ORIGINAL REPORTS Left-handed Surgeons: Are They Left Out? Prasad S. Adusumilli, MD,* Christian Kell, MD,† Jae-Hyung Chang, MD,* Scott Tuorto,‡ and I. Michael Leitman, MD* *Department of Surgery, Lenox Hill Hospital, New York, New York; †Department of Neurology, Universitaetsklinikum Frankfurt, Frankfurt, Germany; and ‡Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York BACKGROUND: Left-handedness has been considered a simple inconvenience by some or something as convoluted as “the sinister,” the Latin word for the left, by others. One in ten medical personnel is left-handed. The perceptions of lefthanded surgeons regarding their laterality related inconveniences are unknown. OBJECTIVES: To determine the perceptions of left-handed surgeons and the way it has affected their surgical training and career. DESIGN AND SETTING: Web-based survey of left-handed surgeons. PARTICIPANTS: Left-handed surgeons in 2 boroughs of New York City, Manhattan and Brooklyn. METHODS: Distribution and completion of the survey. MAIN OUTCOME MEASURE: Career-oriented concerns of left-handed surgeons. RESULTS: Three percent of left-handed surgeons received lat- erality related mentoring during medical school. Ten percent of the programs mentored left-handed surgical residents, and 13% of the programs provided left-handed instruments during surgical residency. Laparoscopy and laparoscopic instruments did not eliminate the problems associated with instrument handling to left-handed surgeons. Ten percent of the left-handed surgeons expressed concerns when asked whether they would be comfortable being treated by another left-handed surgeon when they are the patients themselves. CONCLUSIONS: This study reveals the perceptions of left- handed surgeons in adapting to a right-handed world. Early laterality related mentoring in medical school and during surgical residency with provision of left-handed instruments might reduce the inconveniences of left-handed surgeons learning. (Curr Surg 61:587-591. © 2004 by the Association of Program Directors in Surgery.) KEY WORDS: laterality, dominance cerebral, education, lapa- roscopy INTRODUCTION Eleven percent of Americans (20% of men and 8% of women) are left-handed.1 Studies reflect similar percentages of lefthanders among medical personnel.2 Left-handedness has been considered a simple inconvenience by some, whereas some lefthanded surgeons feel that they are “the last unorganized minority.”1 Although left-handers are considered to be more intellectual,3 musical,4,5 and artistic4,5, studies have documented that left-handed people are more prone to unintentional injuries,6,7 head trauma,8 motor vehicle accidents,9 and increased sports injuries.10 Left-handed industrial workers are 5 times more prone to finger amputations than right-handed workers.11 Surgical professions demand higher cognitive skills, good ergonomics, and coordination. Despite this, there is complete paucity of literature for left-handed surgeons. An online literature search reveals only 5 articles related to “left-handed surgeons.”12-16 No textbook narrates advice for left-handers. There is persistent right hemispheric activation in converted left-handers, despite decades of right-handed writing.17 Schueneman and Pickleman15 have shown that although lefthanded surgical residents are more proficient on a neuropsychological test of tactile-spatial abilities, they tend to be more cautious, more reactive to stress, and have lesser operating skills. In the current study, we surveyed the perceptions of lefthanded surgeons regarding their laterality related adjustment difficulties. METHODS Correspondence: Inquiries to Prasad S. Adusumilli, MD, Memorial Sloan-Kettering Cancer Center, 430 East 67th Street, RRL 417D, Box 516, New York, NY 10021; fax: (212) 717-3053; e-mail: adusumip@mskcc.org Presented at the Society of Critical Care Congress 2002, San Diego, California. A web-based survey was conducted (www.geocities.com/ lefthandsurgeon). This survey consisted of demographic information, childhood experiences, lateral predominance in performing motor tasks, career expectations, mentoring CURRENT SURGERY • © 2004 by the Association of Program Directors in Surgery Published by Elsevier Inc. 0149-7944/04/$30.00 doi:10.1016/j.cursur.2004.05.022 587 experiences, and training support during residency. Openended questions were included seeking the opinions of lefthanded surgeons regarding specific surgical procedures and their advice for the younger generation of left-handed surgeons. Contact information for left-handed surgeons was obtained from colleagues, as no such database is available. Survey forms were mailed (surface mail and e-mail) with greetings on the occasion of “International Left-handers Day” (August 13th). The survey participants were from 2 boroughs of New York City, Manhattan and Brooklyn. The responses were collected anonymously and the results