Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 10.8 Speed in Surgery (+Circs & Autism)
In this episode, Howard and Maddie White challenge shaky claims linking autism to circumcision and Tylenol, then zero in on speed as the byproduct of essential, evidence-based surgery. We show how essentialism, confidence, and efficiency reduce complications, lower costs, and improve outcomes in the OR.
• correlation vs causation in autism narratives and bias in research
• why operative time predicts complications across procedures
• surgeon volume, variability, and outcome differences
• evidence-based cesarean steps that cut time and bleeding
• tool and method choices that are safer and faster
• confidence as self-efficacy, not arrogance
• practical efficiency: setup, flow, visualization, debrief
• lean thinking, standardization, and reducing variation
Be sure to check out thinkingaboutobgyn.com for more information and be sure to follow us on Instagram
00:00:00 Opening Banter & Autism Claims
00:02:35 Circumcision, Bias, and Correlation vs Causation
00:09:54 Why Speed in Surgery Matters
00:15:35 Surgeon Variability and Outcomes
00:19:35 Evidence-Based Cesarean: Essential Steps
00:27:20 Less Bleeding Through Minimal Dissection
00:31:20 Choosing Methods and Tools that Save Time
00:35:05 Confidence vs Arrogance in the OR
00:40:05 Practical Efficiency: Filming, Flow, and Setup
00:45:05 Visualization, Assisting, and Debriefing
00:50:00 Tools, Tech, and Mastering Basics
00:55:00 Standardization, Lean Thinking, and Takeaways
Follow us on Instagram @thinkingaboutobgyn.
Welcome to Thinking About OBGYN. Today's episode features Howard Harrell and Maddie White discussing speed and surgery.
SPEAKER_01:Howard.
SPEAKER_02:Maddie?
SPEAKER_01:What are we thinking about on today's episode?
SPEAKER_02:Well, there's so many things we could talk about. Remember, Maddie is our resident ninja, so we like to focus on resident-focused things or sometimes more basic surgical skills or things like that. But we found that people of all ages and points in their career enjoy these episodes. There's so much diversity in surgery and so many different ways of doing things that I think that most OBGNs enjoy discussions about surgical variety and surgical techniques. And we did say before that we wanted to talk about speed in surgery. And I think a lot of residents and frankly a lot of attendings would appreciate how to be more efficient in the operating room and some things that might help us move along a little bit faster, and the patients benefit from that.
SPEAKER_01:Yes, I am a resident, as you love to remind me. And today we're going to talk about speed in surgery. I'm ready for you to tell me how much faster you are than me. However, before we get to that, Joy, I do have a question about the last episode where you and Antonia discussed Tylenol and autism. I appreciated it. You all did a very, very good job responding to some of the things that are going on that are very alarming and very much scaring our patients. But I do have to point out that you missed the boat entirely. Autism, apparently, is due to circumcision. If you've been keeping up with the news, that's what they're saying now, in which case I've caused two cases of autism just this morning.
SPEAKER_02:Well, I wouldn't admit that, but yes, another week has passed, and so another new cause of autism has emerged. We do have an episode coming up soon where we're going to discuss vaccines. We didn't really get to that in general, but we'll talk about autism and the whole issue there as well. And we have a special guest plan for that, who's an infectious disease specialist, and we have a lot of things that we need to go over in regards to vaccines. So I'm going to save those topics for her expertise. But yes, I did see that it's circumcision, not just Tylenol. Of course, the implication there is that newborn boys who are circumcised receive some Tylenol. So now it's not just antenatal tylenol that the moms take, but Tylenol, even at one dose, I suppose, maybe two, given to a newborn boy who's been circumcised, that must be the cause.
SPEAKER_01:Yes. Well, there was a 2015 Danish National Cohort study in the Journal of the Royal Society of Medicine that looked at a population of boys born in Denmark, and it found a statistically significant correlation between circumcision and a later diagnosis of autism spectrum disorder. Now, in that paper, those authors were hypothesizing that the pain and stress of the procedure during this critical neurodevelopmental period might play a role in subsequent development of autism. They weren't talking about Tylenol there, they were making a different claim. So what do you say about that?
SPEAKER_02:Well, it was an interesting study. And a lot of literature in Europe looks to show harms potentially from circumcision, since Europeans and most of the world honestly, other than the United States, is against ritual circumcision. And Tony and I did do an episode on circumcision where we discussed some of the real pros and cons, and I'd encourage folks to go listen to that episode. We didn't talk about autism as a risk factor, but appreciate that a lot of people do spend a lot of research time investigating potential negatives of circumcision, those who are against circumcision. But I would want RFK Jr. and his folks to know that the lead author of this circumcision article that you're talking about, his name Morton Frisch, also published a paper in 2019 in the Annals of Internal Medicine that showed that the measles, mumps, and rebella vaccination is not linked to autism in children. In fact, RFK has attacked that paper. Such a cherry picker. So if they're going to quote him in one domain, then they need to quote him in all domains. If he has any authority on the subject matter, then we should listen to him in all of his publications. Nevertheless, the mistake here is just one of bias and again correlation equaling causation. So there's there's nothing necessarily wrong with the paper, but this paper was designed to show a harm from circumcision and merely shows some correlation.
SPEAKER_01:Yes. It seemed like every time it's the same conversation where people have done some sort of retrospective data collection and found two things correlated and then assume some causal link. And you all discussed in depth in the last episode why correlation almost never equals causation.
