Humans engage in numerous types of repetitive, rote, and semi-conscious activities every day. Some may teeter close to the edge of the subliminal if the activity has been repeated so often it does not register in your conscious thoughts. I can think of many examples. For instance, when driving your automobile on a multiple lane road or highway, well-trained drivers reflexly flick their left or right turn signal to indicate an intention to change lanes. The exception to this unconscious signal occurs regularly in Texas when drivers of large extended-cab or “Duelie” (two back wheels on each side) pickup trucks switch rapidly across one or more traffic lanes without a turn signal indicating their intent. Apparently, pickup trucks and their drivers are exempt from this common sense and common courtesy maneuver. I apologize, I digress into editorializing. I warrant if any of us were to make a concerted effort to pay attention to every automatic task we perform during a given day, we would be surprised at the number of episodes that don’t register in our stream of consciousness.
A specific event led me down the trail thinking about repetitive activities. Every time I perform a surgical operation, I wash my hands for several minutes at a scrub sink outside the operating room. After rinsing the soapsuds off my arms, I enter the operating suite and the scrub nurse or tech hands me a sterile towel to dry my hands and arms. They then hold out a sterile surgical gown and I place my arms through the two holes while the circulating nurse ties the back of the gown. The scrub nurse offers a sterile surgical glove for my right hand with the opening stretched wide. I slide my hand into the glove, and with a snap he or she releases the glove to clamp down over my surgical gown. I grasp the edge of the left glove with my gloved right hand, and the second glove is extended up my arm and snapped in place. Because I double glove, I’m guaranteed four snaps of the glove every time I scrub into an operation. For reasons I cannot ascertain, three weeks ago, for the first time in over two decades, the snap of the glove entered into my sentient mind.
A dangerous situation, this led to musings about awareness and habits. After pondering for a few minutes, I realized the snap of a glove in the operating room for me is akin to the starter’s pistol for a runner or swimmer. The snap brings me into total focus on the task at hand, the operation to be performed. I am locked, loaded, and prepared to engage the malignant disease affecting my patient. I had become so accustomed to the snap of the gloves the significance was relegated to a subconscious, yet still important place.
Including my general surgery residency, surgical oncology fellowship, and years as a faculty surgical oncologist, I have performed over 8,000 operations. That is more than 16,000 glove snaps over the course of my career. Actually, it is a few thousand more because I routinely “break scrub” (move away from the sterile surgical field and remove my sterile gown and gloves) during the case to stroll with the surgical specimen to the frozen section laboratory to look through a microscope at slides of the resected tumor with a pathologist. We check to assure the resection margins are free of tumor to reduce the risk of cancer recurrence in the surgical bed. After confirming that complete resection of the malignant tumor has been achieved, I scrub my hands again and return to the operating room to repeat the gowning and the double gloving procedure. The operation must be completed!
Thoughtfully, I realize the snap of the glove is a reassuring sound I have heard thousands of times. It is a poignant moment indicating the surgical and anesthesia teams are ready, the patient is prepped and ready to be draped with sterile towels, and the planned operation is to begin imminently. The wearing of sterile surgical gowns and gloves, along with caps and masks to cover our hair and face is a tradition based on the recognition over a hundred years ago of the importance of sterile technique, including sterile instruments, used by the surgical team. Surgical gloves have an interesting back story, being first requested by the famous Johns Hopkins surgeon William Stewart Halstead for his scrub nurse, Caroline Hampton. He asked the Goodyear Tire and Rubber Company to produce thin, flexible, rubber gloves to protect her hands chafed by the carbolic acid and mercuric chloride used to disinfect the skin of patients. It turns out his scrub nurse was also his girlfriend, and eventually his wife, so his act was both thoughtful and chivalrous. Halstead’s laconic description regarding the origin of surgical gloves is a famous piece of modern surgical history:
In the winter of 1889 and 1890—I cannot recall the month—the nurse in charge of my operating-room complained that the solutions of mercuric chloride produced a dermatitis of her arms and hands. As she was an unusually efficient woman, I gave the matter my consideration and one day in New York requested the Goodyear Rubber Company to make as an experiment two pair of thin rubber gloves with gauntlets. On trial these proved to be so satisfactory that additional gloves were ordered. In the autumn, on my return to town, an assistant who passed the instruments and threaded the needles was also provided with rubber gloves to wear at the operations. At first the operator wore them only when exploratory incisions into joints were made. After a time the assistants became so accustomed to working in gloves that they also wore them as operators and would remark that they seemed to be less expert with the bare hands than with the gloved hands.
