Dexterity and the Business at Hand

Does the age of a surgeon affect the ability to operate? Does age impact outcomes? These questions are usually asked in relation to whether an older surgeon in the later part of his career is still as sharp as when he first started. There’s certainly no shortage of research analyzing the impact increasing age may have on surgery.

However, a recent New York Times¹ article flipped this idea on its head, arguing that it wasn’t the older surgeons who had lost their touch but the younger generation who never had it to begin with.

The article cites long-term surgeons who credit childhood activities, such as crocheting, wood- working, and playing piano, with developing advanced manual dexterity. Today’s medical students, they said, rarely partake in those types of activities, instead spending most of their time using smart devices.

How Important is Dexterity

Manual dexterity is an important trait for surgeons to develop and continually hone as they advance their careers. However, the skill base required of surgery is developed long before a person chooses to become a surgeon.

“From a young age, we are taught to hold a pencil with a particular grip. We then spend decades writing thousands of pages of notes using this same grip, thereby building great dexterity,” noted Uday Devgan, MD, FACS, FRCS, Chief of Ophthalmology at Olive View UCLA Medical Center and Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, UCLA School of Medicine. “Keeping this same pencil grip makes for a natural transition to intraocular surgery. It is no coincidence that many of our key instruments, such as the phaco probe, are designed to function like pencils.”

Arghavan Salles, MD, Assistant Professor of Surgery, Washington University, St. Louis, and Co- Chair of the Surgical Education Research Group for the Association for Surgical Education, agreed that many skills required in surgery are inherently taught to children.

“Traditionally, when people think about surgery, they think about tying knots and suturing. Those are the types of tasks that we do with our hands in open surgery. Certainly, in that context, manual dexterity is important to make sure knots are tied properly, that no erratic motions be made.”

Today’s medical students may have grown up using their hands differently than the generation who took Woodshop and Home Economics, but both grew up writing with pencils and tying shoes.

Still, the jury is out on whether growing up with technology has hurt or helped young surgeons.

“This is the generation that has played countless hours of video games—and that requires great dexterity. The younger generation has excellent dexterity; that’s not the issue. The key to success 

for the young generation is to ramp up the drive and determination and work hard—much hard- er than you ever thought possible,” said Dr. Devgan. Dr. Salles claimed she has not noticed any changes in trainees’ manual dexterity, suggesting manual dexterity may not be the be-all end-all of a great surgeon.

“While technical skills are clearly a huge part of a surgeon’s job (and manually dexterity is a major contributor to that), one might argue that clinical decision making and judgment are perhaps even more important,” she said. “A surgeon needs to know who will and will not benefit from an operation and make decisions accordingly. Without that, a surgeon is just a technician and not acting as a physician.”

Adam H. Hissin, MD, 4th Year Medical Student NJMS, PGY1 Orthopedic Surgery Residency RWJ Barnabas, noticed a decline in dexterity among his peers but agreed with Drs. Devgan and Salles that developing other skills may be more important for surgery success. He explained, “In my experience with younger doctors I have noticed that the dexterity levels have decreased tremendously. I believe this to be caused by the excessive use of mobile devices and over-reliance of technology. But I would have to say that the most important skills for a surgeon are working under pressure and being determined, especially when things go awry—it’s a key factor in all great outcomes.”

Dexterity in a Changing Surgical Landscape

When it comes to technical skills needed for surgery, dexterity, as Dr. Salles said, will always remain important. But as the surgical landscape evolves, so do the skills needed for a proficient surgeon.

“The main change in surgery that might better suit a younger generation is robotic surgery,” said Dr. Devgan. “This allows surgeons to sit at a console and control the movements of the robot with a 3D view rather than the 2D view of laparoscopic surgery.”

Robotic surgery is slowly beginning integration into Ophthalmology. In June 2018, researchers from the University of Oxford completed the first successful trial of robot-assisted retinal surgery. Professor Marc D. de Smet, MDCM, PhD, FRCSC, FRCOphth, DABO, FMH, Chief Med- ical Officer for Preceyes BV (the robotics firm that developed the PRECEYES surgical system [Preceyes BV, the Netherlands] for use in the robot-assisted trial), thinks the future is bright for robotic surgery in Ophthalmology.