SPEAKER_02:Yeah, almost never. So the same thing's true here again. In his research about MMR and autism, he found no correlation at all. So it follows that there's no need even to pursue a potential causal link when it's not correlated. But just because he also did some research that found a potential correlation between circumcision and autism, all that does is open the door to try to see if there might be a causal link. You still have to do all of that work to prove causality. And I think lay people like RFK Jr. just don't understand that most research that's published is meant to be preliminary and exploratory. Most published papers are in fact simply exploratory in nature. And we don't want to stifle people from looking for possible links between anything. We want them to publish data when they find some correlation or potential link, but then that's just the beginning of the scientific process, not the end of research. And almost every correlation that's discovered, even in the highest quality studies, they go nowhere because ultimately no causal link is found. But I do think that all of us, physicians included, forget that most things that are correlated are not causal.
SPEAKER_01:Have you heard of this book called The Body Keeps the Score?
SPEAKER_02:Yeah. Yes. And I think that that probably has some influence on this research, not necessarily the book per se, but the sort of literature that was growing up that led to that book. So remember, these guys weren't theorizing about Tylenol. They were saying that the pain of circumcision causes subsequent neurodevelopmental disorders. And they were trying to prove that circumcision was an incredibly painful procedure, even with topical vlady cane or a dorsal penal block or something like that. And therefore, this is one of the many reasons why we should get rid of it. And they definitely have a bias against circumcision. Now that book, The Body Keeps a Score, it came out the same year in 2015. And again, I don't know that there's any direct relationship between the two things, but that but there's a bias, there's a prevailing bias that was occurring in some of the neuropsychiatric literature at the time, looking at whether or not these traumas and pains and stuff like that would cause brain stuff. So I imagine that they were the author of the book and the authors of this paper were likely steeped in some of the same research. And so it wouldn't surprise me if the narrative that traumas somehow remodel parts of our brain and how they work on a long-term basis might have influenced the thought process at the time of that paper, just as today RFK is influenced to think that it must have been Tylenol, a complete supposition that he's just invented out of thin air. Now that being said, the lead author of this Danish paper you're talking about is listed in the paper as having a competing interest because he is essentially an anti-circumcision advocate, like this is what he does. And so, again, bias is important. And such hypotheses, uh as circumcision, for example, don't explain why autism is now more prevalent among young girls. Remember, Antonio and I talked about that. It used to be thought of it was boys and back in 2015 when they were doing this research. I'm sure they thought that. But today the rate is actually higher in girls. And also, we don't see a marked difference in the rates of autism among Jewish or Muslim boys who are routinely ritualistically circumcised compared to their Gentile uncircumcised counterparts. In fact, many of the ritually circumcised Jewish or Muslim boys have no anesthesia. So if anything, the magnitude effect should be even greater than some of the boys that are receiving anesthetics. And of course, the authors of this study, they don't make the conclusion about the link that RFK Jr. is citing. But I would make another point about that book, The Body Keeps a Score, which is that it itself has gone on to receive very robust criticism, and subsequent papers have been published and other analyses that have shown that the author apparently intentionally cherry-picked a lot of the data and studies and didn't make himself didn't use all the data that was available at the time to prove his own narrative fallacy. And at this point, I think most scientists believe that the main narrative of the body keeps a score is actually not true and not substantiated by good science. But it became a best-selling book, and people read it, and it makes a good TED talk, and it makes a good narrative, and it helps people maybe explain some things in their life, and then we forget that it's based on rather weak data. It's the same issue where something gets retracted five years later and it's always on the last page or in a little errata section, and nobody ever reads that. And it's this is why we have such a hard time unwinding narrative fallacies. But needless to say, the idea that early trauma of any sort leads to significant brain anatomic differences and then potential neurodevelopmental issues, which is the claim of the Danish study that the pain that these boys suffered led to autism, is not a proven link and has week to no data to substantiate that.
SPEAKER_01:Okay. Well, speaking of pain and suffering, I think we can move on and talk about long surgeries now, which is our goal of this. So we're going to talk about speed and surgery. I'm sure we'll find something else to blame autism on next week and we can talk about it all again then. But to our main point of this episode, we're going to talk about speed and surgery for a few minutes. And like you said, I think this is something we all struggle with. That and whether we're residents or attendings, we all want to be efficient and fast in our surgeries. It's not always obvious why we're not. And it's frustrating sometimes to try and figure out areas where you can be quicker. Clearly, there's a wide variety in how long different surgeries take different people, and that's what we're going to kind of get into.
SPEAKER_02:Well, first I think we should talk about why speed and surgery is important if it is, right? So there was a paper in the archives of gynecology and obstetrics in 2022 that looked at the risk of prolonged operative time at cesarean. And of course, I mean, I think this is one of those studies proving that the sun rises every day, it predicted that the length of surgery was a marker of subsequent maternal complications. So cases in the 90th percentile or greater for length of surgery were associated with increased hemorrhage, prolonged maternal hospitalization, treatment with prolonged treatment with antibiotics, readmission. And in this study that I'm talking about, they defined that 90th percentile or prolonged operative time at cesarean as something greater than 60 minutes. That's what they found in their sample. Of course, the range of cesareans, they can take as little as 10 minutes, and they can take two or three hours in some cases. But most are well under an hour. And obviously they found 90% were under an hour in total operative time.
SPEAKER_01:Okay, but isn't it true that the reason why a longer operative time predicts more complications is because the hard cases or the more difficult ones, the complicated ones are going to take longer. So if you have a patient who's bleeding excessively or has some other issue going on, it's a repeat, they're obese, that kind of thing, then obviously you're going to have an increased risk of complications.
SPEAKER_02:Of course, yes. And this is the problem with this whole discussion. And it's also how we rationalize sometimes when we have longer cases, right? We blame the patient factors. So we have to make this distinction. So it does depend on what you're looking at. Now, if you were to take all of my cesarean deliveries, Howard Harrell, that I've ever done or that I've done in the last hundred, let's say, might be fairer.