The sterile gloves have a two-way function; they avoid exposing a patient to potentially pathogenic micro-organisms on the surgeon’s or surgical teams’ hands, but gloves also protect the surgical team from infectious agents sometimes harbored within the patients’ blood or body cavities.
The snap of a glove also made me think about Malcom Gladwell’s 10,000-hour rule. When Gladwell first proposed this principle, he suggested that 10,000 hours of “deliberate practice” is required to become world-class in any field. After suddenly and unexpectedly having the snap of a glove move from my unconscious to conscious mind, I began thinking about how many hours I had spent in the practice of surgery. First, it is interesting that in all medical specialties we use the term “practice.” Practice implies ongoing training, education, innovation, experimentation, and elucidation of new medical and scientific understanding is required for continuous improvement in the physician’s craft. I began thinking about my own career and decided to make some gross, conservative, but rational estimates. I have been performing surgical procedures for 35 years. I estimate I am engaged in surgical operations on patients about 30 hours a week. I chose 40 weeks a year performing surgical procedures. I know this is an underestimate, but I did it intentionally to count vacation or time spent away at academic meetings or giving lectures at institutions around the world. I multiplied 30 hours a week for 40 weeks a year for 35 years to reckon 42,000 hours spent in the operating room.
That figure far surpasses Gladwell’s proposed 10,000 hours of focused practice to become an expert in a field of endeavor. This 10,000-hour rule has been debunked in several studies recently. In my opinion, 10,000 hours of practice are not adequate to become a master in the field of surgery. I never believed this number was valid for those of us drawn to a career as surgeons. We all know, whether consciously or subliminally, operations can have unexpected occurrences to derail our plans for a straightforward and successful procedure. New technologies, new equipment, scientific and engineering advances, minimally invasive and robotic platforms, and new combinations of medications and treatments conspire to keep the surgeon learning new material constantly. I know from personal experience if I relax or think I’ve got a specific operation or technique down pat, inevitably it seems some event occurs, including an equipment malfunction, an unusual variation in anatomy, additional tumor nodules or malignant disease extending into adjacent organs not detected on pre-operative imaging studies, or an unanticipated drug reaction. Unpredictable incidents remind me to be constantly vigilant, aware, and humble.
As an example, I have done hundreds of operations for patients with bile duct cancer, also called cholangiocarcinoma or a Klatskin’s tumor, at the base of the liver. This is a challenging and arduous operation, requiring dissection of critical blood vessels and structures, removal of part of the liver, and reconstruction of the bile duct and intestine. I like this operation. Last year I was thrown a hard-breaking curve ball when a patient with complete situs inversus was referred to me after being diagnosed with this cancer. All of his organs are reversed; the liver is on the left side, the spleen on the right, heart on the right…everything is 180 degrees opposite of “normal” anatomy. So, despite performing hundreds of these operations, I proceeded cautiously and mindfully because everything was a mirror image of what I’m accustomed to seeing. I was exhausted at the conclusion of the successful operation. How do you anticipate or practice for that?
Once a pilot has learned to fly a specific plane, he or she becomes expert understanding the cockpit cenvironment. The controls, indicators, and gauges are always in the same place. We don’t have that luxury in our human patients. Variations in anatomy, different pathologic conditions, effects of medications, body size, tissue strength, and concomitant medical conditions combine to make each operation a little different. But like pilots, as surgeons we frequently train in simulated environments to hone our skills and prepare for unexpected situations.
Despite the length of our surgical careers, we go on practicing, learning, and exploring every day. This is a critical core value for surgeons and other physicians. We must be ever watchful for variations or circumstances confounding a well-planned operation. Lately, I made a conscious decision to celebrate the snap of the glove as the moment to focus and prepare to lead the surgical team to manage every operation with expertise, excellence, and calmness. The snap of a glove has moved from my subconscious to conscious mind. I believe we should respect and honor these well-founded surgical traditions, all created to reduce the risk for patients and staff alike. The snap of the glove is now like the home plate umpire shouting, “Play ball!”. The operation begins, and while we have practiced and rehearsed our techniques and maneuvers over thousands of hours, we must be prepared for hits, errors, and great plays. For me, the surgical game begins with the snap of a glove.