Behind Closed Doors: Unsolved Mysteries: Surgeon Preference Sheets

A simple solution that’s anything but.

If you’ve ever worked in the OR, you are aware that the guiding light of any case is not the surgeon, anesthesiologist or even the schedule. It’s the surgeon’s preference sheet.

For those who do not have the experience of working in the OR, the preference sheet is supposed to be a simple document created to tell us what the surgeon likes and wants for their cases. It will fill us in on instrument sets, drapes, sutures, positioning, atmosphere and all the things needed to perform a smooth and successful case. It’s like a Xanax for the OR ... almost.

These days, it seems more like an ancient artifact that was written once, never updated, has many different interpretations and does not do as intended.

Forget Xanax. We’re having a full-blown anxiety attack.

The ancient scroll

It appears that many preference sheets were written during the Clinton administration and have not been updated since. You could read instructions to “have pager ready” or “surgeon prefers Garth Brooks CD in room.” Meanwhile, the younger generations are like, “What is a pager?”

As the times change, we adapt to new surgical techniques and technology, we change vendors, but one thing does not change — the surgeon preference sheets. These remain preserved in a dusty binder like an ancient scroll that nobody wants to touch. If you listen closely, you may hear a nurse say, “I can’t believe Dr. Whoever really wants suture that was discontinued 15 years ago!”

The art of vagueness

Sometimes we get the golden ticket of preference sheets. These are made with the fine-tuned precision we would want from all our surgeons. The details are all laid out clearly — settings for equipment, correct prep and standby items needed.

Other times, preference sheets are like fortune cookies from a Chinese restaurant, reading like this:

• Likes a clamp (just pick one?)
• Prefers music (heavy metal, rap, country?)
• Patient should be comfortable (genius!)

There’s a special place in OR purgatory for the sheets that say “standard setup.” Who determines what “standard” is? This is just straight-up PMO (Pisses Me Off, for those who do not speak teenager lingo).

Contradictions

Often, preference sheets are riddled with contradictions. They could say “use minimal drapes, but cover everything,” “Bovie at 25, unless I say 35,”or “needs suction, doesn’t like noise.” The best is “only open items I will definitely use.” I hope a Magic 8 Ball is on the preference sheet just for that option.

Surgeon personality test

Sometimes reading preference sheets is like a psychological evaluation. You may have a minimalist who just needs a “knife and suture.” I appreciate the minimal setup, but am I being set up for a disaster?”

On the other hand, there’s the maximalist surgeon who offers diagrams, pictures, detailed items and even their Spotify playlists.

Occasionally, we get the hoarder who wants everything — 2X backups, random items and several things on standby. In most of these cases, none of this stuff is used.

To counter the hoarder, we have the OCD surgeon, whose directions may say “mayo stand exactly chest height plus two inches.” Whose chest? Yours? Mine? Anesthesia’s? I have questions!

Lost in translation

It’s fun to try to figure out what is written versus what we actually call the item in the OR. The preference sheet may say “cyclodialysis spatula” but none of us have ever heard of that. Come to find out we just call it a “sweep.” How about we all get on the same page? A sweep is easier to say and spell.

The sheet vs. reality

The moral of this story is that no matter how detailed a preference sheet is, the case never follows it exactly. The surgeon is always going to ask for something that wasn’t on the list, and it’s the job of the OR staff to get it. The surgeon may ask, “Why don’t we have this item?” and the nurse replies, “Because it isn’t on your sheet.” “Well, I like it now,” the surgeon says, which means to add it!

This is where the problem occurs. The next logical step would be to add it to the sheet but, just like the Sunday horoscope, we shall see if it happens.

OR staff requests

Now, wouldn’t it be awesome if the OR staff could have their own preference sheet? Some items I would add would be:

• Surgeon to refrain from saying “This is just a quick add-on.”
• Surgeon should arrive on time.
• Surgeon must specify which clamp before demanding it.
• Surgeon must say “Thank you” after every instrument is passed (this just sounds funny).

Why keep the sheets?

Even with all the flaws, preference sheets are somewhat comforting. They prove that surgeons tend to be creatures of habit, although we have some outliers. Sometimes having extra items on hand is like a comfort blanket for them.

Ultimately, preference sheets aren’t really about instruments. They’re about routine, comfort, familiarity and giving surgeons a sense of control in situations where things can go very wrong. For the rest of us, they’re a fun puzzle to figure out, full of unintended jokes and even some fodder for OR gossip.

Remember: The next time you’re setting up and cursing at a sheet that calls for an instrument that hasn’t been used since the Civil War, it could be worse. We could have nothing prepared and need to ask the surgeon ,“What do you want?”

Oh, the horror! OSM