SPEAKER_01:Or that your medical students have done.
SPEAKER_02:Or whatever, residents, whoever. But and that's a fair point. In that study and in other studies, even if residents do the case, there are groups of attending and attendings who, even with residents operating, are much faster with the same residents than when another attending is operating. And so it's we can't blame this on residents or students either. Like it might be a little bit slower, but this follows. But if you took all of my last hundred C-sections and calculate the average operative time and then look at the range of operative times, and then you subdivide that data and look at my cases that are in my 90th percentile of operative time, then you undoubtedly will have discovered those hard cases that had more that will have had more complications. There might be accretas or procretas or something in there, or atnee that needed to be treated, or a surgical hemorrhage, or just dense adhesions getting in, there was something going on that made that case take longer, and those things are by definition complications. So that's very true. But on the other hand, if you compare my average operative time for cesareans to, say, Dr. John Doe's average operative times, and you find that my average operative time is 17 minutes with a range of 7 to 30, and Dr. Doe, his average operative time is 51 minutes with a range of 32 to 98 minutes, then you'll still be able to show that and predict that there will be significantly more adverse outcomes for Dr. Doe's patients, even when you account for the variability. His 90th percentile is really bad, but his averages are his average outcomes might be like my 90th percentile. So total operative time matters, and you have to compare surgeon to surgeon a little bit.
SPEAKER_01:All right. Here we go again, comparing everyone else to your operative times. Could you just make that average range up for you? An average of 17 minutes with a range of seven to thirty.
SPEAKER_02:No, I looked it up. So one thing, and I'm actually surprised it's so long, but that and nobody knows their own operative times, right? Everybody tends to overestimate or underestimate, I think. I don't know that it's a pattern. So one thing folks can do is look in your electronic health record, and most of them, especially certainly Epic, half of us use Epic, will have this data for you. And so you can take those numbers straight out of Epic, which I think has a rolling average. It does the last X number of cases, 20 or something like that. It's how it predicts your operative times. But you can drill down on this data and you can find this out for all of your surgeries pretty easily. But you can imagine that a cesarean on the shorter end, yes, is going to be on anybody's range, right? Is going to be that primary cesarean, thin patient, not all prior abdominal surgeries, uncomplicated operated on abdomen. And the patient on the longer end is going to be the scar tissue, prior cesareans, prior surgeries, difficult delivery, hemorrhage, atomy, all those things. Or maybe you had to do a salpingectomy or something that makes it take longer.
SPEAKER_01:Yeah, or maybe you'll let the med student so maybe.
SPEAKER_02:But again, I'm still going to be faster with a med student or a resident than Dr. Doe is. So, but think about what shorter operative times mean. They mean less anesthesia exposure. And so therefore, things like fewer issues with nausea or delayed return to bowel and bladder function or development of pneumonia and stuff like that. Those things all translate into quicker recoveries, quicker discharge home, shorter lengths of hospital stay, quicker return to normal activities. Shorter operative times mean that the patient spends less time immobilized in a positioned state, which then leads to fewer cases of thromboembolism and fewer positional neuropathies, perhaps, or retractor injuries, things like that. A shorter surgery also means that there's less time with an open body cavity exposed to the air, which leads to fewer infections and ultimately less sepsis and those sorts of things, also better wound healing. So length of surgery matters. And apart from that, a shorter surgery means lower cost for the patient in the hospital system. And it means more access to care then for other patients, not just because the operating room is more available to more people, but also because the whole ongoing operation is more financially sustained.
SPEAKER_01:Well, I think a lot of those risks and complications you just mentioned are rare enough that most people don't see them within such a short time span and therefore don't necessarily think of them as being related to the length of surgery. And I also think most of us assume that when our surgeries take longer, it's just because it was a difficult or challenging case or a difficult or challenging patient or pathology.
SPEAKER_02:And it may have been, but we also have a problem with blaming the patient a lot of times for failures that we have in medicine. So of course, we're good at rationalizing, and that's why we need data. We need evidence-based medicine and we need objective data about our own outcomes and links to surgery and things like that to show us where our weaknesses are, where our opportunities are, and why these things matter. Now, there's a famous paper by Daly and colleagues published in 2015 that reviewed 100,000 surgical cases from 21 hospitals, actually in Tennessee, and they found that longer operating times were associated with increased risk of uretery tract infection, organ-space surgical site infection, sepsis, septic shock, pneumonia, DVT, renal failure, wound disruption, cardiac arrest requiring CPR, and of course death. They found that surgical site infections, for example, occurred in 14.1 per thousand cases per hour, starting at 42 minutes, and 16.6 per thousand cases of sepsis occurred for each additional hour longer than the standard time above the length of the standard time that the case would normally take. A total of 116 per 1,000 additional negative outcomes were associated with each extra hour of surgery. Whereas, of course, across the spectrum, this is all kinds of surgeries, the fastest procedures had the lowest composite rate of negative outcomes. And some of that was because they were the simple patients. But even when you, again, when you do that intra-surgeon observer who, in theory, over a large number, have a range of equally complicated patients, it still holds true.
SPEAKER_01:Okay. So we need to focus on the things that slow us down, apart from the different patient factors. No one can deny that some people are just faster in the operating room than others, and studies consistently show that higher volume surgeons typically are faster and have the best outcomes. I'll put a link to a study I found from 2016 that showed that the annual volume of the surgeon had a significant impact on short-term interval outcomes at the time of cesarean delivery, even if those cases were just supervised by a high volume surgeon. You want a surgeon who does more cases and you see that pay off and decreased rates of hemorrhage and infection and reoperation and febrile morbidity, but also decreased operative times.
