Abstract
Background
The early 20th century saw pioneering work by Frank and Lillian Gilbreth, regarded as the founders of surgical ergonomics, which brought scientific management in surgery and operating rooms. Through time and motion studies, their research helped improve the operative workflow and surgical efficiency.
Methods
To document the historical work of Gilbreths in surgical ergonomics, we conducted primary archival research at the Purdue University Archives and Special Collections (West Lafayette, IN), and integrated a collection of secondary sources across various formats and modalities.
Results and Conclusion
We describes the early works of Gilbreths in surgical ergonomics and highlight how their motion research in the operating room evolved to incorporate ergonomics and decrease operative fatigue. The Gilbreths were proponents of promoting the adoption of management practices for operating rooms and standardization in hospital design, equipment, and patient records to improve efficiency in health care delivery. Through analysis of their published and unpublished work, we describe how their ideas are still in widespread use today to eliminate unnecessary motions and foster ergonomics in the operating room and in the field of surgery in general.
Keywords
Introduction
Frank and Lillian Gilbreth were pioneers in applying management science and principles of ergonomics to surgery. Through their carefully conducted time and motion studies, the Gilbreths focused on improving efficiency and productivity in the workplace. Their work sought inspiration from the studies of a mechanical engineer-turned-management consultant Fredrick Taylor in the late 19th century. Taylor invented the Time Study method, an approach that involved studying people at work, and subsequently analyzing their repetitive motions to identify areas of improvement. 1 His goal was to find the shortest possible approach to accomplish the task at hand. The Gilbreths adopted Taylor’s system of analysis to maximize worker efficiency, and emphasized the optimization of motion in addition to time.2,3 Their work was a part of the larger milieu of the Progressive Era (between 1890s-1920s), which was driven by the scientific approach of quantifying problems and attempting to find solutions. 4 In this manuscript, we highlight the contributions of Frank and Lillian Gilbreth to the study of surgical time management and ergonomics in the operating room. We will describe how specific ergonomic principles in modern surgery owe their origins to Gilbreths’ work in the early 20th century as they brought their expertise in time and motion studies to medicine.
Frank Bunker Gilbreth hailed from Maine, and Lillian Moller from Oakland, California. In 1885, Frank Gilbreth was accepted into M.I.T. but decided, instead, to take a job at a construction firm. They met in Boston in June 1903, where Frank was living at the time, and Lillian was on her way to Europe with a party of women being chaperoned by Frank’s cousin. A year later in October 1904, the two tied the knot. Frank’s first job was as a brick layers’ helper, where he used his experiences to optimize the motions of brick laying and increase the worker’s productivity. It occurred to him that all the different methods of brick laying could not be equally good. “No two men used the same motions”. If the one best method could be discovered and taught to all bricklayers, it would increase output while decreasing labor costs to accomplish a task. After Frank passed away in 1924, Dr Lillian Gilbreth continued management consultancy, building on their joint work on time and motion studies. The Gilbreths were immortalized in the book Cheaper by the Dozen, which chronicles some of their personal life. 5 Yet, less is known about their work during the early days of ergonomics research. This article harnesses the Gilbreth Archives and Special Collections at the Purdue University, where they spent time as lecturers conducting key experiments in time-and-motion-study in the early 1900s.
Early Work in Micromotion Study and Therbligs
In the Examples of chronocyclegraphs tracking the motion of bricklayers to compare their traditional “old” method against a more efficient “new” way. Source: MSP 8, Box 163. Folder 1, Gilbreth Photographs; 0299-12, file NPTMK. Purdue University Archives and Special Collections: Frank and Lillian Gilbreth papers.
The Gilbreths found that meticulous assessment of their recorded movies could help create a standard best practice for that particular task, which they surmised would improve overall efficiency. Their objective was to increase the worker’s productivity with a commensurate decrease in effort and fatigue. 6 They divided “all questions of motion into 3 classes – fewest motions, shortest motions, and least fatiguing motions”.
