ISSN: 2754-8880
Published 00 11 0000
OPEN ACCESS
Edited by
A.Hussain
Submitted 13 July. 2026
Accepted 10 Sep. 2026
Citation
B Manzouri.The Surgeon’s
Prayer: Rituals, Habits, And
Superstitions
Before The First Cut.Editorial
article:BJOSS::2026:(6);196-
203
The Surgeon’s Prayer: Rituals, Habits, and
Superstitions Before the First Cut
The Rituals Surgeons Perform Before The First Incision
B Manzouri
1*
1
Consultant Ophthalmologist Queen’s Hospital, BHRUT, Rom Valley Way, Romford RM7 0AG
UK Orcid ID: https://orcid.org/0000-0002-4589-0831
*
Correspondence author : Bita Manzouri Queen’s Hospital, BHRUT, Rom Valley Way, Romford
RM7 0AG UK. Email: bita.manzouri@nhs.net
ORIGINAL
Abstract
Introduction: Pre-operative rituals are common in many high-stakes professions, yet little is known
about their prevalence or perceived role among surgeons. This exploratory study investigated
the nature, origins, and significance of pre-operative rituals in contemporary surgical practice.
Methods: We distributed an anonymous cross-sectional online survey through international pro-
fessional surgical networks using snowball sampling. The survey explored the prevalence, origins,
purpose, and perceived importance of pre-operative rituals, together with their relationship to
procedure complexity and operative performance.
Results: A total of 143 surgeons from multiple specialties and countries participated. Overall, 70%
reported performing personal rituals or routines before surgery. Most rituals were established
during training (58%) and were self-developed rather than learned from mentors (81%). Personal
habit (30%) and psychological preparation (28%) were the most frequently cited reasons for ritual
behaviour, whereas only 6% identified superstition as the primary basis. Rituals were generally
unaffected by procedure complexity (70%), and most respondents reported little perceived
impact on performance if unable to follow them (82%). Nevertheless, approximately two-thirds
considered their rituals at least moderately important. Free-text responses consistently described
rituals as enhancing focus, confidence, emotional regulation, and readiness for surgery.
Conclusions: Pre-operative rituals are common among surgeons and appear to function primarily
as psychological strategies for preparing for high-stakes operative performance rather than as
expressions of superstition. These findings highlight an under-recognised aspect of surgical prac-
tice and suggest that personal rituals may contribute to the cognitive and emotional preparation
required for surgery.
Keywords
surgeon, surgery, ritual, superstition, performance psychology, human factors
Introduction
The operating theatre is, in many respects, the most controlled environment in modern medicine.
Instruments are counted, protocols rehearsed, and complications anticipated through layers of
systems designed to minimise uncertainty. Yet beneath the surgical cap and behind the scrub-room
door, something far less empirical often takes place: the surgeon’s ritual.
From the colorectal surgeon who wakes before dawn to walk the same route to hospital and
pack the same breakfast (
1
), to the orthopaedic consultant who will not begin a list without a
particular piece of music playing (
2
)—pre-operative rituals among surgeons are widespread, varied,
and, until recently, largely undiscussed in the peer-reviewed literature. The operating room may
be governed by evidence-based medicine, but the surgeon who enters it is, first and foremost,
human.
Rituals have accompanied medicine since its earliest incarnations. In ancient Egypt, priestly
surgeons performed incantations over trepanned skulls and medieval barber-surgeons offered
prayers before amputations. As medicine transitioned into a scientific discipline, such practices
were expected to fade. And yet, as this survey demonstrates, they have not. Instead, they have
been reframed—often as ‘routines’ or ‘personal habits’—and quietly woven into the daily practice
of some of the most technically trained individuals in healthcare.
Despite their prevalence, pre-operative surgical rituals have received relatively scant scholarly
attention. The existing literature has focused predominantly on superstitions related to patient
outcomes, such as whether operating on Friday the 13th portends harm (it does not) (
3
;
4
),
rather than on the personal, psychological practices of surgeons themselves. This study aimed to
address that gap through a multispecialty, multinational survey distributed across the professional
networks of the author. In doing so, it examines a dimension of surgical practice that is seldom
discussed in the scientific literature. The operating theatre may be governed by evidence, protocol,
and precision, but the surgeon who steps into it remains, first and foremost, human. Understanding
the rituals that precede the first incision offers a window into the psychological preparation that
underpins technical performance.
