Excellence in surgery: Becoming the “best” you can be

John C. O'Brien, Jr., MD, FACS (left), then an attending surgeon and Ashley Egan, MD, then a senior resident at Baylor University Medical Center, Dallas, TX

John C. O’Brien, Jr., MD, FACS (left), then an attending surgeon, and Ashley Egan, MD, then a senior resident, at Baylor University Medical Center, Dallas, TX

Most professionals, indeed, most human beings, aspire to achieve excellence. Motivated by the desire to best serve others and stimulated by internal or external competitive forces, most of us seek to perfect what we do and enjoy the reward of being recognized as the “best” in our field.

Consequently, rating someone in a particular field is part of our culture. For example, rating athletes and their physical abilities is common and relatively straightforward. When athletes compete with each other, a winner emerges. When someone breaks a record or when someone coaches a team that consistently wins, these individuals are deemed the best in their field. The bar is set to a certain level, and whoever exceeds this point and maintains that level of performance is considered to be the best.

Most young men and women who choose surgery aspire to be the best in their field. Yet, unlike other areas of performance, rating surgeons is a more complex task. The nature of the disease, the variety of pathologies that a surgeon treats, the way human beings respond to treatment, the way personal relationships are established, as well as the technical expertise with which operations are performed—all determine the final outcome. And positive outcomes are in themselves difficult to qualify and to quantify: Is it the absence of symptoms? The cure of a disease? The restoration of function? The prolongation of life? Simply isolating results in surgery in an objective way is impossible because the dependent factors vary considerably.

The question of how good a specific surgeon is has always been of interest to those patients who seek their care, to those chairs of surgery who hire surgeons, to the administrators of hospitals where surgeons practice, and to society at large. However, precious little literature addresses the meaning of the word “best” in surgery, and even less is written on the means of getting there.1

Achieving Excellence in SurgeryThis article describes the elements that facilitate the development of excellence in surgeons, as well as the characteristics that surgeons—particularly those who are in the early stages of their career—might emulate to become truly great surgeons (see sidebar). These guidelines are offered by surgeons who have had the chance to reflect throughout their careers on the traits that define “the best surgeon,” and how the character of masters is exhibited. These observations convey the stories and experiences of a life lived in surgery and may serve as a guide to those who seek to develop professionally.

The best surgeons have mentors

Mentors guide us through a career path. They provide sage advice, personal counseling, and support our growth. Mentors go beyond teaching; they impart wisdom.

A mentor not only inspires us but also influences our lives on many levels. This deep influence is the reason why most surgeons who achieve excellence have at least one mentor, and usually more than one. Some mentors excel in the technical details and inspire us to exercise skill, precision, and simplicity in the performance of an operation. Other mentors exhibit keen interpersonal skills. These physicians encourage mentees to develop the communication skills that allow us to establish productive relationships with our patients, colleagues, and teams.

Mentors offer guidance and advice. They motivate their mentees by serving as role models and are always ready to give advice nurtured by their experiences.

A good mentor sees the potential in the mentee and facilitates its development. Achieving excellence, becoming the best, is almost always associated with outstanding mentorship.

The best surgeons know technical skills are not enough

Surgeons often equate excellence with the mastery of surgical technique, which can lead to the erroneous conclusion that the best surgeon is the most skillful one. In fact, many surgeons admire and respect colleagues who show technical ability and have the skills necessary to perform the most difficult steps of an operation. Moreover, it is not uncommon to hear derogatory comments regarding colleagues who are slower, and who have less developed technical abilities.

It is important to assign technical skill its true place, for though it is a sine qua non asset of the best surgeon, technical prowess should be accompanied by other attributes, such as knowledge, poise, and common sense. These virtues separate a good technician from the best surgeon.

Good surgical residencies emphasize the development of technical abilities, as well as decision-making skills in surgery, from the indication of the operation to the moments when the surgeon must decide whether to continue with a plan or change it.

The best surgeons focus on the patient

The ultimate goal of an operation is to benefit the patient, not the surgeon. Although a skillful surgeon possesses a rare ability that, if used well, can yield enormous benefit to the patient, being the best surgeon also involves walking away from the narcissistic concept implied in, “I have done what others could not,” and focusing on whether what we have done benefits the patient.

During our careers as physicians, we study and train ourselves to benefit the sick, to cure when we can, and to mitigate what we cannot cure. The best surgeons are those who constantly challenge themselves to do only what will benefit the patient and not simply what “can be done.”

The best surgeons “first, do no harm”

We should bear in mind something Henri Bismuth, MD, FACS(Hon), an expert in the hepatobiliary field, said when talking about reckless surgeons, “I have never seen a surgeon dying in the operating room as a result of his reckless performance. But I have seen patients die, or feel pain, or undergo complications because of these reckless surgeons.”2 Dr. Bismuth’s observation should prevail when making decisions.

