This dialogue has started at the surface, but we will not remain there long. We next move into the subQ or subcutaneous layer. In surgery with one swipe of the blade we are beneath the skin and into the subcutaneous tissue. To most, this is a layer of little value. It is often barreled through, pulled under tension, or considered insignificant. It is composed of fat, blood vessels, and connective tissue. It is of little consequence to a surgeon – we never sew it back together when closing a wound since it will just reapproximate or heal on its own. However, it too is a layer worthy of discussion. The subQ offers insulation to the deeper contents of the body and is a source of nutrients to the surface. It may be almost invisible in some and you can get lost in it in others. Even on a CT scan, one can determine the thickness of this layer, unconsciously factoring it into the mental calculations as to the ease or difficulty of an operation. It is a reflection of a person’s life – your nutritional baseline, the world you come from, and even your socio-economic status.

When contemplating the purpose of insulation we realize that some are born with it while the majority of us acquire it over time. One group of people have just a thin layer which brings them into closer contact with the world around them – for good or bad. If the skin is punctured, there is no layer to protect the deeper structures, there is less of a buffer to injury. However, others have acquired an excess of insulation. A layer so thick that they start to lose connection with the world around them. All senses, experiences, movements are filtered through a thick layer of tissue – buffering to be sure, but also creating distance of subject from experience. There is no right or wrong as to how thick of an insulation we need, although somewhere in the middle may be the place of maximal harmony.

So how does one find the middle? This seems like a silly question to ask – of course, we are all aware of the midway point. We can mentally separate objects into halves and readily, almost subconsciously, read symmetry. So how could you ever get lost finding the middle? I contend that this act of centering is harder than we allow ourselves to think. In surgery, you can ask any junior resident how easy it is to find the midline. Piece of cake, right? However, I have seen many residents struggle as they chase the wrong path off of the middle and into the periphery. In a large person with voluminous abdominal fat it is easy to lose yourself and end up tracking into an unintended area. So how does one stay on course? The answer is that you read the subtle signs, you let the tissue tell you how to get back. You use traction and counter-traction to your advantage and allow nature to guide you along the way. When done correctly the tissue separates exactly in the center and points you to precisely the place you want to be. If you follow these rules, you will never get lost.

I find this a beautiful and reassuring concept – that the natural order is there if we allow ourselves to see it, or hear it, or experience it. In surgery, as in life, there are many conflicting issues to balance. You can focus on the step before, or the upcoming step and lose touch with the now. No one sets out to get lost or make a mistake, but it happens. And it is usually at a time when conflicting messages or signals are being processed. I believe we all have the ability to appreciate the truth or to make the right decision – no one purposefully goes astray. But sometimes the other elements, other voices, other issues distract us from going where we intended to go. So how does one remain in the here and now? How do we remind ourselves that even small steps have meaning and maintain a trajectory that leads us where we intend to go?

I have found in my own life that rushing, hurrying, or pushing headfirst through the tasks in my day may not be the best way to go. I notice that in the rush to cross things off my list, to move ahead, to cram it all into my busy day I sometimes make mistakes or do things poorly merely because I am rushing forward to get it all done. Even if you were to measure my productivity in a day, those with the most meaningful accomplishments are often the more calm, measured, and manageable days. I’m not saying that as a surgical resident, barreling through the hallways to get all the patients seen, orders in, preop patients marked and prepared for the OR to get the case started on time isn’t a necessity. But I would contend that there are steps in the system that could be optimized to allow planning, thought, reflection, and a less harried and more purposeful day. I believe that this may be a good thing – for safety, productivity, learning, and knowledge consolidation. We focus a good deal of time and energy on resident fatigue, but there is little if any talk about the other behavioral issues that can affect patient safety – rushing, frustration, and complacency. These are common topics in safety literature, but are poorly represented in the discussion of medical errors or residency training.

In 1973, the famous study of Darley and Batson examined altruism by setting up an experiment with seminary students enrolled in a religious course. They completed questionnaires about their religion and then were asked to move from one building to another for the lecture to continue. On their way from building to building, they encountered a person slumped in an alley in need of assistance and examined what would happen. The one variable in this experiment was the amount of urgency the person felt in getting from one building to the other. They were then judged on a scale of helpfulness to the victim from 0 = failed to notice to 5 = refused to leave or insisted on taking him somewhere. Interestingly the major distinction between helping and non-helping behavior was in the hurriedness of the subject. In all, 40% of seminarians helped the victim, but in a low hurry situation 63% helped as compared to a high hurry situation where only 10% stopped to help. They did note that many subjects who did not stop appeared distressed or anxious upon arrival at their destination, to me speaking to their internal conflict. They weighed more heavily the tasks in the forefront of their mind over what they felt in a more subtle way was the right thing to do. I think we are all susceptible to this dilemma. I have found myself rushing by situations in which I would normally help when I have been pressed for time or under psychological stress to do other tasks. I am not proud of this fact, but believe it is one we should be aware of. If your resident/physician/care team member is pushed for time, their ability to process and receive messages from the current situation may be impaired. This is of far greater import to address than to add strategic napping to their day.

During training we were taught to respect the forces of traction and counter-traction. Push and pull. Back and forth. Surgery is an art that requires a partner and optimization of this paired act is a goal to strive for. Many of us can relate to working on a project, playing an instrument with a band, dancing with another, or playing a group sport. All of these require action and reaction and we all can relate to the satisfaction that comes when the forces align and you are in harmony with your partner, your teammate, your patient, or the process itself. Time ceases to have meaning, all other stimuli or forces are tuned out and you are perfectly focused on the task at hand. This is surgery at its finest, but we must eliminate the background noise and allow our practitioners to find their center in order to move this process forward. As physicians, we create our own insulation to allow us to do our job, to see what we see every day and still continue on. However, we need to manage this dynamic carefully and be wary of creating a chasm rather than a buffer.

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