were tabulated. Incomplete responses were excluded in the final analysis. RESULTS Demographics: Eighty percent of the survey participants responded (n ⫽ 68). One in 5 respondents is a female. The median age of the survey respondents was 45 years (range, 27 to 60). Two thirds of the surgeons are practicing general surgery, whereas others are in surgical specialties. These surgeons are in practice for a median of 12 years (mean 15 years and mode 12 years), whereas 13 of them are still in training. Lateral predominance: Sixty-nine percent of the responding surgeons are only left-handed, whereas 31% perceive themselves as ambidextrous. Left-handed surgeons preferentially use their left-hand for writing a report (90%), shaving (92%), throwing a ball (80%), and handling instruments in the operating room (70%), but they use their right hand (68%) for handling a computer mouse. One in 3 left-handed surgeons were forced to change laterality during childhood by their parents, teachers, and peer pressure, although most of the respondents felt that left-handedness was an advantage in team sports (ball-oriented games). Medical school and surgical residency experiences: The experiences of the respondents while entering into medical school and surgical residency were documented in Table 1. The majority of the respondents surgical training programs “did not care” about their laterality (n ⫽ 60). Others were advised “to switch laterality” (n ⫽ 4), were “reassured and offered help” (n ⫽ 3), or were “asked to quit” (n ⫽ 1). Only one in 10 respondents were offered laterality related mentoring by the surgical training programs. One in 2 left-handed surgeons voluntarily sought advice from a senior left-handed surgeon during their training period. While assisting the faculty in the operating room during their training, 30 respondents said that none of the faculty was annoyed by their left-handedness, whereas 38 said that some of the faculty was annoyed. Although half of the respondents were aware that left-handed instruments were available to them, only 13% of the respondents were provided with left-handed instruments by their training programs. Three surgeons considered leaving surgery at some point in their career, and 1 surgeon considered changing specialty (cardiothoracic surgery) because of laterality related frustrations. Laterality preferences in performing an invasive procedure: Twelve percent of the surgeons preferred to stand on the right 588 side of the bed while inserting a urinary catheter, 53% on the left and 35% had no preference. For central venous cannulation, the preferred approaches for left-handed surgeons were left subclavian (38%), right subclavian (33%), right internal jugular (20%), and left internal jugular (4%). The vessel of choice for arterial cannulation was the left radial artery (59%) and for peripheral venous cannulation and phlebotomy was the left forearm (78%). Twelve percent of the surgeons change the monitor and room setup while performing an endoscopic procedure, whereas the rest perform the procedure the way it is originally arranged. Operating room experiences: One third of the surgeons have their laterality preference documented on the surgeons’ preference card in the operating room. When asked whether they had to remind the scrub nurse or technician about their left-handedness during 10 consecutive operative procedures, 27% of the left-handed surgeons said that they never had to remind the operating room staff, 45% of the respondents had to remind their laterality 1 to 5 times, whereas 27% had to remind the operating room staff more than 6 times. Sixty-one percent of the surgeons use their right foot to activate a bovie pedal, whereas the rest use their left foot. Twenty-eight percent felt that they are more prone to needle stick injury and other occupational hazards in the operating room because of their laterality compared with their right-handed colleagues. Contrary to popular belief, the introduction of laparoscopy and laparoscopic instruments did not eliminate laterality related discomfort to the left-handed surgeons. Among the respondents, 31 respondents felt that laparoscopy and laparoscopic instruments did not eliminate any discomfort associated with laterality, whereas 10 respondents felt that laparoscopy eliminated the problems associated with surgical instruments completely. Among the rest of the respondents, 15 felt that 75% of the problems are eliminated by these instruments, 9 felt that 50% of the problems are eliminated, and 3 felt that 25% of the problems are eliminated. Career experiences: During their surgical career, 59 (87%) of the responding surgeons felt that they were never at a disadvantage compared with their right-handed colleagues during hiring or promotion because of their laterality. Four surgeons felt that they were at a disadvantage once during their career, 1 surgeon felt