SPEAKER_02:Yeah, in that study, the high volume surgeons were quicker with the repeats and the primaries, and they were quicker from skin incision to deliver the fetus, they were quicker from skin to skin, total time, everywhere you sliced it. And like I was saying, that included even if they were just the supervising physicians. Every resident in every surgical field, I think, knows that residents are maybe faster or slower depending upon who the attending is. Some attendings you're just quicker with and some attendings you're slower with.
SPEAKER_01:So how long should surgeries take?
SPEAKER_02:Well, that's the million-dollar question, and of course there's no concrete answer to that question. But they should take as long as needed to complete all the important and necessary steps, but they shouldn't take longer than that. Even when you look in published studies of surgical procedures, a lot of the cases that are recorded are from academic centers where learners are participating in the surgery. So some of the average lengths of surgeries that you see published are longer than I would expect them to take a busy private practice surgeon because they do involve learners. But still, it's a good reference point and they're all over the place. I do want to read a quote though that I always think of in this conversation from Joel Cohen, who discussed speed in surgery quite a bit in his own book in the 1970s that was about abdominal and vaginal hysterectomy. And I have to warn you that he's a bit cocky. The whole book is, but I'll let the quote stand for itself, and so this is Joel Cohen. Although speed as such is no criterion of the surgeon's ability, with simplicity and constancy of technique, no waste of movements, and using instruments properly, there is an enormous saving of time. It is therefore necessary for me to say that without hurrying, my own average time for abdominal hysterectomy, that is a total hysterectomy from skin opening to complete skin closure, is usually about 20 to 25 minutes. Faginal hysterectomy with repair, anterior and posterior, is also 20 to 25 minutes for the complete operation, and without repair, an average of 12 to 15 minutes. These are recorded times and not yeses.
SPEAKER_01:Well, and those operative times came before things like energy sealing devices and all the bells and whistles that we have today.
SPEAKER_02:Yeah. And obviously, this is the other problem you get with literature or books or whatever, is the person writing it is the master at what he did. Don't compare yourself to Joel Cohen or whatever. But those times can be fairly realistic, and that's the high end. That's the 95th percentile, I guess. I want to include some times from Joel Cohen or my own cesarean times, for examples, in this conversation, just as a frame of reference, because a lot of people may not have an idea of what's possible or how long surgery takes in the hands of good surgeons. A lot of people in training programs, frankly, have just seen other residents operate and they graduate and they didn't know that people do C-sections in 10 to 15 minutes, they do vaginal hysterectomies in under 20 minutes. Most simple vaginal hysterectomies should take less than 20 minutes. I I've seen a video of one that took six, the whole thing. Most things like laparoscopic salpingectomies should take maybe five to seven minutes, things like that. And most cesarean, even complicated cesarean hysterectomies should take under an hour. But most residents graduate not really ex getting that vibe and having seen that. So really the question is if things are taking longer than some of those times, there's an opportunity for improvement, and then how do you do better?
SPEAKER_01:Yeah, that's what I really want to get into, I think, is how can a surgeon become faster? And I know that you have thoughts on this.
SPEAKER_02:I do indeed. And I've written about this extensively before. The first thing I talk about is this concept of essentialism, or another word for that might just be simplicity, but simplicity of technique is really the hallmark of good surgery of and of good surgeons, and it saves time. It also reduces complexity, which gives fewer steps during which a mistake might occur. It reduces the perceived complexity or difficulty, which in turn boosts the surgeon's self-efficacy. So I love this Einstein quote, which apparently he didn't really say, but I've been using it in talks for years. But something like everything should be made as simple as possible, but not simpler. And it sounds trite, but it's like surgery should take as long as possible to do each step, but not any longer. The key here is learning what those essential steps are. So we see people, first of all, who are slower in surgery because they do all sorts of steps that aren't essential. They're not necessary, they don't add anything to the case.
SPEAKER_01:Yes, cesarean delivery is a great example. People do lots of extra steps. They dissect off layers, they close certain layers that others don't, and it obviously adds to the time and complexity and risk of the surgery. They stare at bleeders, they stop dehemostat and cautery on the way down and on the way out.
SPEAKER_02:Yeah, so so yeah, so let's do essentialism here. So think about cesarean in its most basic form. You have to open the abdomen, open the uterus, you have to deliver the baby and the placenta, and then you have to close the uterus and the abdomen. And those are the most essential things you have to do. But you can add so much complexity to each of those steps. So for example, closure of the parietal and visceral peritoneum are commonly done, but aren't evidence-based and are unnecessary. Using sharp entry and dissection into the parietal and visceral peritoneum are also unnecessary. You can use blunt entry and it's faster and it's better for the patient. Dissection of the rectus vessels off the rectus sheath is an unnecessary step, but I do find that is one of the hardest steps to get people to quit because they're so convinced that they have to do it for their surgeries. For routine cesareans, for almost all cesareans, frankly, it's simply unnecessary and it's not part of the evidence-based cesarean delivery technique. Things like irrigation, manual dilation of the cervix are unnecessary, two-layer closure of the uterus is unnecessary, non-enclosion of the vesicle uterine peritoneum into the hysterotomy closure is unnecessary. People also do things like put clamps along the edge of the uterus before repairing it, and that's an unnecessary step. And Tony and I have talked before about the bove at the time of cesarean, and that just adds many minutes to every cesarean for just no reason at all. I haven't had a bovey on my cesarean tray ever in my career, and I don't know, I've done 1400 or 1500 cesareans, something like that. And so far I've never taken a patient back, knock on wood, to the operating room for bleeding or had a surprise rectus sheet hematoma or something like that where all of a sudden I regretted not having a bovey. Also, cleaning out the uterus with a sponge is unnecessary, and reapproximating the rectus muscles is unnecessary. So if you're just doing the essential steps of making an incision with a scalpel, doing blunt dissection all the way into the peritoneal cavity, and then making an incision into the uterus with the scalpel, bluntly extending that incision in a cephalocad direction, and then delivering the fetus, removing the placenta, doing a one-layer closure that includes the peritoneum of the uterus, followed by a one-layer closure of the fascia, closing a sub Q if the fat's greater than two centimeters in depth, and then closing the skin, and you're halfway good at sewing, then your cesarean is going to be in the 15 to 20 minute range on average, even with that one minute of delayed cord clamping and not being in a real rush. But once you start adding in all this extra sharp dissection and all these other techniques and the bovey and all the extra layers of closure, then of course it's going to take longer.