The Anthropology of Ritual in High-Stakes Professions
Ritual behaviour in uncertain, high-stakes situations has been described across cultures and
professions for centuries. Anthropologist Bronislaw Malinowski’s influential ‘anxiety-ritual’ theory
(
5
) emerged from his observations of Trobriand islanders, who relied little on ritual during lagoon
fishing—an activity considered safe and predictable, dependent largely on skill and experience. In
contrast, elaborate rituals were reserved for deep-sea fishing, where danger, unpredictability, and
forces beyond human control were far greater. His work suggested that ritual tends to emerge at
the intersection between expertise and uncertainty. Surgeons, despite years of rigorous training
and technical mastery, practise daily at precisely this intersection.
Pearl Katz, an anthropologist at Johns Hopkins University, observed as early as 1981 that ‘in
modern operating rooms.. . rituals. . . occur as integral parts of surgical procedures’ (
6
). More
recently, a 2024 Medscape article on physician superstitions (
1
) reported that some surgeons
believe rituals and superstitions are more prevalent in medicine than in virtually any other profes-
sion. One survey respondent, a colorectal surgeon in New York, described a preparatory ritual
spanning nearly two hours: identical wake time, the same breakfast, the same route, the same
greeting at the hospital entrance.
Superstition, Ritual, and Evidence
A distinction must be drawn at the outset between ritual and superstition, and between both
of those and evidence-based routine. A surgeon who double-checks laterality before every
procedure is engaged in best practice. A surgeon who refuses to operate on a ward numbered
13 is engaging in superstition. A surgeon who always ties their left boot before their right is
performing a ritual. These categories overlap, but they are conceptually distinct.
The evidence on whether superstitions affect patient outcomes is, reassuringly, negative. A
landmark analysis published in the Annals of Surgery in 2021 examined the records of 27,914
consecutive patients undergoing general, visceral, or vascular surgery, finding no association
between moon phases, zodiac signs, or Friday the 13th and adverse outcomes (
3
). A subsequent
population-based cohort study of 19,747 adults, published in the Annals of Surgery Open in
2024, similarly found no increase in death, readmission, or complications among patients who
underwent one of 25 common surgical procedures on Friday the 13th compared to flanking
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Fridays (
4
). Indeed, at Lehigh Valley Hospital in Pennsylvania, the second-floor operating suite
designates what would be OR 13 as ‘OR M’—a quiet institutional nod to the persistence of these
beliefs (1).
What the evidence does suggest, however, is that rituals may offer genuine psychological benefit
even when their direct mechanistic efficacy is nil. Psychosocial research has consistently shown
that performing a ritual—even one the performer consciously acknowledges as symbolic—can
reduce anxiety, enhance focus, and improve confidence in subsequent performance (
7
). It is this
emotional dimension that forms the most plausible explanatory framework for pre-operative
rituals in surgery.
Music, charms, and the theatre environment
Music in the operating theatre represents perhaps the most visible form of ritual in surgical
practice. Surgeons frequently cite specific playlists as part of their pre-operative preparation.
Others wear particular items of clothing—compression socks of a favoured colour, ‘lucky’ theatre
shoes, or a specific cap—as talismanic preparations for the day ahead. One plastic surgeon,
referenced in the published literature, wore Wonder Woman clogs to her most challenging cases,
citing not magical protection but a sense of empowered identity (
1
). Beyond personal objects and
routines, verbal superstitions are equally pervasive: the avoidance of the word ‘quiet’ on a busy
shift lest fate be tempted, and the widespread belief in the ‘black cloud’ doctor—the colleague
whose on-call shifts are believed to attract disproportionate numbers of complex cases—are
amongst the most frequently cited examples of magical thinking in medical culture (8).
These practices echo findings from sports psychology, where pre-performance routines are not
only common but actively encouraged by performance coaches. Elite athletes from tennis to
gymnastics employ fixed preparatory behaviours that serve as cues for attentional focus and
emotional regulation. Few athletes have made pre-match ritual as visible as Rafael Nadal, whose
famously precise court-side routine — arranging his water bottles just so, tugging his shirt, brushing
his hair behind both ears in strict sequence — transforms the baseline into something approaching
an altar. Surgery, for all its differences from competitive sport, shares the essential psychological
architecture: a skilled performer, a defined task, and the outcome of a performance that matters
enormously.
Methods
Study Design
A cross-sectional online survey was designed to characterise the nature and prevalence of pre-
operative rituals among surgeons. The survey comprised nine questions covering the prevalence,
duration, basis, purpose, procedural variability, cultural transmission, performance impact, and per-
ceived importance of these practices, plus a free-text question on purpose and a grade/specialty
demographic question.
