Moulding the surgical mind

William Hunter, 18th-century obstetrician and medical educator, once described surgeons as “savages with knives”. Ironically, one of these savages, his brother John, became one of surgery’s icons. In their time, patients were pinned down, screaming and squirming, by burly assistants, and the surgeon’s fame rested on his dexterity, precision and speed. Then, surgeons were feared, surgery was limited in frequency and scope, and plagued by deadly sepsis.

The arrivals of anaesthesia, antisepsis and asepsis changed all that. Now, surgeons are revered, surgery’s scope is virtually unlimited, and waiting list numbers swell.

But what is the image of the modern surgeon?

In their recent review, Surgeons and cognitive processes, Australian surgeons John Hall and Jeffrey Hamdorf and educator Carleen Ellis focus on this image. Surgery continues to be a male-dominated fraternity of adherents of resolute action, aggression, technology and defensive detachment in practice. Their expertise is bound up in experience, and entry into their ranks is influenced by sex and an “intolerance of ambiguity, excessive reliance on high technology, a negative orientation towards psychological problems and a Machiavellianism . . . expressed as ‘the means justifies the end’ or ‘whatever it takes’.”

But Hall and his colleagues believe that something is missing in the moulding of surgical minds — an emphasis on analysis, problem-solving, evaluation, discrimination and judgement. In short, surgeons’ training is short on thinking, reasoning and understanding. The call by Hall and colleagues to move the focus from action to reflection is not new. Eminent US surgeon William J Mayo once observed that “Surgery is more a matter of mental grasp than it is of handicraftsmanship.”

Stressing this mental grasp requires a seismic shift in surgery’s culture.