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In this episode, we dive into the fascinating world of rituals and superstitions in surgery with Carmen Fong, a colorectal surgeon. Discover how these seemingly irrational practices impact surgeon performance, confidence, and patient outcomes. Carmen shares personal anecdotes and insights on the psychological mechanisms behind these rituals, balancing evidence-based practices with personal routines, and the influence of team dynamics in the operating room.

Carmen Fong is a colorectal surgeon.

She discusses the KevinMD article, “The secret superstitions of surgeons: How rituals impact surgical success.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Carmen Fong. She’s a colorectal surgeon. Today’s KevinMD article is “The secret superstitions of surgeons: How rituals impact surgical success.” Carmen, welcome back to the show.

Carmen Fong: Hi Kevin, thank you for having me back.

Kevin Pho: So Carmen’s been on multiple times. Go to KevinMD.com/podcast, you can search for her name, hear her story and prior episodes. But today let’s jump right into this article about the secret superstitions of surgeons. Tell us what this one’s about.

Carmen Fong: Sure. A secret, or maybe not so secret. So what brought this on was that, you know, after I stopped doing like major abdominal surgeries for a while, for a year or so, I found myself kind of doing ritualistic behaviors, and with my kids kind of like parenting with superstitions and trying to do the same thing every night so that, oh, maybe this will make the baby not cry tonight.

And then when I was reflecting back upon that, I actually remembered reading that some Major League Baseball players, and you know, really high-performance, high-level athletes have routines and superstitions, you know, doing the same thing before they hit every time, before they pitch every time, and how this actually impacts their outcomes. They actually perform better. And then some other research has actually shown that not only do these rituals and superstitions actually impact the muscle memory and the actual performance, but there’s mental benefits as well.

So I looked into it a little bit and kind of reflected back on what my routines were prior to surgery, after surgery. So it was kind of fun, kind of interesting to write about.

Kevin Pho: So there’s actual data and research about these high-performance athletes. And as we’re talking, I think, you know, we’re on the cusp of the Olympics, speaking of high-performance athletes. So there’s research saying that athletes and their rituals actually impacts their performance?

Carmen Fong: Yes, yes, yep. And that’s what I was surprised by. So there was one that I read that was like very specific, and I used to play volleyball, so, you know, volleyball players who like dribble the ball like three times before they serve, so that they can be sure that their muscle memory remembers what they’re doing on the follow through. And I just thought that was so, so interesting.

And then, you know, in terms of translation into the OR, it’s the same thing, right? So if I go in the same time, do the same thing every time, put on the SCDs, go scrub the patient’s abdomen, and then I’m standing there waiting for my port to be put into my left hand so I can start putting it in, I can assure myself that hopefully the outcomes will be the same every time and the outcomes would be good, which is what we always want for the patient.

Kevin Pho: So from a colorectal surgeon standpoint, you mentioned some earlier, but what are some rituals that either you do or some of your colleagues do?

Carmen Fong: Yeah, right. So the non-protocolized things would be like what I said, which is I have to go and put the SCDs on every time, say to the patient, see you later, instead of, oh, you know, have a good sleep, which I feel like sounds a little bit morbid, but see you later is optimistic.

I’ve actually been interviewed for a separate article since I wrote this one, and there were a couple of dermatologists who said that they touch their necklace or touch their earring every time before they go into the OR. Wearing the same pair of shoes is a very common one. So wearing the same pair of like dirty old OR shoes that will somehow bring you luck.

It actually was funny, because I was thinking about this on the car ride over, and you know, when we’re kids we were like, OK, don’t step on the crack or it’ll break your mother’s back, or like don’t walk under a ladder. And you know, a lot of these superstitions, and I touch on this as well, back in the old days we did bloodletting and boring holes into the patient’s skull, so that we think that this lets out the bad humors. But at some point one of these things worked, right? So maybe somebody did break their back when they stepped on a crack in the sidewalk, or they walked under a ladder and had the ladder fall under them. So we know that if it worked one time, hopefully it continues to work.

So then the other part of the answer is that some of these things have become protocolized, such as the enhanced recovery after surgery protocol for colorectal surgeries. We know that trimming hair works, we know that keeping their body not too warm and not too cold works, we know that using chlorhexidine scrub works better than Betadine, because it kills the microbes on contact. So things like that. And then also doing postop things like having nausea prevention helps with the recovery as well.

Kevin Pho: Now, to your knowledge, is there any data suggesting some of these non-traditional superstitions, do they have any impact on patient outcomes? Has this even been studied?

Carmen Fong: It hasn’t. And I actually keep thinking that we probably should study it, because I think a lot of us do it. I would be interested to see if non-surgeons do it as well. Do you have anything like this that you can think of in your practice?

Kevin Pho: Well, I have to think about that. I’m not sure if it’s something like touching my necklace or wearing the same pair of shoes, have the same, because I don’t think what I do is as heavily proceduralized. Because I think the correlation between proceduralists and, say, high-performance sports is a much more solid connection than what I do in primary care.