The Gilbreths created a classification of human motions, as a word play on their surname, and called it Therbligs. This system described 17 categories of work motion (Figure 2), which could be graphically visualized on cycle motion charts. These charts plot body parts against time taken to complete a task or motion, and were meant to create a “standardized” way of performing manual tasks.
7
Motion and Fatigue study, Gilbreths believed, “consists of analyzing and measuring all motions and parts of motions so as to find the One Best Way to do Work…[with] the fewest therbligs. This does not mean the fastest motions. It means the easiest, fewest and least fatiguing motions. The speed…depends upon how skilled the operator is. The One Best Way to do Work should not be confused with the subject of the speed with which the work is performed.”
8
Therbligs and their captions. Source: MSP 8 (series 4), Box 51. N file 57; 0304-1. NAPTMT. Purdue University Archives and Special Collections: Frank and Lillian Gilbreth papers.
“The methods used by the fastest man seldom consist of the best motions. The motions of the laziest man usually make the best method.” They further argued, “Of course it is fair to presume that no method will ever become so perfect that it will not be improved. The One Best Way to Do Work is the best way today, with the workers and equipment we have. Suggestions for betterment are always in order.”
Motion and Time Recording in the Operating Theatre
In 1912, Frank Gilbreth made his foray into the operating theatre and noticed that the surgeons wasted more time finding the instruments than performing the surgeries. 9 Gilbreth’s study of surgery was motivated by his presumption that working with the elite professionals of American society, such as surgeons, would guarantee him the right kind of publicity and establish him as irrefutable expert of every trade. 10 In fact, Gilbreth himself wanted to become a surgeon but lacked the funds to do so. However, he had been admitted to the hospital in the past due to work related injuries in construction and noticed the lack of standardization in the hospitals. 11 Gilbreths believed that investigation of the methods of the surgeon was responsible for a major development in time and motion recording studies, viz., recording motion from either up-close or from a distance without moving the camera, and with special considerations such as those present in an operating room. “We must be constantly in a position to take large pictures of the surgeon’s hands, and to change to pictures that will record the surroundings, equipment, tools, and positioning, without interference from noise, distraction, or dust.” 12
Gilbreths were the first to apply the motion picture camera to the recording and analysis of operations. This work helped them formulate laws of motion economy, including the techniques of estimating performance time as the sum of times normally taken for the elementary motions in an operation. Frank and Lillian both drew inspiration from the work of Fredrick Winslow Taylor, who believed that a surgeon was “the finest mechanic”. In a speech at the 1915 meeting of the Academy of Medicine, the Gilbreths remarked that “Dr Taylor’s ideas of manual dexterity and highly efficient, standardized methods for the transference of skill in the surgical profession did not agree with our recollections of 200 or more important operations that we had observed in large hospitals of the highest rank”. 13 This served as an important motivation for them to investigate the hospital, and specifically surgery, from the standpoint of skill transfer, motion studies, and measured functional management.
Through a detailed study of surgical operations, and time and motion studies in the operating room, the Gilbreths focused their analyses of surgeon’s movements to improve efficacy and reduce fatigue. They observed that operating room nurses, for instance, can play a crucial role in decreasing operative times. In the early 1900s, surgeons would spend a great deal of time searching for their instruments. The Gilbreths recommended that this inefficiency can be addressed by thoughtfully laying out the instruments in a consistent manner to facilitate easy access and align the motions of the scrub nurses to the operating surgeon. They recorded motion time to showcase that surgeons were faster and more efficient at picking up tools from standard place on a cross-sectioned tablecloth laid in a systematic arrangement. This forms the basis for how instruments are organized during an operating room table set up today (Figure 3). In a series of articles from 1914 to 1916, Frank Gilbreth wrote about efficiency and scientific management in clinical settings, including the operating room.8,12 For instance, his observation on the variance of surgical practices and instrumentation throughout the country led him to conclude that time and motion studies can be of immense benefit to the surgical workforce. By 1930, the American Medical Association (AMA) had accepted the Gilbreths’ recommendation of bringing procedural standardization to the operating room. Gilbreths proposed rearranging the instrument table to group similar surgical instruments together, minimizing motion for the scrub nurse and improving efficiency for the surgeon. Source: MSP 8, Box 149. Gilbreth Library of Management; folder 0031-9, file NAFDR. Purdue University Archives and Special Collections: Frank and Lillian Gilbreth papers.
