volume, and experience, one becomes “better” at predicting which observations and actions will deliver the optimal patient the outcome. I know my colleagues will comment as it’s a widely discussed topic.?In the end, we are all musicians, but in surgery, the outcomes are where the real music lives.

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