Participants And Sampling
The survey was distributed via snowball sampling through the author’s professional networks.
Recipients were asked to forward the survey to colleagues across surgical specialties and grades.
Respondents included surgeons at various career stages—from trainees to consultants—across
a range of surgical disciplines including general surgery, orthopaedics, neurosurgery, vascular
surgery, plastic and reconstructive surgery, cardiothoracic surgery, and others. Respondents were
drawn from multiple countries across several continents, reflecting the international professional
networks of the author.
A total of 143 responses were received. Individual questions had varying completion rates, as
some were conditional on prior responses (e.g., questions about the nature of rituals were directed
only at those who reported engaging in them).
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Ethics
This survey was conducted as a professional insight project. Participation was voluntary and
anonymous. No patient data were collected. Formal ethical review was not required under
applicable institutional guidelines for anonymous practitioner surveys of this nature.
Statistical Analysis
Descriptive statistics were used to summarise responses to closed questions. Proportions are
reported as percentages of responding participants. Free-text responses to Question 4 (pur-
pose of rituals) were reviewed thematically to identify recurring categories of purpose cited by
respondents. Given the snowball sampling methodology and self-selecting respondent pool,
no inferential statistical testing was performed; the findings are presented as descriptive and
hypothesis-generating.
Results
Overview of respondents
A total of 143 surgeons completed the survey in full or in part. Respondents spanned multiple
surgical specialties and career grades, from foundation and core surgical trainees through to
senior consultants and fellows. The geographical distribution included respondents from the
United Kingdom, continental Europe, North America, the Middle East, South Asia, and Australasia,
reflecting the multinational reach of the author’s professional network.
Prevalence of pre-operative rituals (Q1): “Do you engage in any personal rituals, routines, or specific
practices immediately prior to entering theatre or beginning surgery?”
The majority of respondents (100 respondents, 70%) reported engaging in personal rituals, rou-
tines, or specific practices immediately prior to entering theatre or beginning surgery. A substantial
minority (43 respondents, 30%) reported no such practices. This finding—that more than half
of a large, multidisciplinary cohort of surgeons acknowledge pre-operative ritual behaviour—is
itself noteworthy, given the professional culture within surgery that tends to privilege empirical
reasoning over superstition.
Duration and origin of practice (Q2): “How long have you been following these practices?”
Among those who reported engaging in rituals, the majority indicated that their practices had
been established since training or residency (53 respondents, 58%). A smaller proportion reported
adopting rituals later in their career (29 respondents, 32%). Very few indicated that their practices
varied depending on the procedure (9 respondents, 10%). This finding suggests that pre-operative
rituals are, for most surgeons, early and enduring formations of professional identity rather than
adaptive responses developed to cope with specific cases or career pressures.
Basis of rituals (Q3): “What is the primary basis of these practices? (Select all that apply).”
Respondents were asked to identify the primary basis of their practices, with multiple selections
permitted. Personal habit or routine (51 respondents, 30%) and psychological preparation (49
respondents, 28%) — defined in the survey as practices serving focus or stress reduction — were
the most frequently endorsed categories, followed by religious belief (29 respondents, 17%) and
professional training or tradition (17 respondents, 10%). Cultural tradition (7 respondent, 4%) and
superstition (10 respondents, 6%) were the least commonly cited bases, suggesting that surgeons
prefer to frame their behaviours in psychological rather than magical terms — a finding consistent
with the broader medical literature on this subject. Notably, 5% of respondents (9) attributed
their rituals to scientific or evidence-based reasoning.
Purpose of rituals (Q4): “What purpose do these rituals or routines serve for you?”
The free-text question on purpose yielded themes clustering around focus and mental pre-
paredness, stress and anxiety management, confidence enhancement, and the establishment of
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psychological readiness. Several respondents described their rituals as helping them to ‘switch
into’ a surgical mindset, create a boundary between the pressures of daily clinical work and the
focused demands of theatre, or simply as a source of comfort in a high-stakes environment. A
smaller number mentioned team cohesion and the shared aspects of pre-operative routine as
a collective settling mechanism. Others described a more explicitly spiritual dimension to their
preparation, referring to prayer, trust in God, or placing the outcome of the operation in God’s
hands. For these respondents, religious faith formed part of their psychological preparation,
providing reassurance and humility in the face of the inherent uncertainty and responsibility of
surgery.