As an example, for one his studies, Frank Gilbreth worked with a team of surgeons in Berlin, Germany and captured the surgeon Dr Kuckenstein tying knots and picking up tools. By attaching small lamps on the gloves of the surgeon, Gilbreth photographed and created movie films of the hand motions as he sowed and tied knots on blood vessels, allowing him to carefully inspect his technique and improve his knot tying speed (Figure 4). Gilbreth popularized the use of this chronocyclegraph method with surgeons, attaching small electric lights on the hands of the operator and photographing the paths made by the light (Figure 5). Cyclegraphs of a surgeon tying knots (left) and sewing (right) with economy of motion. The uniform paths in space reflect no indecision or fumbling. Source: MSP 8, box 148, folder 5; NAPTMK. Gilbreth Library of Management. Purdue University Archives and Special Collections: Frank and Lillian Gilbreth papers. The Anne Shaw Chronocyclegraph apparatus. Source: MSP 7, box 2 (Item 20140529). Gilbreth Papers: Purdue University Archives and Special Collections.
Bringing Management Science to Surgery
Gilbreths proposed a number of ideas between 1910-1930 to make surgeries more efficient. Not all of these ideas were popular at the time, and “people thought I was crazy”, Frank wrote to Lillian in 1916, after he shared some of his ideas at a meeting of the AMA. For instance, Frank Gilbreth proposed that all hospitals create a route model, a drawing or series of photographs showing the location of medical equipment and outlining the path by which these are moved to their destination. “A route model of an operating room should show not only the paths by which the materials are moved, but the paths that various individuals [surgeon, nurses, etc.] in the operating room follow”. Gilbreth also advocated for creating instruction cards to be posted outside each operating room, “telling what operations will take place, their medical history, the order, procedure, personnel, etc.”. While these virtual boards are now commonplace in most electronic medical records, Gilbreths went a step further: “To all these records should be added careful micromotion records of the methods in use”. “Taylor’s work – based upon blue collar workers in factories – laid the foundation for Gilbreths’ motion studies, and may explain in part the resistance faced by the Gilbreths’ as they applied these studies to improve operative efficiency among surgeons. The transference of the principles of efficacy from the blue collar Ford assembly line workers to physicians and surgeons, considered the golden collar workers, faced criticism and slow adoption due to the elite nature of this profession.”
In 1916, Frank Gilbreth 14 shared his ideas on motion studies in surgery at the Annual AMA meeting. He described his analysis of hospitals “as far west as California, as far north as Toronto and Montreal, as far south as South Carolina, as far east as Germany”, and how “from a managerial standpoint…some hospitals are so bad that they should be actually closed immediately.” He described to physicians at the time that “great practice with comparatively few tools” is a salient law of efficiency. Gilbreth observed that in the early 20th century, many individually owned, specially designed tools varied so slightly from the instruments of the hospital that operating room nurses frequently mixed them up with instruments furnished by the hospital for the same kind of operations. He argued that the greater the number of tools, the less must be practice with each; “the smaller becomes the chance of having a standard tool used by all, and the skilled use of which becomes the part of the learning and practice of all”.
