Published 8/1/2012

Point/Counterpoint: Music in the OR

POINT: Music in the Operating Room Is a Distraction
Stuart J. Fischer, MD

I love music. I listen to music in my car and at home. For years I lived across the street from Lincoln Center and went to concerts after work.

I just don’t think music belongs in the operating room (OR).

The OR is the one place where every member of the surgical team can enjoy quiet concentration on a single problem and work together as a team. There is a quiet sense of pace and rhythm as well as purpose as everyone moves through the procedure.

Good surgeons should set their own tempo for the room. They shouldn’t need music to do it for them.

The atmosphere doesn’t have to be solemn. But it should be serious and focused on the patient and problem at hand. It shouldn’t be a party-like atmosphere with rock music blaring in the background—not when someone’s life rests in the balance.

I would like to think that if someone played a tape of the procedure back to the patient after surgery, that patient would hear dedicated professionals working on their jobs, not jazz, rap, or opera.

Most orthopaedic surgeons are bombarded during the day with patients, phone calls, verbal orders, reports, and calls from the emergency department. As physicians, we are accustomed to multitasking. The OR should be the one place where we don’t have to do several things at once.

Music—or any noise for that matter—can be a real distraction. An article in USA Today quoted a Yale anesthesiologist who said, “The sound of music may actually hinder patient care because the monitoring may not be clear.”

A more formal study in the British journal Anaesthesia polled 200 anaesthetists and found that “26 percent of the sample felt that music reduced their vigilance and impaired their communication with other staff while 11.5 percent felt that music might distract their attention from alarms. Fifty-one per cent felt that music was distracting when a problem was encountered during the anaesthetic.”

A review in the Journal of PeriAnesthesia Nursing noted, “The main effect of noise on staff performances is related to impaired communication, resulting in a negative effect on patient safety.”

A 2011 study in the British Journal of Surgery concluded that higher levels of intraoperative noise volume were associated with a higher incidence of surgical site infection. The authors claimed “This may be due to a lack of concentration.”

What is the solution? In May 2012, AAOS Now published a roundtable discussion on “Distractions in the Operating Room Threaten Patient Safety.” One of the recommendations was to create a “sterile cockpit” environment similar to the atmosphere for aircraft pilots during takeoff and landing. To help create this environment, William J. Robb III, MD, chair of the AAOS Patient Safety Committee, quoted recommendations from the American College of Surgeons and suggested that “No loud or distracting music” be played during surgery.

Needless to say, medical liability attorneys are now advertising cases in which settlements were obtained against “distracted surgeons.” Imagine being a defendant in a malpractice trial and having to answer the question, “Doctor, were you listening to heavy metal while you were operating on this patient?”

Loud music isn’t just a distraction. It might obscure critical auditory feedback that could be helpful to a surgeon during a procedure. One example might be the chatter of a reamer in a femoral canal that tells indicates the reamer is hitting hard cortical bone and it’s time to stop. Or, while fixing a comminuted fracture, the surgeon could miss the quiet snap indicating that the opposite cortex has fragmented. And what might happen if someone accidentally leans on the cautery and the surgeon never hears the buzzing?

Many surgeons wear hoods with fans when performing total joint arthroplasty procedures, making it difficult for them to hear simple conversations. Music in the room would make it that much harder.

In fact, music can be a source of conflict and resentment in an OR. Usually the surgeon picks the music. But what happens if no one else in the room likes the surgeon’s choice? They will be unhappy about being there and possibly less focused on what they are supposed to do. They won’t just tune out the music; they might tune out the surgeon and the patient as well.

One point is clear in every article about music in the OR: “If a difficulty did occur, the music would be switched off, signalling a change in developments and a need for extra focus,” according to the president of the Royal College of Surgeons, as quoted on the BBC News Health website.

Shouldn’t we as orthopaedic surgeons be giving our patients that “extra focus” right from the beginning of the case? Why wait until there is a problem to ramp up attention?

Dr. Haber, I would someday like to come and do a case with you. But please leave your iPod at home!

Stuart J. Fischer, MD, is a surgeon in private practice in New Jersey and a member of the AAOS Now editorial board.

