“Man is a dupeable animal. Quacks in medicine, quacks in religion, and quacks in politics know this, and act upon that knowledge. There is scarcely anyone who may not, like a trout, be taken by tickling…there is scarcely a disease for which a charm has not been given.”
– Thomas J. Pettigrew
As a surgeon, when I routinely went to the OR, I had a ritual. I would wake up at the same time every day, pack two hard-boiled eggs and a thermos of coffee in my small leather bag, walk to work via the same route, and swipe into the pre-op area, waving hi to the front desk on my way past. I’d talk to the patient, sign the consent with the same ballpoint pen, go upstairs to my office, change into my scrubs, wear the same scrub cap and the same Danskos, then turn on my computer and take a sip of coffee before heading down to the OR. I’d always remove my badge and place it near the nurses’ workstation, then put on the patients’ SCDs myself. I held the oxygen mask while telling the patient, ‘See you later,’ never ‘It will be OK’ or ‘Have a good sleep.’ Then I reluctantly relinquished the antiseptic prep to someone else (most of the time).
This was all to deter bad things from happening. To the patients, that is. For the most part, it worked.
It started when I was in training, and one of my attendings said he did everything the same way every time. He was a good surgeon and someone I admired, though we were never close enough for him to be a mentor. But he had good, reproducible results, so I emulated this tactic and did everything the same for every surgery. Legs in lithotomy, Foley, clip hair, tuck both arms, pad and tape the chest, Bair hugger, then Betadine for the bottom. Enter the abdomen via the belly button and extract the specimen through a Pfannenstiel. Before every colorectal anastomosis, we’d say a little prayer, “Time to make the donuts.” While we could adapt to different patients, there was no room for improvisation. Missing one of these steps led to anxiety on my part. Also, this pre-op, pre-game ritual ensured that everyone in the operating room knew their role and comfortably played their part.
After the surgery, I always went downstairs to check on the patient, talk to the family, and thank the residents after changing out of my dirty scrubs. At the end of the case, never before, I’d take a patient sticker — always torn off the sheet, straight edges, no adhesive exposed — and put it in my white coat pocket for my logbook. I did this happily, of course, and pretended I was chill when things tried to go off-book, but I was firm about it all.
“Superstition is the irrational belief that an object or behavior has the power to influence an outcome, when there’s no logical connection between them. Most of us aren’t superstitious – but most of us are a ‘littlestitious.’”
– Gretchen Rubin
There’s evidence for enhanced recovery after surgery protocols in colorectal surgery. Clipping hair, placing a Foley catheter, and using a warming blanket work in terms of reducing surgical site infections. There’s no evidence that tearing a little name-label sticker the same way every time does anything to prevent patient complications.
I’ve taken a break from surgery in pursuit of motherhood. I thought I’d been freed, my anxiety and neuroticism left behind. But I find myself in my kitchen, ensuring that I drain the baby’s bathtub and place it on the floor next to the sink to let it dry out every night. I stand outside the bedroom door and make my wife mutter, “May the odds be ever in your favor,” before we enter, hoping that this night will be the night that the baby sleeps through the night — which is why I am thinking about superstitions in life and surgery.
Broadly, researchers have looked at whether certain superstitions are valid, such as not doing things on Friday the 13th (they are not). One study also concluded that most of our surgical beliefs, including the choice of wound dressing, were not scientifically grounded.
Most readers who believe themselves of the scientific sort may now divest themselves of superstitious, ritualistic behaviors since all of it is hogwash anyway, right?
Yet, surgeons at the University of Washington reported their OR rituals, such as rubbing a patient’s belly after an embryo transfer. Lester Gottesman, whom I have had the pleasure of corresponding with, wrote last year about examining his hemorrhoid suture lines in the order he sewed them.
Psychosocial research has long shown that ritual has a benefit, even if the performer knows it is a ritual. We do the same thing each time, hoping to get the same results. Ideally, good results. Research shows that rituals are used more often in high-uncertainty tasks, and according to Dr. Juliana Schroeder at the University of California, Berkeley, “engaging in ritual … gives people more perceived control over their environment and reduces their anxiety.” In one study, “even activating a superstition boosts participants’ confidence in mastering upcoming tasks, which in turn improves performance.”
Surgery and medicine are based on superstition. People used to drill holes in skulls, believing that this lets out “bad humours.” The same rationale was used in blood-letting, where letting a bleeding patient bleed more was thought to reduce inflammation. Pearl Katz, an anthropologist at Johns Hopkins, wrote in 1981 that “in modern operating rooms … rituals … occur as integral parts of surgical procedures.”
Does superstition change a measurable patient outcome, such as decreased anastomotic leak rate, surgical site infection, or mortality? Hard to say. But does it improve the surgeon’s confidence, thereby improving their performance? Likely so. Science is not the opposite of superstition; it is the result of superstition, the result of humans trying to make sense of the world and prove each other wrong. We keep doing the things we do to maintain some semblance of control. In further defense of superstition, ritualistic behaviors ensure that the necessary boxes are checked and that we pay attention to the details. In surgery, details matter. So, until there is evidence to the contrary, I will keep tearing off the little patient labels and keeping their names with me in hopes that they do well after surgery.
Carmen Fong is a colorectal surgeon.