Gilbreths also recognized that standardization of tools alone is insufficient. Standardization of equipment and surroundings, arranging tools in an obvious sequence and optimizing motion, would be equally important to ultimately increase surgical efficiency. Their analysis highlighted that an emphasis on ergonomics “can save more than 10% of the time that the patient is under ether…and at the same time give the surgeon more time to do work and with less distraction”. 14
Based on their observations of surgeons of the New York Hospital in the 1910s (today better known as Weill-Cornell Medical Center), Gilbreth remarked “a surgeon’s time is very valuable. Therefore, we should give him these [surgical] tools directly in his hands.” 15
In the early 20th century, as the Gilbreths observed operating rooms and surgical staff in motion during a procedure, they recommended having the operating room floors sectioned or painted with lines on the walls and floors so that their photograph studies can have precise estimates of motion. Frank Gilbreth also recommended that the surgical caps and gowns of the staff be colored or numbered for easy recognition of the staff; “no. 1 for the head surgeon...be purple; no. 2 be blue [for the assistant] (Figure 6)”. More than hundred years later, recent work has shown that these signals on surgical attire can facilitate better intra-operative communication.
16
They made an astute observation that a surgeon’s work is often “solitary, instead of…in colonies”. Gilbreths knew that the quickest or most efficient method in any field cannot be recognized without the aid of accurate measuring methods and devices.
17
Especially for surgeons, Frank wrote in a letter to Lillian, “the period of supervision of short duration”, further adding that “the surgeon’s method of improving his skill…comes not from efficiency determining methods of accuracy of measurements of motion study”. Their work with surgeons sought to fill this important gap. Correspondence from Frank Gilbreth advocating for standardization of surgical attire in the operating room. In a note to Lillian, he wrote “numbers on hoods, sleeves and gowns of surgeons in accordance with their roles…facilitates efficiency.” Source: N file 63: 0416-4. NAPTMVS2. Purdue University Archives and Special Collections: Frank and Lillian Gilbreth papers.
The forward-looking approach of the Gilbreths is highlighted by their proposal to record films of their time and motion studies with surgeons as a teaching tool. “The learning procedure varies for various individuals…the film is a wonderful instructor in that it repeats the method as many times as it may be required, at any pace that may be required”. A century later, this notion is popular in surgery and forms the basis of video-based learning platforms.
Advocacy for Rehabilitation of Injured Soldiers
In addition to their work with surgeons, the Gilbreths had important success in extending their ideas to physiatry during World War I in training recruits and rehabilitating disabled soldiers. In 1916, Frank Gilbreth presented a paper at the Columbus, OH, meeting of the American Association for the Advancement of Science, describing a “motion study for crippled soldiers”. 18 By carefully studying the motion of injured soldiers, Gilbreths demonstrated how the soldiers could be better re-integrated as productive members of the society at the time. They highlighted the utility of a simultaneous motion cycle chart to adapt a physical method to the worker, to assign the worker to an appropriate type of work suited to their injury pattern, and to suggest interventions that will make the work and worker a better fit. For example, they described: “suppose that a worker who has lost his left arm desires to return to his former work, which is work apparently requiring both arms and both legs. We may find [through motion study] that two-thirds of his work is done by the right arm, the left arm doing relatively little. We find that where both arms are occupied simultaneously, for a large proportion of the time either one or the other of the arms is engaged…only for two short intervals are both arms occupied simultaneously. We see at once that it is extremely likely that the left arm’s operations can be transferred, with a slight change in the conditions, either to the right arm or the feet.” 18
Frank and Lillian Gilbreth advocated that injured soldiers who had undergone a limb amputation can be integrated in dental nursing and oral surgical workplace, which would in turn reduce the cost of cleaning teeth for an average person. They performed time and motion studies on dozens of dentists in the US and concluded that “dentistry provides an unlimited, satisfying field for the mechanical genius”.
19
Their analysis suggested that the work of the dentist can be functionalized such that the trained expert does the skilled work, and low-priced workers and disabled soldiers can be taught to do tasks that require less skill. They imagined disabled soldiers as “the cleaners of teeth”, who can polish the teeth by hand “with a stick and pumice” with proper training to optimize their motions and body movements (Figure 7). Representation of how operators with one arm and no limbs were able to be incorporated in workplace based on time and motion study assessment in dentistry practices during World War I by the Gilbreths. Source: MSP 8, box 127. Series 4, folder 8; NNZZ c.a. 1914-1916. Gilbreth Library of Management: Purdue University Archives and Special Collections.
