Neverisms, Alwaysisms And the Dangers of Absolutisms in Surgery

“I’m just a product of my training.”

I’ve heard this phrase, or a version of it, more than a few times in general surgery residency. Usually it’s the explanation offered after a statement—such as “I always use …” or “I never do. …” What I find interesting is that despite the acceptance of core competencies and standardized testing in residency, surgery is still learned from surgeons. As such, my mentor’s tools have become my tools. But by the same token, have his biases also become my biases?

In the middle of an M&M write-up pertaining to the use of T-tubes, I again realized the weight of surgical dogma that I inherited in residency. And by dogma, I mean those tenets or principles that are unquestionably upheld, but impossible to unravel. Inside is probably a fragmented truth, but it is wrapped in layer upon layer of perpetuated bias.

The process of teaching surgery seems always caught between evidence-based medicine and a hodgepodge of experience, anecdotes and dogma. Partly this is inherent to surgery because it is both an art and a science. The truth is, there are actually very few absolutes in surgery. Case in point, we use phases like risks, benefits and indications when we talk about management and treatment. And we talk about the “principles of the operation” because we understand that having enough intraabdominal esophageal length in a hiatal hernia repair is more important than the actual technique or instruments used; as the phrase goes, “There’s more than one way to skin a cat.”

In training, especially in the early years, the wires get crossed when principles and preferences are taught with equal zeal. We ask interns to live, breath and internalize an ungodly amount of information that first year. Through no fault of their own, all of the information is indiscriminately committed to memory. Their education is a confusing blend of textbooks, randomized controlled trials, staff anecdotes and surgical dogma. In the same day, they are reprimanded for not listening to bowel sounds, learn about the Z0011 trial at a cancer conference, listen to a story about a patient who died from a nasogastric clamping trial, and, finally, in the OR, they are told that Hasan entry is the safest method.

I spent most of my junior residency separating and sorting all of this information just to decide: What is preference and what is principle? But there are many residents who will never see the difference, and so interns continue to be scolded for not waiting six hours for a post-pull chest x-ray, or for not placing a Foley catheter during an appendectomy. And before long, there is an entire class of interns who unquestionably believe that silk should never be used on small bowel—or any other sort of idiosyncrasy picked up along the way.

This becomes less of a problem over five to six years of interacting with dozens of different surgeons, from different specialties, working within different hospital systems. As time goes on, residents collect these techniques and choose the ones they can safely and consistently perform. As my mentor likes to say, “You can never be a surgeon who knows only one way to do something.” Each technique has its own merits and risks. And I think that this information—the ability to contextualize each technique—is arguably as important as the technique itself. Knowing all the ways of intraabdominal entry is good, but knowing specific situations that would favor one over the other is far better. With that being said, I anticipate that with time in practice, I will pick and choose techniques that I can safely reproduce with maximal efficiency.

But this brings up, I think, the difference between faculty surgeons and for lack of a better word, nonfaculty surgeons. Faculty surgeons have a responsibility to teach surgical principles and techniques—all techniques—along with the pros and cons of each. Knowing that a partner had a bad outcome with a particular technique does not necessarily invalidate that technique, but instead affords an opportunity to discuss potential pitfalls, ways to mitigate and how to deal with complications. And this is where experience is most valuable. I feel like this approach can’t help but create diverse and conscientious surgeons, and not “one-trick ponies.” It reinforces what makes a surgeon a surgeon, and not a technician.

I think it is fair to say that not every surgeon has to be faculty. It is an incredible responsibility; they have my utmost respect. The process of teaching residents is labor-intensive, time-consuming and anything but efficient. The faculty I have learned the most from are able to put aside their own practice patterns to ensure I experience and adapt to different scenarios. The tune changes from “I never do it that way” to “I typically do it this way because of, … but these are the other ways you can do it as well.” Instead of fixing a hiatal hernia from the patient’s right side, can I also have that same experience standing between the legs? Or this time, can I also modify my port placement and use a different energy device?

I don’t necessarily want the same patterns as my mentor. Instead, I would like to piecemeal together safe techniques to create my own pattern, and by doing so become comfortable or, at a minimum, familiar with all of them. Surgical residency has moved away from long rotations with a core faculty group to shorter rotations with subspecialists who are either building or supporting their own practice. I wonder if this shift is partly responsible for the “product of my training” phenomenon. It has to be asked: Is the goal of residency to produce copies or products, carrying around the same biases? Or is the goal to produce well-rounded surgeons, capable of operating in any OR, under any set of circumstances?

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Dr. Halgas is a chief surgical resident in El Paso, Texas.

This article is from the May 2021 print issue.