SPEAKER_01:Well, I did my first cesareans with you, and I remember doing those steps. I remember never using a bovey and never having an issue with bleeding. And then I went to residency and all of a sudden the bovey was there, and now I've forgotten the tricks that you do for bleeders. I honestly can't think of what I would do if I came to a pumper that wasn't getting better with just pressure. And so it's interesting how easy you lose those techniques. I also feel like at baseline cesareans with your technique were just less bloody. It's shocking how hard it can be to keep good habits and how quickly we forget everything or little tricks to kind of get things under control. Okay, so then how do you decide which steps are essential? You and I have been working on a document with all the surgical procedures we do and all of the steps of each thing and thinking about every single step and each alternative that could exist for each step. And then of course going to see if there's any evidence that one method is preferred to another, which steps are actually essential. We have this now for cesarean delivery, but as you said, people still seem to pick and choose which parts of evidence-based medicine they want to follow, but all those things that you said that are unnecessary don't have scientific s support.
SPEAKER_02:Yeah, you said my technique, but it's really not my technique. I just do the technique that's in that evidence-based cesarean guide. And it is less bloody and takes less time and all that. I also think if you have those questions about that, then listeners will too. So why is it less bloody? Well, part of the technique of a miscoflotic or Joel Cohen abdominal injury is not disrupting the blood vessels that the veins that are that you frequently encounter. So when you enter, you only incise the fat, the subcutaneous fat, for about four or five centimeters in the middle, you don't do it across the length of the incision, and your goal should be to never get into the veins. Whereas other people are stopping and deliberately identifying those veins, clamping them, boveing them. When you do that, of course, you're decreasing the blood supply to those tissues. Or they don't stop and deliberately do that, and they take their fingers and they just rip right through them, and then they're bleeding, and now you You have to do something with them. So it's less bloody because you're not disrupting all this tissue. The goal of the evidence-based cesarian technique is to really be minimally invasive and disrupt tissues as little as possible. But a lot of people do this maximum dissection. When you dissect the rectus sheath off the fascia, you're going to encounter a lot of rectal sheath perforators that are going to pump and you're going to have to then cauterize them or do something with them. And if you don't dissect those rectus muscles off the fascia, which serves zero purpose, it just doesn't serve a purpose. People think it does, and they've convinced themselves they can't do it without it. But anyway, then you're going to have more of those to deal with if you're doing that unnecessary and non-evidence-based dissection. So it's things like that. And let's say that you do get one of those uh vessels on the way in, what do you do? You put a hemostat on it, right? So I mean, I'm not saying this happens every case or even every fifth case, but occasionally you put a hemostat on something for 30 seconds to a minute, and then it's fine. So yeah, we can talk more about those sorts of things. But yes, you've got to do this sort of like deep dive into the steps and find out what the essential steps are for every procedure that you do. And I know you've been working on that with this, and I think about all of the details of each procedure and where's the evidence for it? Is it actually essential? Things like do you really need to tuck a patient's arms if you're doing a quick five-minute laparoscopic salpinjectomy? Do you need to put a uterine manipulator on a patient who's having a salpingectomy and then therefore have to do a vaginal prep and all of that? Do you need to prep the vagina just to drain the bladder before a salpingectomy? Or can you just have the patient urinate right before she comes back for the procedure? Do you need to clamp a tenaculum on the cervix if you're putting an IED in a patient who's six weeks postpartum? So, like every step, break down every step and think about why do we do it? What's the evidence? Is there evidence? And this sort of thinking not only eliminates steps, but it makes our procedures less expensive, less invasive for the patient. And so I encourage people to think in this essentialist mindset. You'll lower cost, improve quality, and you'll become a faster proceduralist. As I said before, surgery is a thousand little things done well. And we should be analyzing each of those steps of surgeries in as much detail as possible, or any procedure, and try to understand them. And you have to think in that level of detail in order to find those essential steps and then become good at them and do them iteratively and make sure you're doing them in with the best technique and doing those right steps every time you do a procedure.
SPEAKER_01:Yeah. You're talking about not doing things you don't need to do, like a uterine manipulator or a vaginal prep, but it's also about picking the best method when there are alternative ways of doing something.