The best surgeons are not the ones who fight cancer regardless of the consequences brought about by this fight and who justify their decisions as necessary to eradicate a disease, even at the expense of their patients’ lives and of serious sequelae or complications. These physicians know that a thorough informed consent does not equal the right to carry out procedures that can lead to serious complications for their patients.

The best surgeons operate slowly, but think quickly

The speed with which a procedure is performed has been erroneously used as a proxy for excellence. We have witnessed, on occasion, a trainee trying to impress the attending physician with quick and even ostentatiously elegant maneuvers. Unfortunately, we have also seen senior surgeons display this behavior.

The best surgeons never seem to be in a hurry. Deliberate, precise movements, without any wasted motions and following the right planes, usually result in a faster conclusion of the procedure. Time should not be the driver; perfection should be.

An excellent surgeon’s ego should not be bruised when there is a need to stop, move back, and rethink when the patient’s best interests are at stake.

The best surgeons make operating look effortless

The best surgeons never seem anxious to end the procedure because their sole objective is to attain a good outcome that benefits the patient. The best surgeons do not seem rushed.

For outside observers, what the best surgeons do looks easy. Operations are carried out with simple maneuvers, unpretentiously, even when a case is complex and difficult to resolve. And when such observers have the chance to treat similar cases, they may comment, “It seemed so easy when they did it.”

The best surgeons are patient

Every so often, we see skillful surgeons act like greedy consumers who gobble down their food without savoring it. The rush to finish a procedure has its drawbacks for the patient because the successful completion of a procedure is subject to a low level of analysis and the consideration of different options.

Furthermore, the push to finish an operation quickly detracts from the joy of surgery. An operation becomes just a task that must be finished, usually to start the following case. For the best surgeons, the operating time ends faster than they realize.

The best surgeons motivate their teams

Today, more than ever, surgical procedures require teamwork. With this in mind, the best surgeons concentrate on building and motivating the best teams. Teamwork requires great communication skills, establishing a shared mental model, explaining everything that will be done, when and how, and maintaining the spirit of the team throughout the operation.3

The best surgeons lead the surgical procedure and support all the members of the surgical team. In this collaborative setting, team members feel protected amid the stress and empowered to speak up and contribute. Respect and mutual support for every member of the team brings out the best in every member.

Crises tend to develop rapidly during the course of operations. Maintaining a calm demeanor, avoiding loud voices, and eschewing criticism of any member of the team at the time of a crisis is essential to managing it successfully. It is at these times that the best surgeons have the opportunity to shine.

An expression of excellence in this respect is that the best surgeons, as leaders of their team, will take full responsibility for the actions of their team when things go wrong. When things go right, excellence in leadership requires that surgeons identify those who made “the right thing” happen. Never miss an opportunity for public praise.

The best leaders ask for feedback and provide it to the other members of the team. Providing feedback to the individual members of the team can be a difficult task. The best surgeons care about their teams, and they meet individually with the members of the team to debrief. During those periods, feedback is given, emphasizing all the good things that have happened as a consequence of the actions of the team member who is being addressed. Criticism should always follow, not precede, the good comments, and it should be constructed in the form of an opportunity for improvement rather than addressed as a flaw in character.

The best surgeons enjoy their work

Some surgeons do not derive joy or pleasure from operating or from interacting with their patients. There may be many reasons for this disinterest. Passion for a profession is like falling in love. You either feel it or you don’t, and it does not necessarily reflect negatively on the physician. But for the best surgeons, surgery is not a job that must be done to survive. It is a choice. The best surgeons feel lucky to be able to conjoin work with pleasure and passion.

The best surgeons know their limits

Experiencing fear before a complex procedure is a normal and helpful feeling. Fear keeps you focused and alert. Only the reckless feel no fear.

Managing fear when facing risks is key to excellent performance in surgery. To benefit the patient, surgeons must first purposely “injure” the body. The burden of this responsibility generates a fear that must be overcome with each procedure. Thus, the best surgeons realize that fear is part of a surgeon’s life.

The best surgeons consistently audit their results. They should be fully aware of both their abilities and limitations and should not be afraid to ask for or receive help from others. Through introspection, the best surgeons are motivated to seek continuous self-improvement.4

The best surgeons are the ones who achieve the best immediate and long-term results. Only the deep and objective analysis of such results will give them the information necessary to reach excellence. The relentless pursuit of perfection in everything we do is the hallmark of a surgeon.4

The best surgeons learn from mistakes and share their knowledge

Good surgeons feel the pain of others as if it were their own. The ability to feel empathy constitutes the reason why the best surgeons should be attentive to the patient’s indications for surgery and recognize the technique or the operation that will result in the best outcomes. Complications worry the best surgeons but do not become an obsession. They try to sort them out, learn from them, and avoid future ones. The best surgeons do not feel weakened asking for help; rather, they feel strengthened knowing that the patient will experience the best possible outcome.

