THE POWER OF VISUALIZATION
Almost every surgeon is familiar with the painting, Contemplation Before Surgery, by Dr Joe Wilder (Fig. 1, inset). Among the many artistic works of Dr Wilder that have been featured in medical journals,1 the New York Times and the Dartmouth Medicine Magazine, this one has become iconic, hanging on the walls in countless of our offices. But, why is that? What is the essence of our experience as surgeons, which is so well-captured by this rather simple depiction of the just-gowned surgeon with interlaced fingers and downcast gaze? To the uninitiated, the immediate response is that the pictured surgeon is praying. Although possible, we as surgeons know this is unlikely the case. Most of us interpret his posture as a reflection of the surgeon gathering thoughts, calming nerves, and fully orienting to the task at hand during those precious moments immediately before engagement in his imminent mental and physical struggle. However, the few truly gifted surgeons among us may offer yet another interpretation...perhaps he is visualizing the intended end result of the operation.
In his fascinating article in The New Yorker in 1999, entitled “The Physical Genius,”2 Malcolm Gladwell delved into the link between gifted surgeon and gifted athlete, eloquently weaving the common thread between physical geniuses such as Dr Charlie Wilson, Jack Nicholas, Wayne Gretzky, and Gary Kasparov.
Gladwell helped us to understand that the unifying factor between master surgeon and the elite athlete is the ability to visualize the end result. If we work to develop a mental picture of the end product, the mind will unconsciously facilitate the subsequent physical task in 2 very different but equally important ways. First, with a well-formed virtual image of the intended outcome, our speed, direction, anticipation, and general flow vastly improve, resulting in higher efficiency performance. Second, as an operation progresses and, as often happens, the real-time visual input deviates from the templated preoperative image of the outcome our unconscious mind sends us visceral signals of anxiety. As the magnitude of deviation from observed to expected increases, the intensity of these signals is amplified, prompting us to take a safer course. Without an imprinted goal image, however, the voice in our head that would otherwise be screaming “something is going wrong here” is silenced, and mistakes, if not disaster, can ensue.
In Gladwell's New Yorker essay, he described the absolute requirement of visualization to produce physical genius. The best example he gives is how Jack Nicklaus would never take a golf shot, no matter how trivial, in practice or in competition, without visualizing every aspect of ball flight, trajectory, landing, etc. The fact that his 18 major golf championships are looking more unassailable every day lends credence to the concept that visualization is the critically important component responsible for elite success at complex physical maneuvers. Likewise, it is well documented that Gary Kasparov's chess dominance can be traced to the fact that at any point in a match he could visualize at least 15 consecutive future moves with all of their options and iterations, far more than any of his opponents.3 With the multiple potential end results clearly in mind, patterns of similarity and dissimilarity can be unconsciously arbitrated, immediately throwing discrepancies forward to our consciousness and allowing the physical maneuvers to become obvious, rapid, and fluid.
In the sports world, the perfect marriage of visualized end result to live action is called “being in the zone.” Many surgeons who are and/or were athletes may have first-hand knowledge of this too often fleeting experience where every jumpshot goes in the hoop, personal best speed in a race seems completely effortless, or 10 consecutive wedge shots land within 3 feet of the target from 80 yards away. Because visualization can be learned and improved, regardless of athletic exposure or prowess, every surgeon has the opportunity to “be in the zone” during an operation. In fact, our patients are hoping that we are in that special mental-physical mind meld every time we ask for the scalpel.
In the not too distant past, the attending surgeon was responsible for almost no documentation. In fact, most of the surgeons I trained under didn't even carry a pen. History and physical examinations and surgical consents were the purview of the service intern. Clinical and operative billing and coding was the responsibility of nonmedical clerical personnel. Operative reports and daily ward notes were charged to the resident who assisted on the procedure. As a trainee, I interpreted the attending surgeon's intentional absence of a pen in the breast pocket of their starched long white coat as a symbol that indicated a freedom to focus on the art of surgery with the primary goal of achieving intraoperative physical genius as often as possible.
