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Supplement Article

Becoming the “Captain of the Ship” in the OR

Achor, Timothy S. MD*; Ahn, Jaimo MD, PhD

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Journal of Orthopaedic Trauma: September 2014 - Volume 28 - Issue - p S18-S19
doi: 10.1097/BOT.0000000000000180
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“Becoming the Captain of the Ship in the OR” does not happen overnight and can be challenging as respect must be earned. As a young practitioner, you will undoubtedly face many challenges in the coming years. Attending surgeons are held to high standards, and there is less tolerance for the “disruptive physician.” Becoming a surgeon leader can be difficult, but is important for you, your staff, and your patients. Surgeon leadership in the operating room (OR) is essential to optimize not only patient care but also your daily operative experience.

The term “Captain of the Ship” obviously has nautical roots; it implies there is ONE person who is in charge (and ideally in control) and ultimately responsible for the ship. This concept is easy to apply to the OR, where the attending surgeon has been considered in the same light. When the term “Captain of the Ship” is searched on the internet as it relates to medical terminology, it has actually been very well described. The “Captain of the Ship” doctrine has its roots in a courtroom in Pennsylvania in 1949: McConnell v Williams. In this case, an intern gave a newborn an inappropriate dose of eye drops, which caused blindness. The Supreme Court of Pennsylvania found the attending obstetrician responsible for the act, even though he was not present nor had any direct knowledge of the intern's actions.1 A comparison is seen with the “Captain of the Ship” as it applies to maritime law: the Captain is ultimately responsible for the actions of all crew members at all times.

As the attending orthopaedic surgeon in the OR, you already are the captain of the ship. Therefore, a more appropriate title for this piece may be, “Becoming an Effective Captain of the Ship in the OR.” Keeping this in mind, we began this piece with a bit of brainstorming: What are the ways in which the surgeon can be a more effective leader in the OR? There were many ideas that quickly came to us (Table 1). As we looked at the list, we realized we were describing our mentors. All of us were once young, impressionable doctors who looked up to the older, well-established surgeons. If your experience has been anything like ours, some of the surgeons you have worked with have also had some less-than-desirable qualities. The doctors we strive to be are caring, compassionate, and in control. They always put the patient first. They were able to clearly communicate the operative plan with the team. They never lost their temper. Unanimously, they all had leadership qualities that we admired. When we looked in the mirror, this was the type of surgeon we wanted to become. Although it sounds relatively easy to do, simply imitating characteristics of mentors is not always so easy to do. The OR presents challenges on a daily basis and maintaining your “Captain of the Ship” persona requires patience and diligence.

How to Be a Leader in the OR

Becoming an effective “Captain of the Ship” requires leadership skills. One important aspect of leaders is not only self-confidence but confidence of the entire team. However, what is the key to achieving this? A surgeon can gain confidence in many ways, but a relatively simple concept is preparation. Preparation for an operative procedure involves much more than just creating a preoperative plan. Preparation for operative cases may sound routine, but it is surprising how complacent surgeons become after many years in practice, performing the same surgery over and over. Having a well-thought-out preoperative plan that is clearly communicated with the entire team is essential to the success of the procedure. The residents, circulating nurses, anesthesiologist, and surgical technologists should all be aware of the plan. Preparation and communication tend to go hand in hand. A surgeon who is well prepared is nothing without his team; as such, the team must be prepared as well.

For example, we have all been in a case where the attending surgeon asks for “My Clamp.” When the team cannot find the particular instrument the surgeon is looking for, he or she loses control and starts screaming at everyone, “How am I going to finish this case without My Clamp? You all know I need My Clamp! Find My Clamp!” Of course, because the surgeon is shouting, everyone is scrambling to find the clamp and after a few minutes, the clamp is finally identified. Unfortunately, the clamp was used last night by another surgeon, and it is still dirty and over at sterile processing. Now, the surgeon is so upset, he/she can barely finish the case.

In evaluation of this hopefully not–too-common scenario, nothing good has happened. The surgeon did not prepare for the case and did not communicate the plan for the case to the team. The surgeon has embarrassed him/herself and was probably “written up” by the OR staff. The entire team leaves the hospital that day demoralized and hoping they will no longer have to work with the surgeon who was such a jerk.

To avoid such situations, the key is preparation and communication. Preparing the operative team can be performed in a variety of ways. In-depth preoperative plans are great, but they should be supplemented with a conversation about the upcoming procedure. Important points to discuss include the room setup, operative table, patient positioning, need for an image intensifier, length of procedure, estimated blood loss, implants, and any anticipated sets or critical events. Many of these topics are now discussed during a routine “Time-Out,” but by then, the patient is already under anesthesia and may be prepped and draped leaving your team scrambling at the last minute to find what you need. There is obviously a hierarchy in the OR, but a preoperative discussion with the team shows them that you are approachable and truly care about the team, the patient, and the success of the procedure. It has been reported that before “Never” events, members of the operative team have stayed silent despite their awareness of an impending medical error; all because they were fearful of backlash from the attending surgeon. Obviously, this is the wrong atmosphere in the OR and in fact the opposite of what you would hope for. Although unplanned events may occur during any procedure, a well-prepared surgeon and team who have a comfortable dialogue will always have less-frequent critical events.2

Preparation also involves discussions with the patient and the patient's family. Patients must be prepared for the procedure they are about to undergo. Patient satisfaction will be improved if they understand the procedure, the magnitude of their injury, and have realistic expectations for their outcome. Families will often have additional questions, and these are important to address as well. The social and financial burden of a loved one's injury and postoperative care can be extreme; any information the surgeon can share is appreciated. Remember, in the world of orthopaedic trauma surgery, you are usually meeting your patients on the worst day of their life.

Becoming an effective “Captain of the Ship” in the OR takes years of experience. Although you do not have to be best friends with your team, we do advocate a healthy work environment where all are treated with respect. A wise friend once said, “You catch more flies with honey than with vinegar.”3 Treating patients, families, and team members the way YOU would want to be treated is a great place to start. Preparation, communication, and respect are essential elements to becoming an effective “Captain of the Ship.”


1. Murphy EK. “Captain of the ship” doctrine continues to take on water. AORN J. 2001;74:525.
2. Weldon SM, Korkiakrangas T, Bezemer J, et al.. Communication in the operating theatre. Br J Surg. 2013;100:1677.
3. Watson JT. Things you never thought of that make a difference: personal goals, common sense, and good behavior in practice. J Orthop Trauma. 2011;25(suppl 3):S121.

leader; mentor; preparation; communication; planning

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