Slow Down and Still Be Good in Surgery, Otherwise Ask William Halsted

Since time immemorial, surgeons' reputations have been built on the presumed necessity of working quickly. This is complete nonsense, and let me tell you why. The mandate for speed originated from the times of no general anesthesia and poor analgesia. Speed was considered essential in the times of continuous suffering and disrespect for tissue and organ function. These were the times of scientific independence, when practicality ruled in the absence of a firm theoretical foundation. Under these precarious conditions, the dictum was: “Operate fast regardless of results.”

With more than one hundred years since the discovery of anesthesia (1846), and with many incredible surgical developments at hand, the speed of surgery should no longer be an issue. In practice, speed is so ingrained in the surgeon's mind that many surgical teachers continue to praise an outdated pace as a surgical virtue. Why? Do patients who undergo a surgical procedure with five hours and twenty minutes of anesthesia fare better than those whose surgery lasts four hours and fifteen minutes? If there are no surgical complications during either case, clearly the answer would be no. Surgeons are aware of this, of course, but many continue to act as if speed still matters. So when will the need for speed disappear? Must we turn to physiologists and anesthesiologists for arguments that will sway today's illustrious cadre of surgeons? Or can we relax and allow our resident colleagues or future surgeons to operate calmly and without the nagging pressure of haste?

Consider a recent hypothetical example. At a respected Midwestern regional university hospital, all operating rooms were empty. Surgeons and assistants had finished their cases by late afternoon and the nurses and technicians were preparing for the next day. The hospital had developed strict guidelines about room turnover, operating times, and complete efficiency. Everyone had to comply by the clock, strictly speaking.

As the head nurse, Elizabeth Svensen, a mature and extremely conscientious lady, was ready to leave the premises, she noted that the lights were still on in Room 14, as if somebody were just beginning the day's work on that cold and misty February evening. She walked to the room, slowly opened the door, and realized that Dr. Joe, as he was affectionately known, and the senior surgical resident, Dr. Ed Macky, were reviewing surgical steps for the next day's case. Dr. Joe was talking through each one of the important hurdles of the procedure, a parotidectomy on a 65-year-old patient with parotid gland cancer. Dr. Joe was showing Dr. Macky the instruments, the various tissue planes, the preservation of the nerves, and the best way to enucleate the gland while leaving plenty of margins.

Ms. Svensen asked, “What are you doing here so late?” Dr. Joe, as the faculty surgeon, said, “We are rehearsing the surgery for tomorrow. It will be a complicated one, and I want Eddie to do well.” Ms. Svensen admired the doctors' dedication, but still could not comprehend why they were practicing in the OR. Why not use the classroom?

Dr. Joe recognized the bewildered look and rushed to explain. “Elizabeth,” he said, “I hope we are not delaying room preparation. We're here because Dr. Macky has advanced extremely well in his residency, but has been frequently criticized for his deliberate slowness in performing surgeries. In fact, he has been threatened with probation if he does not improve his speed.” Gaining momentum, Dr. Joe continued, “We're here to offer Eddie the real arena in which he will be performing before a group of senior surgeons. Dr. Richard Versad—the most senile, dogmatic, and unfair of them, who acts as if he would have been trained by American Civil War surgeons—will be evaluating Eddie's speed in the parotid tumor case tomorrow. I never heard such an irrational approach to the training of surgeons … otherwise ask the master of modern American surgery, William Halsted.”

Dr. Joe was himself a firm follower of William Stewart Halsted's (1852–1922) ideas and principles [[1]]. When Professor Halsted introduced the great benefits of the ‘surgery of safety,’ he changed modern surgery forever. Halsted, the surgical scholar for excellence, convinced all his disciple surgeons that speed was not the foundation of surgery. Like many other distinguished surgeons who followed his school, Halsted taught the importance of using time wisely, of deliberately focusing on safety, of continuously protecting tissue from the roughness imposed by time constraints.