Variability with procedure complexity (Q5): “Do these practices change depending on the type or
complexity of the procedure?”
The majority of the respondents to this question indicated that their practices did not change de-
pending on the type or complexity of the procedure (100 respondents, 70%). This was a somewhat
counterintuitive finding: one might expect more elaborate or intensive rituals before high-risk
or technically demanding cases. However, the consistency of ritual across case types supports
the interpretation of these practices as baseline psychological anchors—habitual behaviours that
provide reliable states of readiness—rather than procedurally calibrated responses.
Transmission from mentors and culture (Q6): “Were any of these rituals learned from mentors, col-
leagues, or institutional culture?”
Contrary to what might be expected, the majority of the respondents to this question reported
that their pre-operative practices had not been learned from mentors, colleagues, or institutional
culture. Only 19% (19 respondents) indicated that their rituals had been transmitted through these
channels, while the remaining 81% (79 respondents) identified their practices as self-generated.
This is perhaps the most surprising finding of the survey, and it cuts against a widely held
assumption about how professional behaviour propagates within surgical training environments.
Rather than being absorbed from senior colleagues or the ambient culture of the operating theatre,
pre-operative rituals appear to be largely invented by individual surgeons—personal solutions to
the emotional challenge of preparing for high-stakes work. This suggests that such behaviours
arise from an intrinsic human need for psychological structure and control under uncertainty (5)
rather than from explicit role modelling or institutional custom.
Impact of disrupted rituals (Q7): “If you are unable to follow these rituals or routines, do you feel your
surgical performance is affected?”
Among the respondents, the majority reported feeling either ‘not at all’ (51 respondents, 52%)
or only ‘slightly’ (30 respondents, 30%) affected in their perceived surgical performance when
unable to follow their usual rituals or routines. A minority reported feeling ‘moderately’ affected
(10 respondents, 10%), and a smaller number felt ‘significantly’ affected (8 respondents, 8%). This
distribution is consistent with the view that these practices are primarily psychological supports
rather than operationally critical prerequisites.
Perceived importance (Q8): “In your view, how important are these rituals to your surgical performance
overall?”
Of the respondents to this question, 29% (30 respondents) rated their rituals as ‘very important’
to their surgical performance, making this the modal response. A further 23% (24 respondents)
rated them as ‘moderately important’ and 9% (10 respondents) as ‘essential’, meaning that in
total, approximately 61% of respondents ascribed at least moderate importance to their pre-
operative practices. However, 26% (27 respondents) considered their rituals ‘not important’ and
13% (14 respondents) rated them as only ‘mildly important’. Taken together, these figures reveal
a nuanced picture: the majority of surgeons who engage in rituals do credit them with some
degree of significance, yet a substantial minority—nearly four in ten—regard them as of little or no
consequence to their performance. This internal inconsistency, in which practitioners maintain
rituals they do not consider particularly important, is itself of psychological interest, suggesting
that habitual behaviour persists independently of its perceived instrumental value.
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Discussion
The surgeon as ritual agent
The principal finding of this survey is that pre-operative rituals are common amongst surgeons, that
they are rooted primarily in cognitive/emotional preparation and habit rather than superstition,
and that they are largely established during the formative years of surgical training. Taken together,
these findings paint a picture of the surgeon not merely as a technical operative unit but as a
psychologically complex practitioner who, like elite athletes, military personnel, and performing
artists, employs preparatory behaviour to achieve optimal functional states (9).
The reluctance of respondents to categorise their practices as ‘superstition’ is telling. As noted
in the published literature, surgeons—as scientists by training—tend to resist this framing even
when the behaviours in question are functionally indistinguishable from superstitious ritual (
10
).
A surgeon who always listens to the same playlist before a Whipple procedure is performing a
ritual; whether it is called a ‘routine’ or a ‘superstition’ may matter less than the psychological
function it serves.
Psychological mechanisms
The psychological literature on ritual performance provides a plausible explanatory framework.
Rituals are thought to reduce pre-performance anxiety by providing a sense of agency, pre-
dictability, and control in uncertain environments (
9
). For surgeons, who face the uncertainty
of human anatomy and biology on a daily basis, this interpretive framework has particular reso-
nance. Structured pre-operative behaviour may serve as a form of attentional focussing, signalling
the transition from the ambient demands of clinical work to the concentrated requirements of
operative surgery.