“I would not be surprised if, in 10 to 15 years, most eye surgery is performed robotically under control of an EyeMD. It will allow us to devise new approaches to surgery which go beyond what we are currently capable of doing or conceptualizing,” he said. “In all fields of surgery, robotics will help to further reduce surgical wound size. If the size of the wound and interventions are more precise, then the duration of surgical recovery times will be shorter. This will also be the case in Ophthalmology, provided we make use of dedicated systems, made to provide μm precision (which Preceyes provides).”

Professor de Smet doesn’t think robotics will be limited to vitreo-retinal surgery. He believes it will eventually make its way into other areas, including the anterior segment—specifically, “robotics will ease the work of the Ophthalmologist but keep him in the loop as he has to select the best approach [and] enter the appropriate subroutines to be performed by the robot, as these vary from patient to patient.”

Although robotic-assisted surgery will require new skills, exactly how many is dependent on the level of automation in the system.

“At present, we keep the surgeon in his traditional position. However, he needs to decouple the movement of the instrument from the direct link he has always had between his hand and the instrument. This separation requires a short adaptation time using a simulator,” he further explained. “If anything, robotics reduces the required dexterity, but as with video games, a specific new interaction develops that makes use of the specific environment.

Can You Teach Dexterity?

Even if manual dexterity is on the decline, Dr. Devgan believes it’s a skill that can be learned. In fact, he argued that developing bimanual dexterity is crucial for ophthalmic surgeons.³

“Ophthalmic surgery, particularly intraocular surgery, is very precise and delicate. We are working in a very small space (<1 cc) with little room for error. Much more dexterity is needed for these very fine and precise movements.

For example, in cataract surgery, the lens capsule is between 4 and 14 μm in thickness, [compared to a] single red blood cell [of ] 7.5 μm in thickness,” he explained. “Or think of a retinal surgeon doing a pars plana vitrectomy to repair a retinal detachment: to access all parts of the retina, it is crucial that the surgeon be able to switch hands. The vitrector should feel equally comfortable in either the left or right hand.”

Similarly, in cataract surgery, right-handed surgeons hold the phaco probe in their right hand and chopper in the left hand. During a phaco chop cataract surgery, most work is done with the chopper, whereas the phaco probe remains in the center of the anterior segment.

A recent study⁴ showed that lifestyle changes that incorporate use of the nondominant hand can improve dexterity. “I tell my first-year ophthalmology residents to start doing daily tasks, such as eating food, shaving, and brushing teeth with their nondominant hands. It also extends to computer use by switching the mouse to the opposite site of the keyboard and sometimes even holding a pen in the nondominant hand,” Dr. Devgan added.

Taking the Good with the Bad

Technology in the medical space—specifically Ophthalmology—has the capability to enhance and harm.

As the New York Times article explains, future surgeons who are “all thumbs” (as a result of primarily using their thumbs to type on smart- phones) may be lacking in manual dexterity when compared to the older generation of surgeons. However, early integration of this technology in everyday life, from childhood to medical school, hones additional skills, such as adapting to new surgical technologies.

Does the good outweigh the bad? With the intricacy required in ophthalmic surgery, one thing is clear: there isn’t a single trait that makes or breaks a great surgeon.

References

1. Murphy K. Your surgeon’s childhood hobbies may affect your health. New York Times. https://www.nytimes. com/2019/05/30/well/live/surgeons-hobbies-dexterity.html. May 30, 2019.

2. First human test of robotic eye surgery a success. University of Oxford. http://www.ox.ac.uk/news/2018-06-18-first-human- test-robotic-eye-surgery-success. Updated June 2018.

3. Devgan U. Bimanual dexterity improves ocular surgery. Cataract Coach. https://cataractcoach.com/2018/09/01/ bimanual-dexterity-improves-ocular-surgery/. Updated September 2018.

4. Yadav R, O’Regan DJ. Left out: A study to determine bimanual dexterity in practising surgeons. Ann R Coll Surg Engl. 2010;92(6):1-6. doi: 10.1308/147363510X507837.