The best surgeons generously share their knowledge. At the same time, the best surgeons are aware that their knowledge is limited and are willing to study and learn from others. They are constantly learning and investigating, and transmit their knowledge to future generations.

The best surgeons are devoid of pedantic egotism and senseless narcissism. People who have nothing to learn from others have nothing to teach.

The best surgeons relate to their patients

The best surgeons establish trusting relationships with their patients and their patients’ families.5 This responsibility cannot be delegated. The best surgeons are always there to explain the course of care as much as it is needed. This act means seeing beyond the disease. When treating a patient, the best surgeons are not focused on or limited to just solving a problem, but to helping human beings. Patients are people—people with needs that extend beyond the mere treatment of a physical illness. Surgeons can see and perceive the pain and suffering of patients and their families. They see their despair and hopelessness. The best surgeons feel the pain of their patients and the concern of their relatives as if it were their own. Physicians who choose to be surgeons must have the sensibility to see and feel this pain and seek to bring comfort and relief.

The best surgeons understand that not only do patients in their most vulnerable state deposit their trust in their surgeon, but patients’ families do so as well—and at one of the most critical moments of their lives, namely, when a loved one is sick. This feeling escalates when patients need to undergo surgery.

It is the ability to discover and interpret these situations that define surgeons as the best. And it is not just about the patient. The family environment has a big impact on the patient’s recovery. So, the best surgeons offer more than technical explanations, but also figure out family dynamics and how they will affect the patient.

The best surgeons see their office hours as opportunities to listen and get to know their patients.

The best surgeons are grateful and humble

The best surgeons do not know that they are the “best” and do not strive to be considered the best. Rather, they know they can always improve and are receptive to knowledge that will benefit their future patients.

The best surgeons are grateful to their mentors and constantly honor their memory by passing on their example to future generations.

Once surgeons have lived a life in surgery and reach a certain age, it can be difficult to humbly accept retirement. The best surgeons know when to leave the operating room for good. It is always better to do so one year too early than one day too late. It is better to be asked “why?” rather than “when?”

The best surgeons have work/life balance

The pain surgeons feel for their patients is inescapable, and it comes with a price that some surgeons unload on their own families. But the best surgeons understand that they have a mission—a mission to heal and comfort those in need. They find relief in the fact that they know that they are doing the best they can and giving their utmost effort. Their passion keeps them moving forward.

On the other hand, we cannot give what we do not have. So, it is important to nourish the soul. The best surgeons know how to achieve balance.

First, they create and surround themselves with the best team. Having people whom they trust to provide the care that their patients expect allows them to leave work in peace.

Second, they dedicate time to family, friends, and loved ones. Finding relief and joy in one’s family may seem obvious, but in everyday life, the stress can be so overwhelming and tiresome that we grow drained and bitter, and we unload these negative feelings on the people we love. The best surgeons master the art of letting go of work to spend quality time with their families.

Maintaining a healthy relationship with one’s family is crucial. It’s important to be attentive to the needs of one’s family and to remember that the people outside the hospital need a parent, a friend, a daughter, and so on. It’s important to listen and dedicate time to them.

The best surgeons find ways to balance these two important aspects of life, focusing on their patients while at work and living lives of fulfillment with family and friends when out of the hospital. The nourishment of the soul provided by these moments will be reflected at work, yielding excellence.

Conclusion

The best surgeons not only exhibit extraordinary technical skills, but much more. They value their mentors, who provide exceptional knowledge of medicine, diseases, and human relationships. They are humble and endowed with the ability to create and nurture a team with empathy and sharing in human suffering, with dedication, and ultimately with love, for patients, for family, for friends, and for humanity at large.


References

  1. Henrickson Parker S, Flin R, Mckinley A, Yule S. Towards a model of surgeon’s leadership in the operating room. BMJ Qual Saf. 2011;20:e570-e579.
  2. Dr. Henri Bismuth. Personal communication. Extract from a speech delivered when assuming the presidency of the Académie Française de Chirurgie. October 1993.
  3. Hu YY, Parker SH, Lipsitz SR, et al. Surgeon’s leadership styles and team behaviour in the operating room. J Am Coll Surg. 2016;222(1):41-51.
  4. Pellegrini CA. Presidential Address: The surgeon of the future: Anchoring innovation and science with moral values. Bull Am Coll Surg. 2013;98(12):8-14.
  5. Pellegrini CA. Trust: The keystone of the physician-patient relationship. Bull Am Coll Surg. 2017;102(1):58-61.

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