The Economy of Surgery

Image: Greg Goldgof

When I was twelve, my sister and I accompanied my grandparents to their annual yoga retreat in the hilly ranges of southern India. We had never been before, but the summer heat was particularly blistering that year, so we persuaded our grandparents to take us along. I envisioned a blissful two-week vacation in a photogenic little hamlet, nestled among tea plantations, in temperatures that were thirty degrees cooler than on the mainland. It was just that, and yet, it was even less complicated than that.

The mean age of folk at the retreat was 67. Bells sounded every morning at 3:30am, and everyone filed out of their cabins and to a little gymnasium in the center of the dwelling, where we all meditated for two hours to the sounds of sitar music and transcendental humming. Meals were served at strict hours three times a day, and consisted of boiled vegetables and grains, with not a lick of salt or spice. The library in the middle of this utopian dwelling held only spiritual and philosophical texts, not the Nancy Drew or Hardy Boys I hoped for. In the afternoons, there were a variety of classes offered ? cooking lessons, devotional classes, music and instrumental classes, and yoga. My sister and I stopped by the latter occasionally, and were always put to shame by octogenarians holding themselves up in impossible poses, such as balancing their entire habitus on the tips of their fingers. I journaled in the evenings, writing each day about a new facet of human life that I?d observed. In the absence of stimulus, my dreams grew vivid and exceedingly detailed.

Over the course of the two weeks, my sister and I grew quiet and reflective. It was then that we began an important switch in our minds, something that has lasted to this day. We began to see value in living leanly, economically, functionally. We began to separate needs from wants, and to discard the ornamentation.

*

Third year of medical school has finally brought me around to my surgery rotation: three months of waking up at 4am, stuffing my white coat pockets to the brim with gauze and tape, retracting skin and fat during long abdominal surgeries, and practicing suturing techniques on pig?s feet procured at the local Stop&Shop grocery market. It?s fast and exhilarating, and deeply satisfying. I was skeptical when I first heard that my preceptor?s favorite procedure of all time was draining a deep-seated abscess. But when I saw it being done in clinic, how a single stab of the thing blade led to the gushing of what felt like liters of pus, I couldn?t help but agree. What a joy to just go in and fix a problem so dramatically, reconstruct a failing human body in a matter of hours!

During orientation on the first day of the rotation, two residents sat down and gave my classmates and me some hard advice. Surgery is a demanding rotation, they said, and it reflects the demanding residency ahead that awaits the select few. We could expect to go in while it is still dark out, and leave after the sun had set, almost every day. Residents and attendings can be rough around the edges, and may be gruff with you, even kick you out of their operating room if they feel like it, but it?s not personal. Or even if it is, we?ve got to shrug it off and keep it moving. Gone are the days of noon conferences and luxurious afternoon didactics, with their promise of free lunches and coffee. We were to eat when we can, sit when we can, sleep when we can.

After an hour of such grim prognostications, my classmates and I took a break and debriefed our feelings with each other outside the bathrooms. Some were giggling nervously with panicked eyes, but most looked inspired. I too felt like I had voluntarily signed up for a warrior training program, and was feeling pretty zen about it. I saw it as a character-building experience: surgery was the time to cut out the silly frills, and embrace a leaner, meaner way of living. It was time to lose the pretty business casual outfits and fancy footwear of internal medicine, and trade them in for utilitarian scrubs and clogs. It promised to be a time of talking less and getting things done.

*

During a recent health management class, my classmates and I discussed the case of a medical center based in Seattle that benefited from industry principles gleaned from, of all places, the Toyota car manufacturing company. Toyota?s revolution as a manufacturing miracle began in the supply-scarce post-WWII Japan, when management was confronted with the challenge of meeting customer needs in the face of little spare capital to hold inventory as a buffer to fluctuating demand. The company then developed a set of principles focused on cutting muda or waste, while pursuing kaizen, or continuous self ?improvement by way of complete intolerance for redundancy. Toyota integrated these principles into every step of production and management.

For instance, Toyota emphasizes innovation on the shop floor by frontline workers to solve problems in production in real time. If a problem is discovered that cannot be fixed within the production cycle time, workers pull a cord that halts the entire assembly line and brings a senior supervisor to the scene. The management aggressively seeks ideas for improvement from employees, resulting in an average yield of close to a million ideas annually, 90% of which go on to be implemented.

Analysts attribute Toyota?s success to its emphatic optimization of flow ? information flow, physical flow of parts, and overall production flow, via standardized processes and continuous improvement. Standardized processes are ones that are streamlined to eliminate aberrations and unplanned redundancies. Waste, measured even in the seconds, is simply not tolerated, forcing a redesign of processes, again and again, which any employee can take on.

In 2004, Toyota surpassed Ford Motors to become the world?s second-largest manufacturer of cars and trucks, surpassing the latter consistently in quality, dependability and value assessments. In turn, Ford began to take cues from Toyota, transforming its assembly-line system to similarly cut out waste.

*

There are two kinds of people in the world: surgeons, and everyone else.

Really, what does it mean to live leanly? I rediscovered it in this rotation. A life in surgery isn?t for everyone, but such an experience is something I truly feel everyone should have. These past 6 weeks have been teaching me to think fast, move fast. They?ve been teaching me to suffice with less, be it food, sleep, or words of appreciation. They?ve been teaching me to appreciate the vulnerabilities of the human body ? for no matter how exhausted or sleep-deprived I may feel, actually laying hands on the more tangible deficits of another?s is always startling and humbling. The end result is a beautiful dance, for surgeons and their assistants, working with their hands, rediscovering the grace of human movement, bring art back into medicine.

I never leave the OR thinking that more is better. I watch instruments fly, I watch the players push and pull, cut and stitch, wash and dry, and I think about things like symmetry, precision, and above all, the beauty of economy.

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