Being a Surgeon

Of all the different specialties within the discipline of medicine, surgery is alone in actually harming the patient in order to achieve good. There are many reasons to operate on a patient, including removal of disease, prevention of disease, restoration or improvement of function, and even improving quality of life through cosmesis. The art of surgery is underlined by the surgical “Bill of Rights”: the right procedure in the right way at the right time in the right patient for the right reason, performed the right way. Surgeons undergo a long apprenticeship to learn the subtleties of operating, and how to turn this “Bill of Rights” from a concept to reality. During this time, they also learn diagnosis, surgical decision making, and the management of postoperative sequelae. Surgical training is tricky when it happens in the operating room. Residents must learn surgical techniques and have access to various types of simulators. However, there will come a time when education happens in the operating room. The most important person here is, of course, the patient, and the process of training must not be allowed to cause harm. There is a cliché that goes “see one, do one, teach one” that reflects badly on what good practice should be. Certainly, it espouses the basic principle of observation, followed by closely supervised performance, leading to independent practice. Surgical procedures vary hugely in complexity and significance. Anastomosing coronary arteries is a lot more critical than anastomosing a colon, which in turn is more critical than repairing an inguinal hernia. The more significant and dangerous the procedure, the longer the training and the more exposure to the procedure as an assistant. The best way to think about this both as a resident who is learning and a surgeon who is teaching is to imagine that the patient is your spouse or sibling.

As a surgical resident make sure you know your stuff. Study systematically to cover the entire curriculum and go on to the ward and into the operating room prepared: prepared to discuss the cases, prepared to answer questions your staff might ask, prepared for possible situations that might arise. Have an idea about what you hope to get out of the day.

As a staff surgeon make sure that you know your stuff. Go into the operating room prepared. Know your cases, know what you hope to achieve, know the alternative techniques you must have at your fingertips, and remember your patient.

The Surgical Stereotype

Surgeons can cure…quickly. They can relieve symptoms…instantly. They can maim…. permanently. They can kill…. inadvertently. These gifts and curses seem superhuman to patients and this sense of mystique has encouraged a Godlike attitude in surgeons that has shaped the public view of the specialty. A generation ago, the stereotypical surgeon was male, self-confident if not arrogant, pompous, and bombastic. He embarrassed medical students and residents just to show how great he was, and he regarded his patients as nuisances that were necessary to maintain his superiority but who were barely worthy of his passing attention. He was at home at his Club, in the company of fellow surgeons, and he regarded Internists and Physicians with scorn. I know this. I experienced it. Things are different now. The stereotype of the twenty-first century surgeon does not include gender at all. It does include sensitivity, a much more compassionate and personal approach to patients, and as humane a relationship with residents as is possible under the circumstances. Practice being a 21st century surgeon. Here are some of the qualities associated with surgical greatness (in no particular order).

1. Talent

Talent is important in any job. This is an aptitude inherent in a person making then naturally a high performer. In most cases it is not to be relied on at all but used as a foundation for improving knowledge and skills, leading to a notably superior outcome. Absence of talent however is a deal-breaker and the talentless should be discouraged from pursuing careers in this area. You know you are talented if things come easily to you, if your hands seems to obey you effortlessly, and if you can’t wait for tomorrow to practice your specialty again.

2. Humility

Humility has never been regarded as an essential part of the surgical personality, and the specialty itself encourages pride. A humble surgeon realizes that he/she is a part of a team, that his/her abilities and talent are gifts and that therefore it is his/her duty to use them to the best of their ability. In fact surgery is a humbling experience as complications and happen to everyone. The proud surgeon blames poor outcomes on others. The humble surgeon will analyze the mishaps, correct issues that can be corrected, and not take things personally.

3. Good technique

It is self-evident that a good surgeon knows how to operate. There are aspects of “knowing how to operate” that can be learned, and aspects that are innate. Innate qualities include a “feel” for tissues, knowing just how hard to pull and how tight to tie a knot; an ability to see planes and to operate within them; familiarity with anatomy and the ways anatomy can vary or be distorted; patience, to persist through a difficult dissection when all you want to do it get the operation over. Surgeons with these qualities living within them have a head start on the road to excellence.

4. A sense of confident poise

Surgeons must never panic. Things are going to happen during an operation…sometimes bad things…certainly unexpected things…but surgeons are the leader of the team and they must maintain their equanimity in the face of unpleasant surprises. They must evaluate the situation, consider their options and chose the best one, all in a matter of seconds. This “even keel” attitude comes with an air of quiet confidence, giving the impression that “we had an upset, but don’t worry. All is well and I know exactly what to do”.

5. Bonus virtues

There is a set of surgical virtues that add to a surgical personality and possession of which allows more steps on the road to surgical greatness.

Kindness and compassion: a kind and compassionate surgeon will have a great bedside manner and patients will love them. Such an attitude can be contagious if it combined with other more essential qualities.

Wisdom and thoughtfulness: wise and thoughtful surgeons have good outcomes because they know when to operate and when not to; what the various options are and which in best in the current circumstances; they know just how adventurous they can be, and their strategy takes in to account not just today’s operation but the next one, and the one after that.

Hard working: Usually the experience of residency will weed out potential surgeons who object to working hard, although the work hours rules have made residency more of a cakewalk than an endurance test. Having graduated from residency, newly qualified surgeons work to establish their practice by building up a contented referral base. Saying “no thanks” to a referral, no matter how minor a diagnosis, is likely to sabotage growth of the practice. Saying “Yes I’d be happy to see them this afternoon or tomorrow morning” will be remembered by the referring doctors.

Be a GREAT surgeon

The All Blacks are New Zealand’s rugby team, and over many years have consistently ranked as number 1 in the world. There is something about the New Zealand lifestyle that makes great rugby players and the tradition is strong. It is the wish of most young kiwis to play for the All Blacks and the pinnacle of this wish is to be the All Black captain. The most famous All Black captain was Richie Macaw, a freakishly gifted flank forward. When Macaw was a boy his uncle asked him what he wanted to do with his rugby. “Be an All Black” said MacCaw. “No”, his uncle replied. “Not just an All Black…. Be a GREAT All Black”. As surgeons, this is what we should aspire to; not to just be a surgeon, but to be a GREAT surgeon.