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What Surgeons Think About That You Probably Don’t

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Every surgeon, perioperative nurse and support staff has to develop a surgical conscience. In one respect, this is an unwavering adherence to aseptic technique during the perioperative period. Every aspect of the environment in the OR - equipment and personnel, are inspected and monitored closely for the entire duration of any surgical procedure.

 

If you consider that some of the predominant resident microorganisms on the skin include Staphylococcus epidermidis, Staphylococcus aureus, Streptococcus viridans, Corynebacterium diptheriae, Enterococci, Proprionibacterium, Peptostreptococci and many others, it’s pretty clear that anything less than the strictest adherence to sterility will increase the potential for postoperative infection. That’s why you can’t come near an OR without first having put on hospital-issued scrubs, a surgical cap, a face mask, shoe covers and gloves. If you’re actually going to participate in the procedure, then we’re talking about a PAINFUL, 5 or 10 minute mechanical cleansing of the hands and forearms, followed by being dressed in a sterile surgical gown and gloves by a staff member.

 

You have to take a scrub class prior to being permitted to enter the OR, and during the class you think to yourself, “Easy enough. I got this.” only to find out during your first real experience scrubbing in, that you really don’t. You walk into the OR and everyone around you can literally smell the scent of rookie emanating from your apocrine sweat glands. Everyone’s eyes immediately begin looking you up and down to see if you forgot any of the mandatory accoutrements. They’re just waiting for you to touch an instrument that hasn’t been prepped or part of the patient that hasn’t been painted with iodine solution; they’re waiting for your biceps to tire and slowly let your hands down from the altar boy position (elbows flexed, with your hands interlocked in front of your sternum - like you’re praying). The second you let up your vigilance… you and everyone else is going to hear about it.

 

Truthfully, it’s a pretty scary experience. It’s supposed to be. Knowingly or not, the surgical staff wants to scare the bejesus out of you because they know that even if you don’t yet fully appreciate just how vulnerable to infection a patient with an open incision can be, at the very least, you’ll try your damndest not to contaminate the sterile field and risk being humiliated in front of your attending.

 

So the first time you walk into an OR, you enter with an appreciation for clinical hygiene, but as you walk out, you do so with the beginnings of a surgical conscience engrained in your mind.

 

This is the voice within you that holds you to the same standard of aseptic technique when you’re scrubbing in alone and no one is around, as when you’re you being scrutinized by your superiors. The surgical conscience is the acceptance of the fact that every decision you make from the moment you decide to enter the OR, to the moment you leave is critically important to the outcome of the procedure and ultimately to the health of the patient.

 

This thought got my philosophical gears going and I came up with a profound thought. It’s intuitive that a high level of attention to detail in the clinical setting is going to save lives. It may not be so obvious, but as a medical student, isn’t our attention to detail in our pre-clinical training just as important?

 

Maybe it’s a bit stretch, but shouldn’t be there such a concept as the pre-clinical conscience? If so, making the right decisions about when and how to study would be akin to making the right hygienic decisions in the surgical setting.

 

Along that train of thought then, the ritual of the scrub-in would be to surgery, as your independent study ritual in your pre-clinical years would be to your future clinical practice.

 

What if you applied the same standard of conduct in the OR to other areas of your medical training? How much better would you be as a medical student? I certainly believe that your conscience will dictate the caliber of student you will be. I also believe that it will dictate the caliber of physician you will be.

 

Here’s why:

 

When faced with a decision, the conscientious student of medicine will choose to dedicate the right amount of time to focus on the course work they are expected to. The conscientious student will choose to discern data that is relevant to clinical practice from material that isn’t. The conscientious student will then choose to learn that information. Later, the conscientious physician can choose to draw upon the relevant data they have identified and learned prior, to make the right medical management decisions.

 

Let’s look at a clinical scenario to illustrate this:

 

A 24 year old Asian female phones your clinic complaining of dysuria (burning when she pees) . She also thinks she’s running a fever. A conscientious physician knows that her symptomatology is consistent with a urinary tract infection. They also know that they should have her come into the office immediately for further work up.  They also know the test of choice is a urinalyasis, which in this case came back positive. The conscientious physician knows that urine culture is not necessary at this stage. And they also know that first line, empiric antibiotic treatment is a double strength tab of Bactrim™ every 12 hours for 10-14 days. The conscientious physician also knows that Bactrim™ is a synergistic combination of the drugs trimethoprim and sulfamethoxazole (double strength tab 800mg of sulfamethoxazole and 160mg of trimethoprim). Further, they would not forget the fact that sulfamethoxazole is a sulfa drug. Surely they know they had better inquire if the patient has a known sulfa allergy. If they do, an alternative antibiotic they would know they could use is Ciprofloxacin. They also better be sure that the patient doesn’t have renal insufficiency, as Bactrim™ is excreted in the urine.

 

In order to ensure that the above information was memorable and accessible, the conscientious physician might have chosen to ignore the fact that sulfa drugs are named as such because they are derivatives of para-aminobenzenesulfonamide when they were learning this material as a student.  I can’t see how that bit of data would influence anyone’s medical management. Can you?

 

This scenario is a vivid example of how to take information that may be presented to you in a vacuum in medical school and how to have the foresight to apply it to clinical practice.

 

So I hope you can see how being a conscientious student of medicine can have a huge impact on the quality and quantity of information you are able to learn and apply. It’s the right approach to take in your training, not only because it’s ethical, but because it will also help you get the best grades in school.

 

Take away point: The concept of the surgical conscience is having the highest standards for your conduct and your decision making, whether others are watching you or not. In the OR it means scrubbing in properly and adhering to aseptic techniques. Similarly, in your pre-clinical training it is committing to finding and learning as many clinically relevant concepts in your course work. Knowing and being able to apply what you have learned will ultimately dictate the quality of healthcare you can deliver for your patients when the time comes.

 

Yours for higher grades and an infinitely better lifestyle in medical school,

 

Cesar E. Orellana

Publisher and editor

www.MedicalSchoolReport.com

 

PS: For an easy recipe to help you become a conscientious student, visit: www.MedicalSchoolReport.com/free-book

 

References:

Levinson, Warren. Review of Medical Microbiology and Immunology, 10th Edition. Lange. 2008.

McGraw Hill Medical. Drug Monographs.