Carmen Fong: Right, right. No, and that’s most likely it, because surgeons have been compared to high-performance athletes as well, and so you’re probably right, it’s more of a procedural thing. I think in general though, it kind of makes us reflect on why we do the things we do in medicine, and what things are actually helping people, and what things are actually improving outcomes, and what things are just kind of like, yeah, whatever.

Kevin Pho: Now, on the flip side, is there something that you stopped doing because it was associated with a poor patient outcome?

Carmen Fong: Actually yes. So this is a weird one. One of my very first surgeries when I was a young attending, so you’re a surgical attending, and I think you actually had a different episode about this because one of my friends was on your podcast. I used to play Broadway musicals, you know, because you get to pick your music, and I was like, 80s rock ballads, Broadway musicals, that’s my jam. Like, I don’t want the Notre Dame anthem, or which one of my attendings actually did do, or whatever else.

And so I played the Hamilton soundtrack in one of my very first colon surgeries. And I remember thinking, oh my God, this is actually taking a really long time, because the entire thing is like three and a half hours long, and we almost finished the entire soundtrack. Not that I had a terrible patient outcome, but the patient ended up having a small surgical site infection. And ever since then I will not play Hamilton in my OR. I was like, I don’t know if it’s because it took longer and we were like jamming to it and being a little slower or whatever. You know, if everything else being equal, that would be the only difference. I have since not played Hamilton in my OR.

Kevin Pho: Silly or not, but are most surgeons and surgical subspecialists, to your knowledge, is there superstition in that culture?

Carmen Fong: I think that they don’t call it such. You know, like, I feel like superstition sounds so hooey, and I wouldn’t say that we call it superstition. But when I’ve observed it, most people will do the same thing the same way every time. When you’re doing, for example, seven vascular surgery cases a day, right, you also want to do it the same thing the same way every time. You’re like, you have your IV here, you have your A-lines here, laid out in a certain order, so you’re like, bing bang bang bang boom. It also helps with the flow of things. Maybe it’s, superstition isn’t like as accurate a word as ritual. Ritual, yeah.

Kevin Pho: How about within the surgical team? Because as you know, surgery is not a solo sport, you have various team members in the room. Any rituals within that team that you’ve heard about, or in your own OR?

Carmen Fong: So in the OR there’s also always like the preop checklist that we have to do, and so we have to confirm the patient and their name, the location of the surgery, things like that. I feel like that is a form of ritual for us, you know, because of Gawande’s work we know that checklists work. And so that is part of the ritual, is like we’re saying, OK, patient name, location, blah blah blah blah, this is what we’re doing. And I find that talking it through with the team ahead of time, and that they anticipate that I’m going to talk it through ahead of time, helps.

Right, on the anesthesiologist side, it’s a good question. I feel like they’re always doing something different, you know, playing sudoku or like checking their stocks or whatever. So no, no, no. Honestly though, they are very much a part of the team, and I think that when we know the way that each other works, I’m like, OK, so I’m going to hold the face mask while you do some sedation, and then you’re going to do the intubation and stuff like that. Those things, we kind of know how each other works, and it is very much of a team sport. And you know, practice might not make perfect, but practice definitely makes better.

Kevin Pho: How about those new physicians, residents, and fellows who rotate in the OR with you? Do you encourage them to develop their own rituals, or is this something that just comes innately to every surgeon?

Carmen Fong: I encourage them to observe as much as possible and pick out what works for them. I feel like it does differ depending on the individual. But over time, it’s kind of interesting when you ask that, because I have noticed that if I trained with like Stony Brook as a fellow for example, but I did my residency with like Mount Sinai Beth Israel, there will be things that I do that are exactly like the Mount Sinai attendings, and there will be things that I do that I’m like, oh, obviously I picked those up from the Stony Brook attendings. So I do think you kind of integrate all of that into your own practice.

Kevin Pho: I’m going to put you on the spot here. What’s the strangest ritual that you’ve observed or even heard from?

Carmen Fong: The strangest, let’s see. I actually think that one of the weirdest things I’ve ever seen is when I had a surgeon colleague who told me a story after writing this once, about they had to put their shoes in a certain spot, like before the operation. So again it’s the shoes. So before going into the OR, you would have to put your shoes in the locker in a certain spot, and it would have to be like right at the bottom of the locker, facing a certain way, not facing to the side, not facing outwards. I mean, that seems a little bit. But then again, you know, I made sure I ate two boiled eggs every morning, so I can’t comment on anyone else’s rituals.

Kevin Pho: We’re talking to Carmen Fong. She’s a colorectal surgeon. We’re talking about her KevinMD article “The secret superstitions of surgeons: How rituals impact surgical success.” Carmen, as always, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Carmen Fong: Yeah, no, and I think I kind of mentioned it at the beginning, which is that it’s like funny to talk about superstitions and rituals, but at the end of the day we’re just all doctors trying to do the best thing for our patients. And so if it’s something that makes you reflect on your own practices and say, hey, why do we do what we do, we do a lot of that in medicine, but probably we should do more of it.

Kevin Pho: Carmen, as always, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Carmen Fong: Thank you, Kevin.