SPEAKER_02:Sure. So yeah, in the previous episode we did together, you and I, we talked about laparoscopic entry techniques. And the conclusion of that episode essentially was that the most evidence-based way of gaining laparoscopic entry was with a direct entry optical trocar. We decided that was safer than some of the other methods that we talked about. Obviously, we also talked about where to put the trochars in the abdomen. But I don't know, recall if we explicitly said that direct optical entry trochars are also faster. It's just simply quicker to gain peritoneal entry with a direct optical entry trocar than with, say, a varus needle or a cut-down open laparoscopic method. Very often the thing that's better for the patient is also quicker. And even if sometimes the thing is a little bit longer, well, it prevents complications that then makes it quicker. Like it's just a natural truth that usually the quicker way is the better way. I think I also, in that episode, allowed for using barb suture as much as it pains me to close the cuff at the time of laparoscopic hysterectomy, even though those sutures are more expensive, and I quietly am judgmental about it, but it works well, it's safe, and it's safe, it doesn't have higher dehiscence rates or anything like that. And for most operators, it will cut many minutes of OR time, which is expensive and more than pays for that suture, and therefore produce a shorter surgery, which is better for the patient. So we want to eliminate unnecessary steps and unnecessary complexity from every surgery and procedure. And sometimes slower surgeons will look at faster surgeons and just assume that the faster surgeons are skipping important steps or taking shortcuts for the sake of speed. But that's that could be true. But I think that's usually just an unfair criticism. I'm not lazy. I don't do things just to be fast. So I don't, for example, rip the fascia and peritoneum during abdominal entry for a cesarean. I don't rip it open, which is the way people describe it. I don't use blunt the blunt technique of the Joel Cohen Ms. Gothlotic style entry because I'm trying to go fast, but because high quality evidence shows that it's associated with better patient outcomes. It's evidence-based. If sharp dissection of the peritoneum, or closure of the peritoneum for that matter, was better for the patient, then I would do that. In the same way, I don't use an energy sealing device at the time of vaginal hysterectomy because it's quicker, but because it's safer for the patient and it results in less blood loss and less pain. And yeah, it's a great side effect that it's also quicker. And that's good for the patient, and it ends up actually probably being cheaper because the savings and operative time for most surgeons is going to more than pay for the cost of the device. So speed is the achievement of good surgery. It's the end result of good surgery, not the goal.
SPEAKER_01:Well, I do agree that a lot of the procedures we do are just built up over time, and a lot of things have been added and made more complex because of previous misunderstandings or one-offs or things like that. And so it does require a new thought process to go back to the basics and try to understand what's really important and what's really necessary. I think if you asked people that bovied all the way through the sub Q or the FAT and they got those vessels and they put hemostats on them, they're still going to tell you that they did the standardized operative cesarean delivery. They still believe that they're doing just the basic steps and that those little things, even though they're not specifically mentioned in the paper, aren't necessarily additional steps that are unnecessary. So, yeah, that's essentialism, I guess. What else?
SPEAKER_02:Okay, well, the next broad area is just confidence. I saw a video on social media recently that presented some scenario about which surgeon would you rather have? And it was the comparison was an older surgeon who was slow, then methodical, or a younger surgeon who was a bit cockier and had faster surgeries. But in theory, they supposedly both had the same outcomes. In the comments, I thought were interesting. Most people in the comments wanted the older, slower surgeon and didn't like the young surgeon who was portrayed as being overly confident and went too fast, I guess. But that's a false premise. The younger, faster surgeon in real life would have better outcomes than the older, slower surgeon. So, like, don't use being methodical or whatever as an excuse for being slow. But let me highlight a difference here between self-confidence and self-efficacy and then just ego or arrogance. So self-confidence and self-efficacy are essential to the essential qualities of a good surgeon, but there's no room really for ego and arrogance. These are not the same things. In fact, arrogance is usually what's exhibited by surgeons or people who have low self-efficacy and low self-confidence. In one of my favorite books called Techniques and the Use of Surgical Tools, the authors write that the quote, the surgeon who terrorizes his operating team is advertising his inadequacies and lack of self-confidence. You will actually want a surgeon who's confident, not arrogant, and believes that they know how to do your surgery, they can handle what's going to come up, they know how to take care of, recognize, and take care of complications. That's not arrogance, that's confidence. The truth is most surgeons lack self-confidence and they lack self-efficacy. And so they stumble and stutter through the surgery at a slow pace, questioning every step. They're diffident, which is the opposite of confidence. So my second point to work on after essentialism is confidence.
SPEAKER_01:Okay, well, how do we become more confident?
SPEAKER_02:Well, knowledge. I think first is just to learn as much as you can about your procedures and as much in in as much detail as you can. Our discussion we just had about going through every single step and dissecting it and analyzing it and looking for the evidence and understanding it is the way you start that. You have to read, you have to watch videos, you have to ask good questions of mentors and teachers, you have to watch good surgeons, and you have to watch bad surgeons for that matter, and understand what they're doing poorly and why things are why they're struggling and what went wrong. I've often said that I've learned more from watching bad surgeons than good surgeons. The key, the good surgeons sell through and there's, whoa, that was easy. And the bad surgeons are like, oh, why are they struggling? Why did they have that problem? And you go look for those answers and try to understand it. The the key then when you see surgery is to reflect and understand why people are struggling or why things seem complex or difficult. You also need to learn anatomy very well. And I'm shocked at how bad a lot of surgeons and OBGYNs are at honestly just basic anatomy. No one says it out loud, no one admits it, right? But you should be very interested in anatomy. And I would encourage most residents or even practicing OBGINs for that matter to go back to the very basics, get your anatomy book from first year med school and reread about the anatomy of the pelvis now that you work in it every day. And I think it'll have a lot of meaning to you now. It'll remind you of a lot of things that you once knew or learned that you've forgotten, and it'll mean it'll obviously make more sense now. The other thing I would say is that people really need to focus on the how of the technique and not just the why. There are a lot of folks who do surgeries every day and they're pretty good at it, but they're just mimicking the steps that they were taught in a way that on the order they were taught to do them, and they have good outcomes and they get by and they're fine, but they don't really understand why they're doing those steps. They're just copying the people who taught them. So for example, if you see somebody who's still making bladder flaps at the time as cesarean, because someone they're mimicking someone else, and then you ask them, well, why do you do that? Why do you make a bladder flap? They'll come up with an answer. They'll have a why, but it's usually not true, right? They'll say, well, I'm trying it's protects the bladder. Well, no, it doesn't. It puts the bladder at more risk. Well, it helps expose the location for the hysterotomy. No, it doesn't. It's it'd be too low if you did that. They don't actually know why they're doing it. And the narrative fallacies they create to explain it are dangerous and perpetuate myths in our specialty. But they just started doing it because when they were younger, somebody taught them to do it that way. They learned the step from someone who taught them, and that person learned it from someone who taught them, and the cycle continues. So I say, no, don't be a parrot. Learn why you're doing each step. And if there's no reason to do it, you shouldn't be doing it. If you can't tell me the reason why you do the step, even if you do it really well, you probably don't deserve to be doing the surgery or you shouldn't be using it, right? These things will help you with confidence when you know what you're doing, and they'll help you be a more deliberate surgeon, not just going through some rote steps, but deliberately moving through the case in a positive direction with confidence, with options, with a knowledge of what to do if something goes wrong, with repertoire, with the ability to adapt. You see new residents stutter and stammer through surgery. They take the needle, say at the time of cesarean, and they don't just throw the bite through confidently, but they pick the tissue up and analyze it and stick the needle in and then take it out and make a two millimeter adjustment and move it back and forth, and they're kind of looking for approval and second-guessing every little step and wondering if they should be one millimeter further to the left. And they're worrying about little differences that just don't make a difference. They're not confident. They they may be right or they may be wrong, but they're not confident about what they're doing. So the goal here is to make purposeful, confident, deliberate progress with every step and to be intentional, and that takes knowledge and confidence.