How so much has changed in so little time! Over the course of 15 short years, we have seen an unprecedented and extreme “escalation of documentation” up the chain of command to the point that most of the documentation, billing, and coding tasks mentioned earlier now solely sit on the plate of the attending surgeon. The upward movement of the documentation burden was slow at first. But soon, largely based on our skill at completing these tasks, the escalation of documentation has rocketed upwards. A recent Physicians Foundation survey determined that 22% of a physician's time is spent on nonclinical paperwork, and other studies indicate that administrative and medical documentation now occupies over half of our work time.4 With new regulations and requirements on the horizon again focusing on the attending physician, including the Physician Quality Reporting Initiative and the Centers for Medicare and Medicaid Service's new regulation for mandatory completion of admission orders by the attending admitting physician, there seems to be no end in sight for shifting the burden of documentation. As a practicing surgeon in the current environment, I now have to carry at least 2 pens to avoid becoming professionally crippled if one runs out of ink.
Together these documentation burdens have encroached on our ability to have a quiet moment before surgery to visualize the intended outcome. One of the most recent areas of intrusion on the surgeon's visualization time has come from the arena of surgical safety. Some of these encumbrances are well-designed (eg, World Health Organization Safety Checklist); however, most are implemented as quasi-medical requirements that serve much more of a regulatory function with little to no published data supporting their favorable impact on patient outcomes (eg, Surgical Care Improvement Project metrics and preoperative history and physical update form).5 Although these recently added safety initiatives are aimed to bring up the rear, helping the relatively few careless surgeons among our ranks to avoid “never” events, there are unintended consequences that have occurred on a population level. By inserting more and more distractions into the perioperative process, however well-intended, we may be shifting the median overall surgical performance downward and making the true genius performances scarce. As the recent groundbreaking study linking technical skill to patient morbidity and mortality from Birkmeyer and colleges6 has demonstrated, there is only one opportunity for a surgeon to perform a high-quality operation and a high-quality operation is the key to both a safe and positive outcome for the patient.
There is no argument that the current emphasis on perioperative safety in surgical practice is warranted, necessary, logical, and well-meaning. The problem is the choice of a single effector instrument. Surely, we can complete many regulatory and administrative tasks for the hospital system. But just because we are good at checking boxes doesn't mean the overall health care system benefits from us taking on these tasks.7 In fact, what we learn by applying Gladwell's constructs to surgery is that, by diverting the surgeon's attention away from the task of visualization during those preciously valuable and mostly irrecoverable moments right before the operation starts, the surgeon loses one of the only accessible times to embed a vision of the patient's optimal outcome in his or her imagination, and the patient loses the opportunity for their surgeon to achieve physical genius (Fig. 1.).
The immediate perioperative environment, in particular, has become cluttered with distracting regulation and documentation that is not evidence based. One of the latest examples of this phenomenon is the preoperative history and physical update form. In many, although not all hospitals, the responsibility for completion of the preoperative history and physical update form falls to the attending surgeon. Unfortunately, completion of this document has never been shown in any study to improve any patient safety or other outcome metric. In the 3 years that the attending surgeon has been required to complete this form at our institution, we are devoid of even one case that was cancelled, or even partially manipulated, as a direct result of the form's completion.
In addition to its lack of efficacy, delays associated with the preoperative history and physical update make it one of the least valuable (outcome/cost) documents in the history of medicine. Conservative estimates indicate that unnecessary operative delays due to the preoperative history and physical update process cost our surgeons and hospital 3 million dollars per year. If even half of this figure was applied to the 4500 hospitals that perform surgery in the United States, the annual cost of this document to the US health care system could be more than 7 billion dollars.
