Pangs of jealousy mixed with joy filled my gut as I witnessed my students create a Stamm tube gastrostomy and mature a colostomy in our simulation laboratory. I thought back to my younger self, 16 years ago, when I was just discovering my passion for the art of surgery and would have quasi-literally given my right kidney to operate. Now I stood supervising a new generation of students who have gone well beyond gowning and gloving themselves in a perfectly fake real OR. Today, one student works as a circulating nurse, another as scrub tech, and two assist each other in the performance of a bowel resection. I pace the room, sometimes advising, sometimes peering over the drape, and sometimes waiting for that moment that never happens when lack of progress makes me scrub in. They are preparing themselves for their upcoming internship year in a way I only dreamed of, and I am delirious.
Afterwards, we sit around and debrief. We discuss the “Swedish” closure with a running 4 to 1 suture length to wound length ratio. We talk about how some surgeons in some situations prefer figure of eight or simple interrupted closure of fascia. We talk about maturing ileostomies using a Brooke technique, but then observed that we chose to mature our colostomy flush against the abdominal wall. We talk about how we matured the stoma with Vicryl, but how many still use chromic gut. We discuss suture survival differences between PDS and Vicryl. We venture into when to use silk and monofilament nonabsorbable sutures like polypropylene and nylon. We then talk about braided Ethibond and explored closing hiatal repairs laparoscopically using extracorporeal or intracorporeal techniques. While many of my residents have developed tunnel vision and see procedures in terms of one way of doing things according to attending preference, my students suddenly were exploring an enormity of possibilities of what we could have done, of their choice to close the skin with staples and not with subcuticular sutures… but what about leaving the wound open? I am swept away by their next question: “What should we have done?”
I answered, “Well, it depends.”
I recounted to the students the work of Charles Bosk, a sociologist, who over the course of 18 months in the 1970s embedded himself in the surgical residency at the University of Chicago. In his graduate thesis, Forgive and Remember: Managing Medical Failure, Dr. Bosk subdivided the concept of surgical “error” into four categories: 1) technical errors, 2) judgmental errors, 3) normative errors, and 4) quasi-normative errors. I stressed to my students that in their upcoming intern year, they will discover that the process of dealing with error and discussing complications with others is part of the core ethos of becoming a surgeon. I also reassured them that the quasi-norms of their attendings and senior residents will be the ones that they will have to be prepared to appease, learn from, but also to diffuse and learn to not to get too stressed about at the end of the day.
Bosk expands that technical errors are “expected to happen to everyone because surgeons understand that theirs is at best an imperfectly applied science.” Errors in judgment occur when “an incorrect strategy of treatment is chosen”, which in convoluted logic is tied to a poor outcome. Both types of errors are discussed and deliberated in Morbidity and Mortality conferences, and ultimately most fall within the scope of the attending’s responsibility and authority. The resident is insulated from the implications of these errors, but has the privilege and opportunity to learn from these missteps.
What are more distressing for residents are normative errors, or “when a surgeon, in the eyes of others, fails to discharge his role obligations conscientiously.” Examples of normative errors include if a junior does not notify their senior about an event, if a surgeon is disruptive with their nursing staff, or if a trauma resident sleeps through their pager. The possibility of a resident or surgeon putting personal needs above the needs of the patient makes a normative error of greater importance and consequence in comparison to errors of technique or judgement.
Quasi-normative errors are distinguished from normative errors by Bosk as “eccentric and attending-specific”. When I was a resident, if I placed a chest tube in the emergency room, I would need to know who the attending on call was in advance, not for the benefit of patient care, but to make sure I would not have to hear an unnecessary complaint. One thoracic surgeon required the chest tube to be secured by a silk horizontal mattress suture, tied with a slip knot, then the free ends wrapped around the tube and secured to the tube with a perfectly placed steri-strip, followed by a simple dry sterile dressing. The other thoracic surgeon requested a simple interrupted Prolene to secure the tube, followed by a Vaseline gauze occlusive dressing. Neither surgeon would accept the other surgeon’s signature style, and both would check religiously in clinic, as one would always have a silk suture left in place once the tube was pulled, and the other none. In contrast, the trauma surgeons did not care, but left it to the preference of their chief residents, who became partisan in their preferences towards black or blue suture and Vaseline or plain gauze.
While quasi-norms of attendings may appear to be irrational to the resident, they are sometimes well-intentioned. My quasi-norm includes a personal hatred for Monocryl as a subcuticular suture. If I see it on the field, I know the scrub tech did not pull my card. If I see it in a dictated operative report, I cringe and immediately know the resident did not pay attention to what we did, or does not know me well enough to understand my quasi-norms. My dislike for Monocryl isn’t just because Monocryl is transparent, slippery, and more expensive. When the buried knot from Monocryl spits, it feels like an ingrown hair, and if the patient complains about this, I throw my fist in the air and blame the resident for that moment of personal and patient unhappiness. Sure Vicryl spits too, but when it does, it is soft and supple, and not a nuisance signature of careless suturing.
While quasi-norms may seem unnecessary to the process of teaching surgery, and certainly make the perfectly randomized surgical trial impossible, I would venture that they are critical to understanding our craft. The art of surgery cannot be understood and advanced by doing the same technique, but by replicating and merging multiple techniques and methodologies learned from different surgeons. An artist only becomes truly proficient when they have gained an understanding of their media, and by sampling their teachers to develop their own signature style. Residents are obliged to follow the practices of their instructors, but when they go into practice, can pick and choose the elements of their teachers which ideally are practical, pragmatic, efficient, and associated with good patient outcomes.
So as part of their “Resident Readiness Selective”, I gave my students an education not just on the nuance of surgery, but also the nitpickiness of surgeons, and why a student can never fully prepare in advance for the program they will match into. They will perform errors and they will learn from them. And they will become better.
Bosk, Charles L. Forgive and Remember: Managing Medical Failure. University of Chicago Press, 1979.