by Jarrod Shapiro, DPM Joined practice July 2006 of John K Throckmorton, DPM Lansing, Michigan

Throughout my education some concepts have stuck with me more than others. Three of these concepts stand out above all, and I’m sure all of you have heard these at some time or another. Determine the cause of the problem and treat it Form follows function Economy of motion I’d like to talk about the third concept, economy of motion.  During my time as a new doc, I’ve found this to be an increasingly important notion in both medicine and personal life.

The first time I heard this idea was in reference to surgical technique.  The surgeon’s goal is to limit the number of physical motions he or she makes during a procedure, economizing hand and body movements to decrease wasted actions, decreasing surgical time and surgeon fatigue.  If fact, the most talented surgeons I’ve met seemed to barely move during a case.  The body tissues seemed to part from each other as the scalpel drew near.  As a consequence, the case seemed to flow smoothly with minimal apparent effort.

To the observer, the action appears simpler than it actually is.  We’ve all heard someone say, “He makes it look easy.”  The first surgical procedure I did was a digital arthroplasty during my fourth year of medical school.  Of course, I’d already observed countless arthroplasties, and they seemed effortless.  Incisions were made, the joint was exposed and osseous resections were performed with ease.  It seemed simple: a couple flicks of the wrist, and the procedure was complete.  Then I had my chance.  All of a sudden the scalpel blade seemed too large for the toe, I had trouble finding the joint, and I felt like I had butter fingers.  With patience on the part of my attending I managed to complete the procedure without any complications.  I had a new appreciation for appearances and economy of motion.

My misjudging “simple procedure” for “economy of motion” is understandable, common, and not isolated to medicine or surgery.  This is very common in the sports arena, for example.  Two greats of their respective sports are Tiger Woods (golf) and Roger Federer (tennis).  Considered the greatest to ever participate in these sports, they are described as having very efficient and superior techniques with little physical strain and body wear and tear.  They have an economy of motion that makes what they do seem simple.

Economy of motion also translates into everyday life.  Let’s take something like cooking a meal.  Economy of motion would dictate obtaining all ingredients prior to starting.  How successful would your meal be if you had to run out to the store in the middle of cooking to pick up an essential ingredient?  How about getting dressed?  Do you put your underwear on after your pants?  Of course not!  How difficult would it be to get dressed backwards?

The same is true for surgery.  Would your bunionectomy go well if, in the middle of the case, you realized you didn’t have a saw?  How about applying an Ilizarov external fixator without pins or wires?  Good luck.

Clearly, we instinctually apply this concept to much of what we do.  However, the truly technical excellence comes when we consciously apply it to our tasks.  Recently, I had a busy surgical day with seven cases scheduled.  I knew the first step to economical motion is preparedness.  So, I reviewed the histories of my patients and checked that the hospital had the equipment I needed beforehand.  Then, before each case, I visibly checked the OR room to be sure we were ready to proceed. The day would have been a disaster if certain pieces of equipment were not ready when I needed them.  I also know that communication is essential to any successful endeavor, so I maintained this communication throughout the day, making sure the next patient was ready when I was.  The day went well with few significant issues.

So if economy of motion is an important and useful skill in both medicine and everyday life, how can we improve these skills?  Here’s my prescription for obtaining excellence in economy of motion:

1. Desire – the first step in any endeavor is caring to do what’s necessary
   
   
2. Definition – set a specific goal
   
   
3. Preparedness – figure out beforehand what tools are necessary to accomplish your goal
   
   
4. Practice – no one ever became proficient in anything over night.  Becoming a superior surgeon takes time, practice, and repetition
   
   
5. Patience – be patient with yourself.  Some skills have a greater learning curve than others.  Don’t berate yourself when you make mistakes.  Just don’t make the same mistakes repeatedly!
   
   
6. Analysis – review your performance and honestly self-critique how you may improve
   
   
7. Joy – enjoy what you do.  You should be a physician because you enjoy it.  If you don’t then find something else to do that brings you joy.

Here’s a small exercise you can try.  For the next surgical case you do, try to perform the entire procedure from skin to skin without once looking up from the surgical field.  Prepare yourself and your staff prior to the start, review the procedure steps in your mind, and attempt to complete the case without looking away from the field.  Time yourself and compare the time it takes to do this procedure with prior cases of the same procedure.  You may find that after one or two attempts, your surgical time will decrease, and the cases may go more smoothly. 

If this goes reasonably well, you might try it outside of the OR.  Personally, I make it into a small game for myself.  How efficiently can I complete a task?  Can I complete that task without having to repeat steps?   I’ve found that over time I have become increasingly efficient overall and have more time for other activities.  Remember, do it with joy or don’t bother doing it.  Economy of motion – give it a try.

Jarrod Shapiro, DPM
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