Wednesday, December 9, 2009

On Surgery

One Surgeon's perspective

This blog is called Heard in the OR, a place I spend many hours most days, rummaging around inside people’s bodies. I hope that you will get a glimpse into what can be the bizarre thoughts of one surgeon and I hope you enjoy what I have to say. I welcome any and all comments.
For more than twenty years I have made my living as a general surgeon. This is more than a job, perhaps even more than a profession; it is best described as a passion. The surgeon is called to be passionate about what some would call the unthinkable, the extraordinary, the epitome of arrogance. “Arrogance”, one may say, “how can that be?”
What a surgeon does can only be called arrogant. The surgeon takes an incredibly sharp instrument, slices through living human tissue, and in the course of the operation decides what organ is offensive and is to be removed and what is innocuous or important and is to remain. Or, the surgeon may rearrange our tissues, taking what was once God’s perfect creation and altering it for a, presumably, nobler purposes. Man nobler than God? “Impossible”. Such is the arrogance of the surgeon.
Of course, I don’t in any way imagine any man, surgeon, priest, baker or used car salesman to be nobler than God. It is one of the consequences of living in this fallen world that we need surgeons. Diseases and the specter of Death having been released with the first taste of the forbidden fruit create a need for physicians and surgeons to help keep these evils at bay.
What is it that makes anyone do such a thing? How is it that out of a typical class of one hundred medical students some will choose to pursue a career in surgery. And, after years of rigorous training, of getting out of bed at three in the morning to attend to an anonymous individual who had the misfortune to be hit by a bus, shot, stabbed, suffered a perforated intestine or any number of maladies that can’t tell time, this endeavor remains a passion, something done for the reward of seeing the sick and injured walk out of the hospital alive and whole.
I’ve often considered that what surgeons do for a living would be reason for incarceration if it was done away from the operating theater. In general, cutting people open with sharp objects is considered socially inappropriate and frowned upon by legal authorities. To avoid this hazard the operating theater was developed and we surgeons try to limit such endeavors to that location. Theater is an appropriate description; surgery used to be performed in just such a way. Students and professors would observe the operation from seats in an amphitheater; sterility not a prime concern in those days. Even after the research of Joseph Lister introduced the concept of asepsis to surgery, thus eliminating the open spectacle, the operating room still had observation decks, frequently seen in old movies, but rare today.
So, we surgeons, haughty actors of the medical world, ply our trade before a smaller, but captive audience: anesthesiologist, circulating nurse, surgical technician, surgical assistant and the occasional student. But, the star and center of any operation is not the surgeon; rather it is the patient. Above all, the patient is given the most attention, loving care with every detail of the procedure geared towards carrying this individual to a successful outcome.
Before any operation time is spent evaluating, examining and explaining the operation to the patient. A very common question I hear is something like this: “This is routine isn’t it?” Most of the time the answer is that a particular operation is common, hopefully straightforward, but I never consider it routine. Every operation requires proper planning, attention to detail and the utmost care. And, with every procedure surgeons have a single goal; to perform the right operation, at the right time, with proper technique so that our patient returns to their normal life as expeditiously as possible.
A general surgeon spends 5-6 years in residency after medical school studying and practicing every aspect of the profession so that at the end of his time he believes he is fully and properly trained. This residency provides the necessary basics; how to evaluate a patient, plan surgery, carry out the operation and provide post-operative care. All those years certainly seems to be enough time to learn all that needs to be learned. But, in reality, the practice of surgery is a lifetime of learning. Every day brings the potential for something new, an unexpected anomaly, a new presentation of an old disease, a situation never previously encountered; one that may only echo a vague memory of an article read in an old journal.
So, in our arrogance, we are humbled. It is this humility that separates the good and very good surgeons from the great surgeons. Because, every person that picks up a scalpel has to have the arrogance, the confidence that says I can do this better than anyone. If this belief is missing and the surgeon believes that another surgeon can do the job better, then it is in that patient’s best interest to be referred to that other surgeon. If humility is lacking, the patient may suffer.
What about humility? Physicians quickly learn that, despite our best therapeutic efforts, the human body can be a frustrating and unforgiving subject. Invasion by micro-organisms, tumors, external forces and foreign objects or even by the body attacking itself can rapidly overcome all our good intentions. We do all we can to give our patients the greatest chance for complete recovery and, happily, we are successful in the vast majority of cases. But, every individual is unique and every individual demands our unflagging attention. It is something I am reminded of everyday. The truly great surgeon is never so arrogant as to believe that something can’t be wrong. It is an unfortunate truth that patients sometimes become sick after surgery; that our best efforts may not have been good enough. When this happens we start to look for a reason; all our searching usually leads back to the original operation; something bleeding or not healing as expected, an infection or a wide variety of other potential complications. And so, it is the surgeon’s humility that allows him or her to say, “something’s not right, I need to figure this out and solve this dilemma.” It is this attribute that comes with experience and is the single, most difficult thing for the young surgeon to learn.
Arrogance and humility, truly an oxymoron, but no two words give a better description of what we surgeons are made of. It takes a truly unusual, dedicated person to follow the trail that at the ends bestows the title “Surgeon”. I have followed this path for twenty years and have always enjoyed the challenge. I hope you are informed and entertained by my words as I record them in the months and, hopefully, years to come.