PRECIOUS COMMODITY The only thing harder than acquiring block time is maintaining it.

What's more valuable and precious than gold, Super Bowl tickets and a free lunch to any surgeon? Block time! Scheduled block time is what surgeons aspire and fight for. It's hard to get and, once attained, it can be even harder to hold on to. As a sage and wise anesthesiologist once advised me: "Block time is earned, not freely given."

All surgeons have to take some shots early in their careers in order to ascend to the elusive peak known as dedicated time. As a young surgeon, my starting times averaged 1 p.m. (Greenwich Time). My cases were bumped more than a Times Square pickpocketer, and the head nurse liked to place my cases after the vascular surgeon who was so slow that the circulator kept a diary. When you follow another surgeon, anything can happen. The quick lap chole can morph into Nightmare on Elm Street replete with extended open incisions and frantic attempts to control bleeding. Four hours, 3 drains, 5 vascular clips and 2 units of packed red blood cells later, my calculated 2 p.m. start has transformed into permahold status.

In those early pre-block-time days, my wife (Saint Marie) never knew when I would return home. At the start of the day, she didn't know whether to pack my lunch or pajamas. I used to get home so late I kept Conan O'Brien waiting.

Slowly, I earned dedicated 7:30 a.m. start times, and, after years of apparently demonstrating reasonable proficiency, attained the Holy Grail of every surgeon: 2 rooms. However, it's just as challenging to maintain 2-room block time as it is to attain it.

• Use it or lose it. Some surgeons, delighted that they reached the elite 2-Room Club, decide to kick back and dial down their volume. "Two Roomers" are often more senior and perhaps more interested in fixing their golf swings than in filling their schedules. When the 7:30 a.m. to 5 p.m. block ends at 1 p.m., however, it may be time for them to join the Senior PGA Tour. Their block time is on life support.
• Time release. Our administrators ask surgeons to release their block time several weeks in advance so that other surgeons can fill the time, but many ADHD-riddled surgeons simply forget to inform their staff of absences. Repeat offenders may find themselves on the block time cutting board.
• Make the grade. Once you earn your block time stripes, you must maintain them. Surgeons age, many don't keep up with technology and surgical innovations, and some merely lose their edge. What once took 30 minutes is now an arduous 3-hour affair. Two cases a day just doesn't make it in today's world. Some surgeons test the system and book complicated cases that clearly belong in the main hospital. The projected 5 p.m. finish really resulted in an 11 p.m. extravaganza and an, ahem, unplanned hospital admission. Did the multi-ligament knee reconstruction with tibial plateau and distal femur fractures really belong in the surgicenter?

Policing the schedule
The hard calls nurses make to surgeons are by no means easy, yet they are necessary. Block time is a precious commodity and should be treated with appreciation and reverence. I do not take mine for granted and for now, at least, it is far more important than my golf swing.