SPEAKER_01:Okay. So so far we have essentialism and confidence. Anything else?
SPEAKER_02:Then there's that part that Joel Cohen talked about, which is just actual what we would call efficiency. So let's say that we've decided on the best steps of the surgery, we've done that analysis, and we know why we're doing the surgery, and we know the anatomy well, and we have a plan and we're deliberately moving through the case with confidence. We've got the best techniques, we've got the right instruments, and all those sorts of things. That's the basics. But there's still a lot to be said for just plain old fashioned efficiency. Now Joel Cohen, when he wrote his book, he actually took photographs and did a time analysis of every step of his surgeries and he looked for ways to gain efficiencies in the same way that an assembly line in a company making some widget might look to make their own manufacturing process more efficient.
SPEAKER_01:Okay. Well, give me some deliberate things to do to improve my efficiency.
SPEAKER_02:Well, one of the best things, honestly, is to film yourself. That's essentially what Joel Cohen did, and I've done it, and it's wonderful. You don't even need to film the surgery, and that's nice, but you need to film the operating room and see how things are flowing. Going through and then intentionally analyzing where you're losing time and which steps are slowing you down and what things you had to wait on in the OAR, what things weren't opened or prepared before the case started, those sorts of things. You'll learn a ton from doing that and looking at it from the total team perspective. In a good surgery, you have all the sutures and equipment that you need already open. There's just a natural efficiency of movement. When you need something, it's in your hand. In a bad surgery, there are long pauses between getting what you need after you ask for it, and sometimes they have to go out of the room to find things, that sort of thing. So those are easy, low-hanging fruits. Another thing I'm a big believer in is visualization. So I use visualization for every procedure or process that I do. Even like talking to a patient, you can do visualization. Close your eyes and do a cesarean in your mind. Do it in as much detail as possible. See how the needle's loaded in the driver. See the needle moving through the tissue. See how you grab the tail of the suture and how you tie the knot. See the knot coming together. And is it a flat knot? Is it a square knot? Is it laying down correctly? What are your hands doing? If you can truly visualize a surgery in every detail, you'll become so much better at it, and you'll learn about your gaps and inefficiencies. I also think that assisting other people is just a superpower. I think I learned more about vaginal hysterectomy by assisting people than by actually doing them myself. I'm trying to anticipate their needs and their next steps, and I see why they're struggling, what they need, exposure they need, what's difficult, and how it could be made better. And then I can in turn take that and translate that when I'm doing the surgery to help people help me better. You've got to analyze this on a very fine level of detail in order to benefit from it. You can't just stand there as the assistant and not participate. But in many ways, I think the assistant's more important than the surgeon or self. And in the same way, you want to watch good surgery. And you don't need to do that even in person. You can get that on YouTube nowadays or other surgical video websites. Watch as many good surgeries as you possibly can. I think debriefing at the end of a surgery is very important, whether with yourself or with your team. What steps were difficult and why were they a struggle? What how can you make those things better? How can you cut down on the struggle the next time you do it? What can you work on outside of the operating room before your next case in order to make that struggle easier? That might be, I don't know, intercorporeal knot tying, for example. You can do that in a sim lab or with a trainer. You don't need to struggle with that every time in surgery, but find your weakness and work on it. Learn about different surgical instruments and make sure you're using the best tools for each job that you do. One of the greatest tricks I know in vaginal hysterectomy, I always talk about this, is using a right angle clamp along with a bovey to take down the last part of the uterusacral cardinal ligament complex for a non-descending uterus during a vaginal hysterectomy. Well, most vaginal hysterectomy trays don't have a right angle clamp on them. They also don't have things like jorgons and scissors, but I love using jorgons and scissors when I do morcellation because they're usually the sharpest instruments in the OR, and I have a lot of confidence with the acutely ankled tips that I'm not cutting too deep into the tissue that parts I can't see. So if I didn't know that jorgens and scissors existed or that right ankle clamps existed, these vascular clamps, for example, it would make my life as a vaginal hysterectomist much more difficult. So be familiar with all the instruments and all the things that are available to you, and even the variety of needles and stuff like that. Some people struggle at vaginal hysterectomy because they use needles that are too large and they have this perpetual difficulty getting the needle driven through the tissue, especially high up on a pedicle where there's not much room, which is part of the struggle. But get a smaller needle and take advantage too of enabling technologies like an energy sealing device for hysterectomy or that barb suture for your laparoscopic cuff closure. You can take these things too far. You don't want to be the first person that every rep calls on when they have a new product. You don't need to use an energy sealing device to do salpingectomy at the time of cesarean, for example. That's just a waste of several hundred dollars. So again, enabling technologies and equipment's not an excuse to order all sorts of specialized glenar clamps and retractors and stuff your operating room doesn't have to gain two seconds of efficiency or something like that. But in many cases, do the right analysis, and these things will make your surgeries easier and probably save money if they're really cutting down on your operative times and your complication rates. And all that being said, master the basics. I think that these surgical reps come in and take advantage of frustrated surgeons who are struggling with parts of their case, and they bring in new bells and whistles and new tricks and gadgets that are very expensive and add tremendous amounts of cost to what we're doing when that surgeon just needed to go back and master the basics. Remember,$800 golf club doesn't fix a$5 swing. So most people struggle at basic surgical procedures because they lack competency, not because it's difficult. Surgery should be mostly enjoyable and it should seem easy while you're operating. And so if you're always feeling uncomfortable and you're struggling during every case and you're worried and anxious, that might be a reflection that you haven't mastered the procedure yet. And so get back to the basics, master them step by step. And that gets back, I guess, too, to what we talked about with just confidence.
