The decision not to become a surgeon

Every medical student goes though a process of elimination when deciding what kind of doctor they want to become. We hear the old saying, “Internists know everything and do nothing; Surgeons know nothing and do everything; Psychiatrists know nothing and do nothing; Pathologists know everything and do everything but it’s too late.” We hear that pediatricians wear bow ties, are short, and love to laugh and play; that surgeons are decisive but arrogant; that proceduralists are “scoping for dollars”, that orthopedists have long hairy arms that reach to the floor, that family doctors are the best balanced, etc. There may be grains of truth in the medical school palaver, but I think we decide both based on our experiences during medical school and our own personality (plus the need to repay school loans).

The first case I ever scrubbed in on was an open heart procedure back in 1963. The unfortunate patient had severe aortic stenosis (narrowing of the valve) in the days before artificial valves were invented. Having changed into my scrubs, put on my cap, paper booties and scrubbed in, I meekly entered the inner sanctum of the OR. The head nurse spotted me and immediately barked, “Here take this gown, go stand in the corner and don’t do anything until I tell you.”

Other staff came in and one by one put on their gown and gloves. This is a little tricky because you can’t touch anything, otherwise you’re contaminated. As you might suspect, I put my gown on wrong, was barked at again but given a second chance. Finally I was at the side (almost the foot) of the operating table, trying to peek around the two residents assisting the thoracic surgeon. A huge incision was made, a blade much like a small hoe inserted and the handle given to me, “Here, here’s your job. Keep pulling on this so I can see. Harder!”

The left ventricle was punctured bluntly and a curved blade-like instrument inserted up through the aortic valve in attempts to open it up. There were dense calcium deposits so the going was tough. After several tries, the operation was completed, bleeding controlled, and the patient sent back to the surgery floor.

Almost immediately the patient had low blood pressure and a slow heart rate – not good signs. I was asked to sit at the bedside and administered a levophed drip to try to keep him going. He died at about 3am. At the autopsy, it was found that the wall between the left and right ventricle was punctured, not the aortic valve. I don’t know what the surgeon felt. He was the author of the major textbook on thoracic surgery and the author of many papers. This was in the very early days of heart surgery and it had to start somewhere I suppose, but it didn’t make me want to be a pioneer.

The pace of the surgical service was amazing. The chief would arrive at 6am and expect the residents to give him full report on the status of the patients. He would be in the OR from 7 to 9am, then off to a breakfast with the University Regents. There was a pecking order and pyramid system for the surgical residents’ survival. It was very difficult to survive this structure to become a chief resident.

After all this, I chose internal medicine and ultimately more training in infectious diseases, pulmonary and critical care medicine. Strangely, the intensity of the ICU isn’t that different from the operating room. But in the OR, there is only one leader. You don’t break for a conference or try to reach a team consensus. The surgeon is expected to know what to do, to do it well, and to do it fast (better outcomes with less time under anesthesia). As a nurse said, “The surgeon is like a god in the OR.”

But surgery is changing. I walked into the ICU to see a post-op consult in recent years, and asked the “nurse” what the vital signs were and her assessment. She kind of smiled and said, I’m the new urologist and just created an artificial bladder for this patient with bladder cancer. I profusely apologized for my gaff and she let me off gently. In fact at the nurse’s desk later, I asked her to explain the surgery. She replied, “It’s just sewing. You take a piece of colon, make a pattern, stitch it all together, plug in the ureters from each kidney, and voila!”

Well, although you might see why I didn’t become a surgeon, I hope you understand that I have great respect and awe for their arduous training, for their skills, and stamina, and, yes, guts.

Jim deMaine is a pulmonary physician who blogs at End of Life – thoughts from an MD.

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