Channeling DOCTOR Manners in the OR: A Guide for Physicians and Medical Students

While medical student blogs are very common, few physicians have blogs dealing with advice for their trainees. Most physicians start blogs in an effort to educate patients and market. But this space could be used to educate medical students and residents. We feel that this is important and due to the recent popularity of the last "channeling Miss Manners," post we have decided to take this head on.

Miss Manners

Most medical student rotation textbooks deal with the path or phys about the rotation, but few address professionalism advice and decorum...Let's call this segment "Dr. Manners."Here, we have identified another area that deserves attention: The operating room. Between the revolving door of personalities and, in general, the stress of what happens there, manners can be easily tossed out the door, but they really shouldn't - right?

There should be a baseline set of guidelines that young physicians and medical students should incorporate during training. Medical education is no doubt changing but the goal of excellent patient care does not change. If you are ultimately swept up in ego, following OR specific mores can only enhance your ego because ancillary staff, your trainees and others will enjoy working with and talk about "how great you are in the OR." You can still have the mean streak in the OR though, just have some manners if you need to let it out!

What follows are my observations based on being in undergraduate, graduate medical education for the last 13 years. Please note that the goal is not to preach that a certain way is better, but to stress the importance of professionalism in the OR.

1. "...and Who are you?"

Rule number one at any job is know the names of the people that you work with. Okay, so they change over time, but after awhile you have a core group of people that you work with on a daily basis. You should know their first names. There is nothing more satisfying than being addressed by your first name once introduced...it goes a long way!

The same is true for the OR, however people tend to get lazy about this one. It's okay if the medical student or resident forgets on day one of the rotation, but it should not happen repeatedly. Fine, you don't like your surgical rotation and can't wait to never be in the OR again...at least have the courtesy to introduce yourself to the scrub tech and the circulator. They still have to account for you.

It should be the job of the fellow or senior resident on the team to write the name of all members of the surgical team on the board. Think it's the circulator's job to do that? When the surgical team has 4 people standing around...think again! Let the circulator know that you will do this to make it easy. As a circulator, there is probably nothing more annoying than having to hunt down everyone's ID to make sure the names are spelled right.

The surgeons (primary and first assist at least) should, at minimum, introduce themselves and their role (i.e resident, medical student) to the circulator, the scrub tech and the anesthesiologist/anesthetist. The call to order provides a good opportunity to do this. Nothing screams "inconsiderate" more than when OR staff or physicians try and get someone's attention by, shouting, for example, "anesthesia" to give you a "bit more relaxation" because you are having trouble closing fascia. LEARN THEIR NAME and then ask!

Why should I know their name? They change staff all the time? They get breaks, etc? It is a two way street...agreed. But, fine you want to argue that this is the culture of the OR and they are being too sensitive...I would disagree because it's not 1960 at the Boston Lying-In and we don't live in the hospital anymore either...life is generally better so cheer-up! Times are changing and frankly it's better if we act professionally around each other. The work environment will improve and remarkably patient care will too!...getting off my soapbox now.

The circulator is critical in making sure your specimens get labeled correctly and get to the right pathologist. They also make sure your equipment needs are met during the case. THAT IS WHY A MEMBER OF THE TEAM SHOULD MAKE SURE EVERYTHING HE/SHE MIGHT NEED IS AT THE READY AND FUNCTIONAL! You know what the case might entail...Minimize your circulator's out-of-room time by preparing before the case starts and things will move much smoother...This is especially critical in the middle-of-the-night when you have a team that may not be familiar with the case and instruments. You are ultimately responsible.

The scrub tech. Sure he/she is used to being asked for the "Kelly," "stitch," and what not, but you should really know their name too...they are responsible for your speed and efficiency as well and outside of the academic setting your first assistant many times. So treat them well...Don't throw stuff!

Finally, before leaving the room to go scrub, PULL YOUR GLOVES and GOWN. Do not assume that someone magically knew your glove size and the particular sequence and type of glove that you enjoy. Furthermore, scrub techs usually pull 3-4 gowns...if the entire surgical team is scrubbing then make sure all gowns are accounted for. Never scrub until you confirm that your gloves and gown are pulled!  

1a. "ummmm, let me see that..."

Famous last words to an eager physician in training (ie you) who just lost their opportunity to operate!

In general, when operating, things should be progressing forward. When they stop progressing forward, one should stop, re-evaluate, and try something else. Usually one maneuver change works (different technique/approach when removing a fibroid abdominally for example), but if it doesn't, one needs to change again.

It is up to the chain-of command to determine when progress is not being made and adequate effort has been exhausted. Having an internal time limit is better than a minimum number of attempts, in my opinion. As a supervisor, having a time limit means that I am giving the trainee time to learn on their own with my guidance/advice as needed. Oftentimes, like in operative hysteroscopy/laparoscopy it is getting oriented that takes practice - so give the trainee the chance within reason.