“I see,” said Ms. Svensen. “So I should be more consistent in protecting residents from the tyranny of time. I realize now what you've so frequently commented, Dr. Joe. You do not have to be that fast in surgery to be good, otherwise ask William Halsted. Is it not so, Dr. Joe?” “Indeed,” replied Dr. Joe, “and thank you, Elizabeth, for your kind understanding.”

The famed Tulane surgical professor, Rudolph Matas (1860–1957), appreciated Halsted's contributions to careful surgery in an article written after his death [[2]]. Matas defined brilliance not based on ill-conceived speed, but on the ability of the operator to demonstrate good judgment during surgery. In Matas' own words:

“Allow me to detain you for a brief space with a few reflections, suggested by the commentary, occasionally heard, that Dr. Halsted was not what is popularly described as a ‘brilliant operator,’ a statement which might be interpreted as depreciatory of his technical abilities by those who are unfamiliar with his aims as a surgeon and the principles that governed his operative acts. If by ‘brilliant’ we mean the surgeon who utilizes his opportunities to dazzle the public with the prodigies of his skill, who listens for the plaudits of the multitude more intently than he does to the murmured approval of his conscience, and who burns his incense to the gods of the gallery, then, we must agree, Dr. Halsted was not one of that class. But, what do we mean by a brilliant operator? In the sense in which it is most commonly used, brilliancy is a quality whose chief characteristic is speed, the quickness and dexterity with which an operator executes and accomplishes the operative act. This is a quality in which our forefathers excelled, to acquire which they bent all their energies, and in which they vastly surpassed us. In this respect, we, the surgeons of the present generation, can no more compare our performances with theirs than we can make comparison between the speed of a horse car and that of a twentieth century limited railroad express. But when we consider the effects of a collision between horse cars, on the one hand, and railroad trains, on the other, including the wreckage that follows in each case, we may form some idea of the relative effects of speed as applied in the cyclonic operations of the older surgery and the calm but sure and safer motions of the surgery of the present. Happily for us and for humanity, the time has long passed when surgical brilliancy and ability could be gauged by the clock, or when the relative merits of surgeons could be estimated by the rules of the prize ring or the authority of the Marquess of Queensbury. That was well enough in the dim days of antiquity, in the days of Galen and Celsus, when limbs of conscious men were amputated with an axe or a guillotine; or in much later days, when a Lisfranc, a Dieffenbach, a Lizars, or a Liston, could disarticulate a hip in five minutes or less, provided that in the flourish of blades, one or more of the assistants were not put hors de combat by the lightning maneuvers of the operator; or that one could say of a modern master what was said of Fergusson, who, in lithotomy, proceeded with such lightning speed and skill that someone advised a prospective visitor to his clinic to, ‘Look out sharp, for if you only wink you will miss the operation altogether!’” [[2]]

No doubt Matas exhaustively clarified this issue for us and for the incredulous surgeons who continue to believe that speed is the essence of surgery [[3]], [[4]], [[5]].

The next day Dr. Macky was undergoing his evaluation by the stern, mister-no-personality Professor Richard Versad, and things, for a change, were going well except for the final nerve separation and tissue closure. Dr. Versad uttered a lament, “Residents never learn how to hold the needle holder and how to wipe the blood oozing from injured tissue.” No response was expected, and therefore, the comment went unanswered. As Dr. Versad was leaving the room, he said, “Very well, Macky, I feel better about you, but you are still lacking some speed even though your patient did satisfactorily.” “Thank you,” Dr. Macky responded. He knew, however, that Dr. Versad was not going to understand that one could slow down and still be good.

“Different schools of thought, I guess,” said Dr. Joe amicably as he was leaving the surgical dressing room. “A long and fruitful day,” said the pleased and perplexed resident. Even after centuries, it would take more time for most surgeons to recognize that it is possible to slow down and still be good in surgery, otherwise ask William Halsted.