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At 1st glance, the juxtaposition of clamps, clips, and computers would appear to be a simple exercise in alliteration. Surely the low-tech surgical clamp would appear to have little in common with the array of relatively advanced surgical clips now available—and even less with the symbol of our age, the ubiquitous computer. However, I submit that these items have a shared attribute: they are all tools of the surgeon's trade. As such, their design, acceptance, and use should have some elements in common.
Somewhere in the mists of the long and honorable history of surgery, there appeared the 1st surgical clamp. Although it may have been designed and constructed in response to a surgeon's needs, its most basic enhancement—the ratchets that produce that magical sound and so augment its utility in our hands—was in all likelihood adapted from some other mechanical tool. No doubt the same “lineage”—adoption and adaptation from other disciplines and usages—can be found in the history of the surgical clip, be it hemostatic, cutaneous, or other. Finally, the computer was not originally designed for all the myriad tasks to which it is today indispensable. Rather, as with the other tools, it has been adopted and adapted.
What does all this mean for us as surgeons? The purpose of these opening lines is to lay the groundwork for an analysis of what tools mean to us as surgeons, how we use them, how we learned to use them, and what we demand of them.
Most of us probably got our 1st exposure to surgical clamps as medical students, where the many ways in which a simple hemostat can be useful were revealed. On our surgical rotation, we saw them used as designed and perfected, in the operating room, grasping and holding tissue. We then saw them used as “tags” in various situations, “passers” in others. The vast assortment of specially designed clamps slowly came to our attention. In other scenarios, they appeared as “openers,” “spreaders,” and even “racks” (for rolls of tape, etc.). We learned to hold them properly: there is nothing intuitive about putting the 4th finger through the 2nd ring; it is an acquired skill. Slowly, in an almost imperceptibly quiet manner, we grasped the need for clamps particular to our surgical specialty. The attributes of a “good” clamp, be they strength, precision, construction, weight, etc., became part of our knowledge and later our expectations.
I will not go through a similarly detailed narrative on the meaning, use, learning curve, and attributes of all manner of surgical clips. Suffice it for the reader to pause and reflect on the type that he or she encounters and uses in daily practice—and why that type as opposed to another. However, I will embark on an exploration of the same line of reasoning in regard to the computer.
First, let us recognize it for what it is, a tool. This is not an idle comment. It is the recognition that the computer is an instrument that can assist us in completing a step or steps in the overall task of patient care. And, in common with a clamp, it should be designed to whatever specifications the user requires. The metallurgic or ergonomic engineer may have a very different view from the cardiac surgeon on how the ideal aortic cross-clamp should look and function, but if that clamp does not fulfill the requirements of the surgeon, it will not enjoy widespread use. Indeed, all of us can think of a piece of surgical equipment that collects dust because it did not meet our expectations of usability and efficaciousness, even though “it seemed like a great design” at the time of purchase. Thus the computer needs to be designed, configured, networked, etc., according to the needs of the end user, and not according to the wishes of the Information Technology (IT) department. This is an important point that we as physicians need to reiterate at every juncture as hospitals move ever more quickly into the “computer age.”
Okay. So now we have a tool—a computer—that is constructed to meet our requirements in the delivery of patient care. So far, this has cost us nothing but our insistence and persistence at committee meetings. We may even have gotten some satisfaction from asserting some measure of control over what “tools” the hospital is going to purchase for us. Now we have to think of using the computer—and that means learning how to use it. How did we do that as residents, in regard to clamps and clips?
We observed others who already were adept. We even may have pocketed one or two of those inexpensive clamps that came in the disposable suture trays, or the leftover skin staplers from that last case, and have practiced in the call room, opening and closing the ratchets with 1 hand, grasping small objects, tying “instrument knots,” or stapling towels. We also improved our skills incrementally in the O.R. by using the tools. All of those learning techniques involved an investment on our part: the investment of time. The 1st distal anastomosis was a slow, painful experience for all—the attending, the resident, the scrub nurse, maybe even the patient who mercifully was unaware. The attending certainly could have done it faster. We as chief residents could have done it faster than by teaching the junior how to do it. But we invested time, either in learning the skill or teaching it, either in learning how to use the tool or teaching others how.
Fast-forward a few years. The advent of all manner of minimally invasive procedures brought a whole new set of tools and skills to our attention. Once again, we invested time to learn how to use the former and acquire the latter. Let's return to our computer. Computer? Tool? Learn how to use it? Acquire the order-entry or documentation skill? Teach a colleague how to retrieve data, maintain a patient list? Invest time? Do we detect a pattern here?
As surgeons, we demand that our clamps have characteristics that enhance their utility and quality. As a corollary of demanding and receiving $2,000 Castroviello needle-holders, we give up (one hopes) the convenience of tossing them idly onto the Mayo stand. Perhaps the scrub nurse will hand us simple thumb forceps to pick up that wad of tissue rather than the DeBakeys we asked for, simply to preserve the latter for the moment when we really want and need them. The point here is that, having demanded and received certain tools with certain attributes, we incur certain responsibilities in their care and use. Let's look at the following list of attributes that we as physicians demand in regard to our hospital computers:
These all sound pretty reasonable and fundamental. Let's look at another list:
These all sound like a lot of time and effort. But notice how well they match up. For every demand that we as physicians make, there is a corresponding responsibility on our part—just as with any other tool. It has to conform to our needs. And we have to learn how to use it appropriately, work with it, and take proper care of it.
Electronic medical records (EMRs) are the wave of the future—and the very near future. An EMR is a tool in the delivery of patient care. Those who will not adapt and learn to use that extraordinarily powerful tool will find themselves just as much an anachronism as those who do not use any minimally invasive procedures. As the ad campaign for the New York State lottery said, “to win it, you gotta be in it.” Physicians must invest the time and effort to influence the design, build, and configuration of these systems—not by becoming computer engineers, but by ensuring that the end-user needs are catalogued and communicated to the designers and builders of the system. Doctors must regard these systems as tools and the use of them as the acquisition of a new clinical skill.
How powerful were the discipline, responsibility, and sense of obligation that drove us to stay up nights learning how to clamp, cut, sew, tie knots, and put in central lines. Our patients expected that of us, and we understood it to be the price of the privilege of operating on them. The mastery of the new tool will require the same discipline and responsibility. Our patients will demand it, and they deserve it.
Address for reprints: Dan A. Morgenstern, MD, MBA, P.O. Box 1769, Conway, NH 03818. E-mail: moc.oohay@dmnretsnegromd