at a disadvantage 3 times, and 5 surgeons felt at a disadvantage several times during their career. Twenty-five percent of the surgeons said that their patients never noticed their laterality, 15% said patients noticed up to 3 times, and 60% said patients noticed several times during their career. Ninety-four percent of the responding left-handed surgeons said that their patients never expressed concern regarding the operating surgeon’s laterality, whereas 6% reported patient concerns 1 to 3 times. Ten percent of the responding left-handed surgeons expressed concerns when asked whether they would be comfortable being treated by another left-handed surgeon when they are patients themselves. CURRENT SURGERY • Volume 61/Number 6 • November/December 2004 TABLE 1. Career-related Perceptions of Left-handed Surgeons in Percentage (n ⫽ 68). Numbers Are Represented in Percentage. Perceptions of Left-handed Surgeons Yes No 1. Did you encounter practical difficulties in medical school because of your laterality? 2. Were you offered mentoring for your left-handedness in the medical school? 3. Did you anticipate laterality related problems prior to entering into the surgical profession? 4. Did you communicate with a left-hand surgeon prior to entering into the surgical profession? 5. Were you discouraged or cautioned by your peers, surgical seniors or family in choosing surgery as a career because of your left-handedness? 6. During surgical residency interviews, did any of your referees mention your laterality in their reference letter? 7. During surgical residency interviews, were you asked about your laterality? 8. During surgical residency interviews, did you mention your laterality? 9. During surgical residency, did your program mentor you for your hand preference? 10. During surgical residency, did you voluntarily approach another left-hand surgeon for advice? 11. During surgical residency, were you aware of any left-handed instruments? 12. Did your program offer any left-handed instruments? 15 85 3 97 24 76 10 84* 13 87 0 84⫹ 4 3 10 96 97 90 49 40** 50 13 50 87 ⫹ Do not know 16%. *No left-handed surgeon available 6%. **No left-handed surgeon available 11%. DISCUSSION The present study illustrates the perceptions of left-handed surgeons in adapting to a right-handed world. Although it may be easier to mentor the surgical skills to a right-handed trainee, there are no studies or teaching material available to teach lefthanded surgical residents. One in 4 left-handed surgeons in our study was anxious entering into the surgical profession. Laterality-related guidance was reported to be minimal in medical school. The first practical exposure a medical student has in the operating room is handling the scissor, clamp, needle holder, and tying a knot. It is only conceivable that unpleasant initial tasks and difficulties during medical school surgical rotation might be deterring left-handed medical students from choosing a surgical career, although no data are available to correlate this. Intrinsically, tools and instruments are built with a distinct advantage for either the right or left-handed individual. Among survey respondents, only 13% (9 respondents) were provided left-handed instruments by their surgical training programs. Having basic sets of left-handed instruments (scissors, clamps, and needle holders) available in the teaching hospitals for medical students and surgical residents may minimize the inconveniences associated with learning. Nearly half of the left-handed surgeons surveyed were anxious about their laterality related difficulties and sought advice during surgical residency, but only 1 in 10 programs mentored for laterality predominance. A previously published study by Schueneman and Picklemann15 has shown that although lefthanded residents are more proficient on a difficult neuropsychological test of tactile-spatial abilities integrating tactile and kinematic information, they tend to be more cautious, more reactive to stress, and have lesser operating skills compared with their right-handed colleagues. Authors caution that there might be a bias in their study by the senior attending surgeons in evaluating the performances of left-handed surgical residents because of the inconvenience associated with assisting them. Nevertheless, there is a lack of laterality related mentoring for left-handed surgical residents as is shown in our study, which might be another contributing factor in the perceivable difference between right- and left-handed surgical residents. Lefthanded surgeons preferred an approach that might be different than a right-handed surgeon in performing an invasive procedure as revealed in the present study. Mentoring by a righthanded surgeon or a senior surgical resident will only leave the left-handed residents to teach themselves a procedure. Perhaps the situation might be different if there is an understanding