Lillian Gilbreth’s Expertise in Industrial Psychology Applied to Surgical Efficiency
Lillian Gilbreth had several firsts to her name throughout her career. She was the first woman to deliver a commencement address at the University of California in 1900. After earning her PhD in the psychology of management, she went on to become the first female Professor of Management at Purdue University. Her training in industrial psychology had a remarkable influence in shaping the focus of the time and motion studies being performed in the 20th century. After Frank Gilbreth’s death in 1924, she incorporated the notion of worker satisfaction and motivation to her analysis of the motion films. The original motion studies focused largely on external factors affecting the worker. Lillian Gilbreth 20 also looked into social factors and placed an emphasis on minimizing unproductive and wasteful human effort.
Her work was celebrated by the U.S. by creation of a commemorative American postage stamp with her picture on it. Dr Gilbreth urged the employers to conduct a survey of workplaces and determine what they can do to eliminate unnecessary fatigue and increase comfort of each worker. 21 Both her and Frank believed that the similarities between a hospital and a social community suggest that problems arising in a hospital arise in other fields as well, and information from these other fields can be harnessed to improve hospital efficiency. 22 Gilbreths wrote, “There is no place in the world where waste is of more importance than it is in the hospital…The hospital worker, and particularly the surgeon, is so occupied with his work that he has little time to travel and learn the methods of others”, which motivated their time and motion studies with surgeons. They further wrote that “the profession of surgeon and, in a lesser degree that of nursing, demand such a long and specialized study that those in the field naturally feel themselves to be specialists of the highest type; therefore, working under rules applicable only to their own special field. This, however, should be counteracted by a knowledge that these professions possess as to what a science is and as to the far-reaching field that scientific laws cover.” 23
Having visited dozens of hospitals in 1910s, in a lecture on hospital efficiency, the Gilbreths concluded that “the operating room is the most important department of the hospital”. They also felt that “surgeon is looked up to by all members of the organization that, if he takes the lead in having an intensive survey made in his department, the problem of securing other detailed surveys will be much simpler.” 24
Conclusion
Ergonomics and management in the operating room remain crucial to the execution of a safe and successful operation in modern surgery. Several of the principles stressed on by the Gilbreths during their careers continue to play an important role in maximizing efficiency. Frank Gilbreth was once asked how one can start to incorporate the science of management and efficiency in daily practice. He remarked that observation and careful examination of the different methods of work would stimulate people to learn more about their work and the underlying science of their work. “Count your motions…try to make shorter motions and make less fatiguing kinds of motions [and] you will certainly make progress towards finding a better way to do your work”. 25 This advice continues to be relevant to the modern surgeon. It is worth noting that none of our research on the Gilbreths showed evidence that their direct observation potentially influenced their reported outcomes. This Hawthorne effect, which was itself a time and motion study, is particularly relevant as filming occurred in much of the Gilbreth’s work, yet none of their work or writings in our analysis acknowledge or mention a “Hawthorne Effect”.
Nonetheless, in 1917, the Gilbreths remarked “No definite and permanent advance is made in any kind of work, whether with materials or men, until use is made of measurement.” 26 They believed that a surgeon was “a different human being from all other people. He at some time ceased to be a common worm like the rest of us and became a butterfly.” Their work focused on observation and measurement, which in turn helped advance efficiency and systematization in the operating room and hospital management at large. This essay sought to highlight their contributions towards introducing principles of scientific management and ergonomics in surgery, themes that are more relevant today than ever as the field of surgery welcomes new technologies and training paradigms.
Footnotes
Acknowledgements
Tina Bharani and Divyansh Agarwal are grateful to the Purdue University Archives Research Travel Grant, which allowed them to conduct research at the Gilbreth archives in West Lafayette, IN. We thank Archivist Professors Stephanie Schmitz and Katey Watson for their assistance in obtaining some of the original material used in the preparation of this manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