This is consistent with the responses to Q4 of the present survey, in which the most commonly
described purposes of rituals were focus, mental preparedness, and stress reduction. It is also
consistent with broader evidence on psychological preparedness in surgery: Wang and colleagues
noted in a comprehensive review that preoperative anxiety carries physiological and psychological
adverse effects, and that non-pharmacological, behavioural approaches to anxiety reduction are
increasingly recognised as beneficial in surgical contexts (11).
The origins of surgical ritual: individual invention, not cultural inheritance
One of the most striking findings of this survey is that the vast majority of surgeons reported
that their pre-operative rituals were not learned from mentors, colleagues, or institutional culture.
Only 19% of respondents attributed their practices to these external sources. This challenges
a natural assumption—that the rituals of the operating theatre, like its technical traditions, are
passed down through the hierarchy of surgical training.
Instead, the data suggest that pre-operative rituals are predominantly self-generated: personal
responses to the cognitive demands of surgical practice, constructed independently by each
practitioner. This is consistent with the broader psychological literature on ritual formation,
which holds that individuals spontaneously develop ritualistic behaviours in high-uncertainty,
high-stakes contexts as a means of achieving cognitive control (5). The implication is not that
surgical culture is irrelevant to how surgeons prepare for theatre, but that when it comes to these
private preparatory practices, culture appears to be less influential than individual psychology.
This finding may also have implications for how we understand the limits of professional social-
isation in surgery. Whilst the operating theatre clearly transmits a great deal—technical skills,
hierarchy, norms of communication—the inner, pre-operative life of the surgeon appears to remain
largely a private affair, shaped more by personal temperament and individual coping than by the
influence of mentors and institutions.
Limitations
Several limitations of this study merit acknowledgement. The survey was distributed via snowball
sampling through the professional networks of the author, introducing selection bias: respondents
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were more likely to be connected to the academic and professional spheres of the author, and may
not represent the global surgical workforce. The response to individual questions varied, reducing
the completeness of the dataset for some domains. The absence of quantitative data on the
specific content of rituals—that is, what surgeons actually do—represents a gap that qualitative
follow-up research could address. Finally, the cross-sectional design precludes any inference
about whether rituals are causally related to surgical performance or outcomes.
These limitations notwithstanding, this survey represents one of the first multispecialty, multina-
tional explorations of pre-operative ritual behaviour among surgeons, and its findings provide a
foundation for future, more detailed investigation.
Implications and future directions
The findings of this survey have implications for surgical training, team culture, and performance
psychology. If rituals serve genuinely useful psychological functions—as the data suggest—then
surgical educators and training programmes might consider how to support the development of
healthy, functional pre-operative routines in trainees. This is particularly salient in the context of
the growing literature on surgeon burnout, mental health, and performance under pressure.
Future research might usefully employ qualitative methods to elicit the specific content of surgical
rituals across specialties, grades, and cultures. Mixed-methods approaches combining survey
data with ethnographic observation and performance measurement could begin to address the
empirically important question of whether, and through what mechanisms, pre-operative rituals
influence intraoperative performance and patient outcomes.
Conclusion
Pre-operative rituals are alive and well in the operating theatres of the world. Just under two-
thirds of the surgeons surveyed in this multispecialty, multinational study reported engaging in
personal routines or practices before surgery, the majority of which were established during
training, transmitted through mentorship, and grounded in psychological preparation rather than
superstition. Most surgeons report little operational disruption when these rituals are disturbed,
yet three-quarters of respondents regarded them as at least mildly important to their practice.
These findings invite us to take seriously the human dimensions of surgical performance—not
because Wonder Woman clogs confer demonstrable operative advantage, or because an identical
breakfast enhances technical precision, but because the surgeons who perform these rituals
believe, on some level, that they help. In a profession where confidence, focus, and mental
readiness may be the difference between a good operative day and a poor one, that belief may
not be entirely without merit.
What, then, are we to make of the rituals surgeons carry with them into the operating room —
the particular order of scrubbing, the preferred arrangement of instruments, the habitual silence
before the first incision? They may appear, to the uninitiated observer, as superstition dressed in
sterile gowns. But they are something altogether more purposeful: the mechanisms by which a
surgeon crosses a threshold, leaving behind the ordinary world of corridors and human fallibility
and entering a space that demands something close to perfection. Ritual may not directly alter
surgical outcomes. But it may alter the surgeon — sharpening focus, reinforcing identity, and
helping create the composure upon which good surgery so often depends. Surgery may aspire to
perfect rationality. Surgeons, fortunately, remain human.
Conflict Of Interest
Author declare no conflict of interest and no funding for this study.
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