The direct impact of the recent escalation of documentation is erosion of enthusiasm within our field. The euphoric joy that follows a well-performed operation has continued and likely will continue to counterbalance all of the long hours and hard medical work associated with a surgical practice. However, the intensity and duration of this dopaminergic stimulus cannot stand up to the noxious feedback from the ever-increasing administrative and logistical demands of the job.
During the last decade, we have observed several disturbing trends that point to a general dissatisfaction with surgical practice. At the top end of our profession, we are seeing an increasing number of master surgeons in the prime of their careers choosing to spend their nights and weekends in business school classrooms as a pathway to escape surgical practice.8 More disturbingly, as evidenced by up to 80% of finishing general surgery residents applying for subspecialty fellowship, the number of medical students and residents willing to enter general surgery practice is declining.9 This is at least in part attributable to the low morale among supervising surgeons they interact with, almost half of which would not encourage even their own children enter the practice of medicine.10 Combined, these trends signal a loss of talent apparent across the continuum of surgical training and practice that has us in a true crisis.
Growing up my father never allowed me to complain or pose a problem without bringing a solution to the table. In an effort to heed this good advice, I would propose that there are viable, although difficult, solutions to these problems in surgery and that the ultimate remedy will be based on a collaborative team approach to documentation and safety.
First, we need to focus on the team members who already support the patient and the surgeon. We need to lobby for relaxation of the rigid and arbitrary rules that have concentrated the vast majority of the responsibility for documentation onto the attending surgeon, empowering residents (all of whom are licensed physicians), nurses, and mid-level providers to complete the portion of medical and administrative documentation that is well within the scope of their training and expertise.11
For example, there may be no better trained or capable person to assess a preoperative patient for recent changes in health status than a preoperative holding area nurse. Within the nursing documentation that these professionals are already completing is an assessment of our patients that is infinitely more detailed than any of the discussions that I have witnessed between patient and surgeon during the completion of the preoperative history and physical update form. Independent of the facts that this document has never been shown to improve patient safety, has radically changed the workflow of the operating room and annually steals billions of dollars in lost productivity from hospitals and surgeons, isolating the responsibility for this form to the surgical team sends an erroneous signal to the nurse that their clinical impression is not valid and their expertise is not appreciated.
The second area we need to advocate for is the addition of another member to the team...the hospital administration. It is interesting to note that the degree to which a perioperative safety checklist is adopted by a surgical staff is directly proportional to the engagement of the hospital administration in the process.12 Although there is compelling evidence that compliance with a surgical safety checklist impacts patient outcomes, the improvements are subtle, rarely seen at the single surgeon level, and are mostly realized over long periods of time. Given these dynamics, it is only logical that the hospital participate in the process by providing dedicated safety personnel in the operating room to verify that the subset of hospital process-based components embedded in perioperative patient safety are available, functional, and correct (fire equipment, blood products, antibiotics, etc) allowing the surgeon, anesthesiologist, and operating room nurses to focus on the critically important technical issues that directly impact the patient in the moment (ie, sidedness of the operation, airway, intravenous access, sterility and operative plan). Furthermore, addition of dedicated safety personnel to the operating environment would put us on par with many of the other “high-reliability” industries that we are now being compared with, including aviation and manufacturing.
The morale benefits of having dedicated safety personnel in the operating room to free surgeons, anesthesiologists, and nurses to refocus on actual patient care would be tremendous, not to mention the financial gain from more throughput and efficiency. Indeed, the future viability of our specialty may be dependent on our ability to partner with our hospitals to develop functional, team-based documentation and safety programs that return the focus of the providers to the care of the patients.
Third we need a strategy to evaluate and vet future administrative rules, regulations, and forms that seem to relentlessly be added to surgical practice. For this, I would propose a fairly simple litmus test. As each of these new initiatives is considered, we should measure it against the yardstick of “Does this help the doctor to help the patient?” Any new proposal that does not clear this hurdle should be sent back to the drawing board.
Together these novel initiatives would protect surgical teams, restoring an environment that replaces distractions and documentation with contemplation, visualization, and focus on the patient.