At some point though, trainees need to know that they are on the clock. In football, if you have 5 minutes to score a touchdown or you will lose the game, you are going to focus your energy in accomplishing that goal. The same is true in the OR...If you have 5 minutes to clear the screen and start cutting that uterine septum or you lose your opportunity, the trainee will re-focus. This is not about being mean or nasty...its about teaching efficiency without compromising the educational mission. And you shouldn't abandon hope for your trainee after the first five minutes either.

1c. "Oh, my pager is still on me" and answering calls in the OR or while doing a c-section on L&D

Take your pager off when you come into the OR. This means EVERYONE - including medical students...the likelihood of you getting paged, I know, is unlikely, but if you carry a pager into the OR, don't forget to take it off. And if you are expecting to be notified about something serious, make the circulator aware.

Also, if you prefer your pager to be on vibrate, let the circulator know or change it to audible because the circulator won't hear it rattle on the other side of the OR.

OK. If you are calling into the OR you will get the circulator most likely. Quickly identify yourself, the individual you are trying to reach, and the brief message. Most of the time it is not urgent and you are trying to relay a message/get permission, whatever to "move" things on the floor or ED. If the message is dire, walk down to the OR, and wait for a member of the OR team to address you when you arrive. Trust me. They recognized you when you walked in, but on the off hand that they did not it will become obvious quickly whether or not it is a "critical moment" in the case. Once that moment passes then address the individual you came for..."Dr Jones, its so-and-so, just wanted to let you know X." Don't do it while there is hemorrhaging and everyone is tense.

Let's flip it. If you are in the OR and someone is trying to communicate with you, be brief as you are likely relaying conversation through the circulator. Not to mention you should maintain focus on the case at hand. Avoid the "circulator-holding-the-phone-up-to-your-ear" if possible. Sometimes you can't though and consider scrubbing out if the situation warrants it. It always makes me laugh whenever we have the circulator hold the phone up to the surgeons ear for like 5 minutes and then 30 minutes later, path calls and they get put on speakerphone. Force of habit I guess, but remember to take advantage of the speakerphone ALL the time.

2. "is GYNONC around?": asking for an the intraop consult

When you know them, it is different. When you don't, the anxiety can get ramped up. Did you call the right person? How long will it take? Just say the facts when they come. Introductions are obviously necessary. And, please, if they are fixing a complication (your complication) don't leave the OR and go to lunch.

3. "can't tell if this is ovarian tumor or not?": providing the intraop consult

Bring one person with you. Depending on what is going on you should not need to bring more because after 2 people you just need assistants - and their hands are more than capable. Sometimes it is nothing more than a visualization. If you get called in...scrub and take a look yourself even if it is for a short period of time. You shouldn't be staring at the laparoscopy monitor or looking overhead unscrubbed directing traffic. Use your assistants. 

4. Logistics/Transport

So when you transport the patient to the OR, there is a cascade of choreographed events that occurs:
1) Patient moved from stretcher to OR table
2) strapped in and blanketed
3) induction and intubation
4) positioning (Wait until the ET tube is taped-i.e secured-before doing this!) 
5) LIGHTS CAMERA ACTION!...don't leave to go scrub until the lights and monitors are positioned appropriately. You don't want to come back and bother the circulator (who is probably busy looking for that special trocar you have to have) to do this...just delays things further.

Another pet peeve: the surgeon (or member of the surgical team) HELPS transport the patient to the stretcher and walks with them to the PACU. Usually with a team of four people, the medical student and resident do this. If you think about it, the resident is the only physician there during transport and while the anesthetist is capable in the event of an airway issue, a physician should be present.

5. "Base Hit now, Base hit!"

In baseball, cheers usually come in couplets, in the OR instructions should come in triplet! For example when calling out a path specimen: identify the site, the specimen, and the fix (permanent/frozen). For example: "Left fallopian tube, permanent" x 3. The first time gets the circulator's attention, the second announcement allows it to be recorded, and the final one confirms the specimen. Thanks Dr Spann.

The same goes for the "sign out." At the end of the case, the anesthesia team and the circulator need to record the case. Tell them what you did so that it is consistent in their records. There is no reason it should not read the same. Most of the time this is straightforward, but often times it is not and you should provide guidance! Thanks Dr Spann.

6. "So...uhhh...have you tried that new Chinese place off Olive?" Small Talk at the Scrub Sink

The scrub sink is a place for any last minute game planning but it can also become the hub of casual awkwardconversation. Remember two people can share one faucet...so don't run away from the team just to scrub...stay and enjoy the conversation and bond with your team before tackling a very stressful albeit glorious experience. Be aware though, turning the sink on and off is noisy,  the water hitting the metallic basin is noisy, and everyone is wearing a mask so it can difficult to hear one another. And invariably someone (usually a junior resident or medical student) will get soaked.

There are other situations that we may have forgotten but these are the CORE elements of maintaining decorum in the OR. By conforming to these mores, your life in the OR will be enjoyable and patients will benefit from a more cohesive unit caring for them. It is up to us as physicians to lead this charge and it starts at all levels. Stay tuned for the next installment where we tackle Labor and Delivery.