SPEAKER_01:Yeah. And I know you and I have talked about teaching as well. I think that's one thing attendings do with residents. And then one thing that residents should do in order to master procedures is they should be able to teach them. And that's just true of everything. Your ability to teach something will reflect your mastery of it. And so going through and explaining to your student or your junior resident or whoever as you do each step why you're doing it or what you're thinking about is a very useful learning tool both for your learners, but also for yourself. You should take the time to practice before you're teaching them. And I think that's what residency is all about is your chiefs are dictating to you and then you're doing the steps, and then you should be able to do that to the medical students in the future.
SPEAKER_02:Yeah, and teaching reflects mastery, absolutely.
SPEAKER_01:Yeah. And you mentioned recording with a camera, your procedures, but that's not always that easy to do. It takes time to obtain consent and all those sort of things. So it's not always super practical for most people. But another thing you and I have talked about before, and I know that you've done this, is just wearing an audio recorder that records an audio track while you operate.
SPEAKER_02:Yeah, absolutely. So what you do is they have all these little inexpensive digital recorders. Now you wear a recorder around your neck, it can be under your gown. And then as you operate and you do that teaching you just mentioned, where you're talking through the steps and in detail, well, then you can take the audio and you can use AI transcription software to make a transcription that's time coded. And then you can go through and analyze, like Joel Cohen did, how long did you spend with each step? Where were you struggling? What things took longer, what were when you asked for something, where were the pauses? You can work on all those inefficiencies and you can kind of narrate them as you go. You can even have keywords that you use during your case to find the part you're interested in, because with AI-enabled transcription software, which you can do for free nowadays, you can have a word that you say that you search for and draw attention to some part and then find it and work on ways to improve. But the timestamping of that's really interesting. When people struggle, I often ask, oh, well, what took long? Well, they don't really know. And then if you have timestamp of that, you find out, well, gosh, you spent 35 minutes closing the cuff on this laparoscopic hysterectomy. You know, let's talk about that. Do we need to get barb suture? Do you need to learn how to sew or practice in a dry lab? So that's another way of doing it without all the struggle of a video camera. Another thing I think about is lean manufacturing or lean production. It's a set of principles that are used in the manufacturing world to minimize waste and promote efficiency in manufacturing. A lot of these principles you see in a lot of hospital and quality improvement projects or efficiency projects, flow times through the operating room or the ER or things like that. And the principles here, you want to get rid of waste, which includes wasted materials, wasted equipment, wasted steps. You want your process to be easy to teach and easy to learn. And you want to use standardized processes and standardized proofs of your processes. I would encourage people to apply these processes to surgery and attempt to reduce unnecessary variation, which is a principle too of lean processes. Variation is the root cause of unpredictable and unexpected outcomes, whereas standardization and simplification helps to reduce variation, and then that improves reliability. We have too much variability in our surgical techniques. This is one of the potentially great things about like the standard evidence-based cesaring technique is that residents can learn the same technique and they can do it over and over again, which means they become better at it. And then as a culture, we can take this standard process and study it well and make iterative improvements as we learn from it. But when people, you know, don't adopt it completely or do have all sorts of variation, you never that that potential never comes about. If you meet five OBGYNs, you'll find 55 different ways of doing a cesarean, not to mention every other surgery that we do. And we need to do better than that. We need standardization.
SPEAKER_01:Okay. Well, things that I've learned on this podcast today, essentialism, confidence, not cockiness, and efficiency. And also that I should learn how to do a 17-minute cesarean delivery the way that Howard Herrell does.
SPEAKER_02:No, the way that the standard technique will allow you to do it, that that everybody should have that as a goal.
SPEAKER_01:Sorry, the way the standard technique will allow me to do it. Okay.
SPEAKER_02:Well, let's have some listener questions about things or maybe things other people have learned or thoughts they have. There's so many things like this, and hopefully soon you and I will make available the project we've been working on for residents to use. It it's a lot of work and takes some time. But, you know, it's really just in promoting this idea of thinking about all these procedures and thinking about the essential steps. And so learning surgery is a very deliberate process and takes deliberate practice. It's not something that you do accidentally or by osmosis or by mimicking other people.
SPEAKER_01:So sure it is. Well, thank you for having me.
SPEAKER_02:We'll be back in a couple of weeks.
SPEAKER_00:Thanks for listening. Be sure to check out thinking about obgyn.com for more information and be sure to follow us on Instagram. We'll be back in two weeks.