Michelin-starred theatres
Authors: Richard C Newton, Samir Damji, Maryam Alfa-Wali
Journal: Journal of the Royal Society of Medicine (2010)

The recent universal adoption of pre-procedure surgical checklists illustrates how modern surgical practice has benefited from lessons in safety culture, courtesy of high-risk industries like commercial aviation1,2 and petroleum exploration.3 Such ideas are implemented to reduce risk and avert catastrophe, but perhaps surgery can also share tips with less hazardous professions.

As celebrity chefs roll up their sleeves for more broadcasting of the perfect roast goose recipe, perhaps we can consider their more restaurant-tied comrades, and their skills and attributes. Cooking seems to have parallels with surgery. Modern surgical care and the finest commercial gastronomy have the shared aspiration of providing dependable excellence. Haute cuisine chefs and leading surgeons must deliver a personalized service which is self-critical and constantly improving in a high-pressure environment. A limp souffle may be less catastrophic to the recipient than a poorly-fashioned anastomosis, but errors must still be universally avoided.

Knives apart, the working day in a Michelin-starred kitchen functions with the surgical precision of the most well-oiled theatre. There is a hierarchical division of labour from the kitchen assistant to the head chef. Even with exemplary assistance from the multidisciplinary team, ultimate responsibility for gastronomical governance rests with the chef. He or she must be an inspiring leader, effective communicator and proactive manager. The chef innovates with the menu and ingredients, audits the quality of dishes, deals with suppliers, monitors recruitment and staffing, still leaving time for communicating effectively with the occasional dissatisfied customer. He or she also ensures resources used are cost-effective without compromising quality, and oversees the safety and professional development of the team.

Optimum success in surgery does not just require technical competence, but a Raymond Blanc style passion and work ethic to achieve the absolute best. With this personal focus, both professionals learn the importance of timing. Unplanned delays to surgery lead to poor outcomes,4 and glitches during operative lists create inefficiencies and frustration.5 Chefs also understand the sequelae of delays: spoilt food and hungry diners. They avoid this with meticulous timing as a product of anticipation, practice and clear communication. A restaurant's success is judged by both reputation and, because of financial necessity, by the number of profitable diners fed. This is effectively ‘payment by performance’, and has been a strategy to shorten surgery waiting lists and improve care over the last decade.6 It remains to be seen how the proposed abolition of NHS targets will affect the reputation of surgical provision.

While surgical training is changing,7 both professions are still taught through the apprenticeship model and necessarily dependent upon an effective teacher–apprentice dynamic. With reduced hours and the conversion to shift work patterns, many surgical trainees have no continuity with their trainers, and would be envious of the stable supervision that the head chef provides to underlings. Both experts pass on technical skills and understanding: the chef looks, smells and tastes; the surgeon looks, listens and feels. Admired techniques are adopted; others rejected. But with practice, careful supervision and encouragement, the successful trainee matures from assisting lipoma excisions to teaching endarterectomies, and the kitchen assistant graduates from peeling potatoes to demonstrating how to create sashimi and manage a restaurant. As the surgeon develops a subspecialist niche, the chef cultivates a signature dish.

Cookery has even benefited from evidence-based practice. The structured methodological analysis of ‘molecular gastronomy’ elucidates which culinary dogma is relevant and why. It produces rationale for streamlining processes, improving outcome, reducing mishaps and facilitating innovation. There are international seminars and professorships in the discipline,8 and at El Bulli in Catalonia and the Fat Duck in Berkshire, virtual databases of structured culinary experiments.9 Surgeon scientists have modified practice, for example following the extensive investigation of the effect of temperature on patient outcome during surgery.10,11 Research has taught the gourmet chef to use liquid nitrogen to create smooth crystal-free ice cream, and sous-vide waterbaths to poach the perfect steaks.8 Technological developments provide novelty and excitement, and, as has been demonstrated with minimally invasive surgery, can improve patient care. Nevertheless, reminded that a well-honed traditional fruit crumble trumps any botched bacon and egg ice cream,12 we must be sure that surgical innovation provides a genuine improvement upon the status quo. For example, Da Vinci surgical robots (Intuitive Surgical, California) offer many theoretical advantages over open or laparoscopic surgery, but cost-effective clinical benefits must be proven before there is more widespread uptake.13

In some respects, the gourmet kitchen resembles the surgical firm of a previous era: extreme hours not protected by the European Working Time Directive, under the Ramsay-esque control of an autocratic consultant. But as surgery has learnt and borrowed concepts of incident reporting from aviation, and teamwork from the Ferrari pitlane,14 perhaps it can learn from high-end cuisine, even if just to marinate the thoughts and be reminded of the need for excellence and attention to detail.