By Heidi Splete

Left-handed surgical residents and fellows reported persistent disorienting advice and stigma during training, according to a new study of 31 individuals from 15 US institutions.

"Surgical education is designed for the right-handed," wrote Timothy J. Gilbert, MD, of the University of Michigan, Ann Arbor, and colleagues. Left-handed medical students "contend with instruments designed for right-handed use, perform worse on surgical skills assessments that are biased toward the right-handed, and are assumed to be right-handed by educators," they said.

Challenges for left-handed medical students are not new. A study published in 2010 identified eight major issues for left-handed surgeons:

1. Anxiety about laterality

2. Lack of mentoring on lateral preference

3. Difficulty handling traditional instruments

4. Difficulty with minimally invasive instruments

5. Inconvenience while assisting a right-handed person

6. Pressure to change lateral preference

7. Possible disadvantages with certain procedures

8. Possible advantage situs inversus

Previous studies have shown reports of stigmatization and a lack of training and educational resources as barriers to improving the experience and fostering the skills of left-handed students, but the current data on the subjective experiences of left-handed students are limited, the authors said.

"Some of the members of the research team are left-handed, and I think their personal experience/understanding of the topic informed their desire to do projects within this space, since handedness is so thoroughly taken for granted by the right-handed majority," Gilbert, who is right-handed, said in an interview. "It was important for our study to have parity between handedness to reduce bias in data interpretation," he said. "In an era where much has been done to ensure equity between different groups, there's not as much discussion about handedness within surgery as I believe there should be."

In a new study, the researchers recruited 31 self-identified left-handed surgical residents and fellows in six surgical specialties (general surgery, urology, plastic surgery, obstetrics and gynecology, otolaryngology, and neurosurgery) and conducted semi-structured interviews between January 31, 2021, and June 20, 2021. The study population included 21 seniors (postgraduate year of 3 or higher), five juniors (postgraduate years 1 or 2), and five surgical fellows.

Overall, three themes surfaced from the participants' educational experiences:

1. Disorienting advice from faculty or residents

2. Discouraging right-handed pressures and left-handed stigmatization

3. Expression of the educational wishes of left-handed medical students

Conflicting Advice

The interviewees described feeling confused by conflicting advice about how to manage surgical procedures given their left-handedness, the researchers said. Some respondents reported being told to learn to do everything with the right hand; others were told to use their dominant hand (right or left) for fine motor skill elements but use the right hand for sewing.

Persistent Stigma and Switching

Survey respondents reported perceptions that others in the surgical setting were judgmental and inconsiderate; workshops involved demonstrations with a right-handed focus; and surgical technicians prepared needles that were loaded right-handed. "To minimize this negativity, participants often changed to their right hand," the authors wrote. Some students who changed handedness reported an improved learning experience, in part because their handedness aligned with the instruments they used.

Educational Wish List

Study participants expressed the need for destigmatization of left-handedness in surgical through strategies including tangible mentorship, more granular and meaningful instruction, and normalization of left-handedness.

The study was limited by several factors including the focus only on surgical residents and fellows, with no left-handed medical students who pursued other specialties, the researchers noted. Other limitations included the retrospective design and potential bias from left-handed members of the research team, they said.

Notably, left-handed medical students reported negative experiences during training whether they operated with the right or left hand, the researchers wrote in their discussion. "From a strictly technical perspective, a left-handed medical student who is operatively left-handed will struggle to use hand-discordant tools in their dominant hand, whereas one who is operatively right-handed will struggle to use hand-concordant tools in their nondominant hand," they said.

The researchers emphasized the need to consider the data in context; a nervous left-handed student who has been shown only right-handed tools and techniques and has not disclosed their left-handedness struggles when asked to close an incision may see themselves as the problem rather than the surgical education.

Takeaways to Improve Training

The current study showed the diversity of needs of left-handed surgical trainees and how more positive encouragement and support could improve their experiences, said Gilbert.

The strategies to improve training for left-handed medical students vary according to educational level, said Gilbert. "If you're a surgical fellow or chief resident, you probably want more formal training, different tools, access to attendings who have experience performing an operation left-handed. If you're a medical student, that is likely less important than feeling like you won't be penalized of looked down upon for your handedness," he said.

In the survey responses, "I at least was struck by how far a few accepting words could do when said in the right way at the right time," he said.

"I think the most important takeaway is that educators should consider more what they say and do in the operating room to these junior students/trainees, as our data suggest even a single sentence at such a vulnerable point in time can push them into a choosing their handedness," Gilbert said. "That's not a small decision to make, and educators should be more thoughtful when engaging in the topic."

Also, educators should offer left-handed resources during clerkship orientations on techniques such as knot-tying, he said. "This normalized handedness and may make students more comfortable with themselves in the operating room."

Finally, "educators should be able to teach medical students the level-appropriate skills in either hand. If a medical student asks how to tie a knot or throw a stitch in their left hand, the educator should be able to demonstrate this to them effectively," Gilbert added.

More research is needed to understand the needs and wants of left-handed medical students, including those who do not pursue surgery and of the skills of the residents and attendings who are tasked with educating these students, said Gilbert.

"Eventually, the goal is to implement concrete changes to improve resources for these students, but I think the most effective way to design these resources is to fully grasp the desires and concerns of all involved parties," he said.

Residency Director Perspective

"We are increasingly sensitive to individual differences, but for some reason, left-handedness is a blind spot, although 10% of the population is left-handed," said Stephen M. Kavic, MD, professor of surgery at the University of Maryland School of Medicine, in an interview.

"Interestingly, we do not ask handedness on residency applications, suggesting that it may be viewed as a negative trait in the selection process," said Kavic, who also serves as program director of residency in surgery at the University of Maryland.

"While not left-handed myself, as Program Director, I have been tasked with training left-handed residents, and I appreciate the challenges," Kavic said. "Our department is about 6% left-handed. Most left-handed surgeons are far more comfortable with their nondominant hand than right-handers are with theirs," he noted. "We do have left-handed instruments available, but the ratio of sets is easily 100:1 right to left."

With regard to the current study, Kavic said it was understandable that left-handed medical students feel stigmatized. A message for educators is to not presume right-handedness; instead, ask students about the hand preference on first meeting, and then training will be more inclusive, he said.

"There is a fundamental difference in mirror image training when a righty tries to teach a lefty. How do we do this better and in a standardized fashion? This article clearly shows that we still have a problem; now we must do the work to fix it," Kavic said.

The study received no outside funding. The researchers had no financial conflicts to disclose. Kavic had no financial conflicts to disclose.