COUNTERPOINT: Music in the Operating Room Is a Focusing Tool
Lawrence L. Haber, MD

Surgery is one of the most unnatural professions that exist. Surgeons cut people open for a living and, while doing so, take on an immense responsibility with every patient.

Every surgeon finds ways to add normalcy to this otherwise unnatural setting. Some create rigid parameters of behavior. This may include compulsive activities that, in the surgeon’s mind, may limit the range of variables that exist in the room and provide a sense of organization and well-being. Others may use idle chatter, jokes, or prayer to bring comfort to this unnatural setting. But surgeons may often not realize the impact their choice has on others in the room.

Music is a way to create a more soothing atmosphere, while one is simultaneously engaged in an activity that requires concentration and thought. Played appropriately, music is not a source of distraction.

Studies have shown how music affects surgical performance. A 1994 study in the Journal of the American Medical Association measured the heart rate, blood pressure, response times, and task accuracy of 50 male surgeons aged 31 to 61 years who habitually listened to music while they worked. It showed positive improvements in problem-solving during a complex and stressful subtraction task when the surgeons were able to select music to listen to, as opposed to experimenter-selected music or no music. The researchers, from the State University of New York at Buffalo, surmised that listening to music, especially music of a surgeon’s own choosing, led to decreased stress and increased performance.

A recent survey of surgeons in the United Kingdom, reported in the online publication The Guardian, found that 90 percent of respondents played music while performing surgery.

The fact that music and surgery mesh well together is not surprising. There has always been a connection between music and surgeons. One need not look far to realize how many surgeons also excel at music. Both disciplines require active thought, manual dexterity, and practice to create perfection. One observer in my OR insisted that surgery is like a choreographed dance, so it’s only natural that music would be playing in the background.

When the surgery is a difficult case, appropriate music can stimulate the surgical team and add rhythm and synchrony to the surgical activity. Any surgeon who habitually listens to music in the OR has heard from the staff: “I know what’s wrong with this case; we forgot the music!” On come the tunes and suddenly the team is reenergized, the solutions flow, and everything becomes easier and more enjoyable.

The most common concern expressed about music in the OR is fear of distraction from the work at hand. Clearly, music must be played of a type and in a way that does not disrupt communication or other essential activities.

Those who believe surgeons should all work in silence often compare the OR to the sterile environment of an airplane cockpit. As a pilot, I know that this is an inaccurate portrayal of the activities in flight. Although a sterile cockpit is essential during takeoff, landing, and critical events, most of the time the cockpit is a laid-back area of conversation and fellowship, and yes, music is frequently played.

Just as in flight, there may be times in a procedure when a sterile cockpit is needed. Examples might be the time out at the beginning of a case or a critical part of the procedure that requires maximum communication among multiple individuals. But during other times, music might be appropriate.

For those who do not indulge in music, but would like to try, I offer a few suggestions. Choose music that makes you happy and relaxed, but also is compatible with deep thought. Avoid depressing music or lyrics like “When I die young.” Middle-aged rockers or those with some appreciation of rock history might try Pink Floyd’s Dark Side of the Moon (great with knee scopes), the Rolling Stones’ Some Girls, or The Who’s Who’s Next (great with anything).

Anything loud and destructive will do for hard rockers. My personal favorites are Guns and Roses, Nickelback, and The Cult. However, surgeons should avoid this genre when angry and must be careful about the lyrics.

Johnny Cash never fails classic country fans. For more modern country, try the likes of Garth Brooks, Carrie Underwood, or Darius Rucker. Musical lovers might strike a chord with Les Misérables or Rock of Ages. For those with more refined symphonic taste, anything classical will do. My personal favorite is Dvorak’s Symphony No. 9 and almost anything by Mozart.

Whatever you choose to do to make your OR environment more aesthetic, be aware that for many orthopaedic surgeons, music is the answer.

Lawrence L. Haber, MD, is a pediatric orthopaedist on staff at the University of Mississippi Health Care.

Editor’s Note: This new feature in AAOS Now presents two viewpoints on issues in orthopaedics. Some may be clinical issues; others, like this introductory Face-Off, will focus on nonclinical topics. Readers are invited to weigh in as well; cast your vote on the role of music in the OR now.