that an ergonomically different approach might be more convenient and safe for a left-handed learner. Provision of a left-handed mentor and other environmental modifications could be used to minimize the recurring difficulties for left-handed learners. It is interesting to note that laterality preference of the lefthanded surgeon is noted only 35% of the time on the operating room preference card. Simple documentation of the surgeon’s laterality preference might eliminate the interpersonal conflicts and inconveniences between surgeons and the operating room staff and promote a congenial operating room environment. Studies in other professions have shown that only 45% of the left-handers are left-footed and 57% of the left-handers are left-eyed.18 The observation in our study that 61% of lefthanded surgeons prefer their right foot to use the bovie pedal is consistent with that. This observation might be of significance while developing modern ergonomic robots and other minimally invasive consoles. CURRENT SURGERY • Volume 61/Number 6 • November/December 2004 589 Left-handed surgeons felt that the following surgical procedures are difficult to learn standing on the right side of the operating table: open cholecystectomy, pelvic surgeries, right hemicolectomy, and procedures around the gastro-esophageal junction. Left-handed surgical residents should be given a chance to stand on the left side of the operating table, which is “right” for them to learn. Left-handed surgeons also felt considerable difficulty in handling the following instruments: long vascular needle holders (difficult to keep the tip moving while disengaging the ratchet), heavy hemostatic clamps, righthanded scissors, and a wheat Lander. Modern stapling devices and endovascular instruments have significantly eliminated problems for left-handed surgeons. The popular belief that laparoscopy and minimally invasive surgical instruments have completely eliminated difficulties for the left-handed surgeons does not hold true for the respondents in this study. Laparoscopic surgery involves more static posture of the neck and trunk with more frequent awkward movements of the upper extremities than open surgery.19 A study by Emam et al,20 which compares ergonomic needle drivers to the conventional finger loop instruments has shown that with ergonomic needle drivers, a different pattern of joint movements along with a reduction in muscle power exerted during endoscopic suturing results in an absence of muscle fatigue. Therefore, it is important to note the observation in our study regarding laparoscopic instruments to facilitate designing and developing left-handed instruments during the current era of laparoscopic and minimally invasive surgery. We were surprised to learn that 1 in 10 left-handed surgeons have perceivable difficulty in being treated by another lefthanded surgeon. Unfortunately, our survey did not have the provision to inquire into the reasons for this perception. A simple website, a chapter in surgical textbooks, or a pocket manual outlining the guidelines in performing invasive and surgical procedures specifically for left-handed surgeons that lists the available left-handed instruments might be of benefit for future left-handed medical students and surgical residents. Our study has several limitations. The sample group may not be representative of all left-handed surgeons, but no such database is available. There might be a source of bias in the study as the questionnaire is specifically designed to elicit the perceptions of left-handed surgeons only. But the responses received are fairly consistent with the maturity of the responding surgeons. We purposefully eliminated a righthanded surgeon’s control arm, as our aim is not to elicit performance differences among right- and left-handed surgeons but to simply seek perceptions of left-handed surgeons. Future studies with a larger number of participants and appropriate psychometric evaluation of the survey may help to reduce the above limitations. CONCLUSION REFERENCES 1. Rohrich RJ. Left-handedness in plastic surgery: asset or liability? Plast Reconstr Surg. 2001;107:845-846. 2. Henderson NJ, Stephens CD, Gale D. Left-handedness in dental undergraduates and orthodontic specialists. Br Dent J. 1996;181:285-288. 3. Annett M, Manning M. Arithmetic and laterality. Neuro- psychologia. 1990;28:61-69. 4. Schachter SC, Ransil BJ. Handedness distributions in nine professional groups. Percept Mot Skills. 1996;82(1): 51-63. 5. Gotestam KO. Left-handedness among students of archi- tecture and music. Percept Mot Skills. 1993;70:13231327. 6. Graham CJ, Dick R, Rickert VI, Glenn R. Left-handedness as a risk factor for unintentional injuries in children. Pediatrics. 1993;92:823-826. 7. Graham CJ, Cleveland E. Left-handedness as an injury risk factor in adolescents. 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