I am a surgeon: Therefore I think

“If you can’t do this drunk, you shouldn’t be doing it at all.”

The eminent professor was speaking to a friend of mine about heart surgery. He was not supporting operating under the influence, or am I.

The point is that the technical component of surgery — the cutting, the sewing, the rearranging — is very easy. It is true that in the OR, as on the golf course, some are more gifted than others, some more experienced. But almost anyone can get through an operation or a round of golf, given training and equipment necessary to the act. In more than ten years as surgical faculty, I worked with only one resident whom I considered technically hopeless, and he proved me wrong. We don’t speak of this ease very often, if at all, within the fraternity or without. The aura of technical virtuosity distances and distinguishes us from those who do not operate, just as the rites of the temple did the priests from the laity.

That distinction cuts both ways, though, and lends credence to the claim that we are mere doers and not thinkers. One of my gastroenterology colleagues would tell patients in my presence that he would put “the X on the spot” and tell me what to do about it.

The disparagement goes much broader, even into the US Congress, with talk of cognitive versus procedural physicians and their relative value to society.

One of my more admired professors became a friend, colleague, patient and occasional adversary. He had entered a surgical residency but left after a year to pursue sub-specialization in internal medicine. He once confided his awe at the courage it took to be a surgeon, to transect the aorta for instance. My counter was that it took no courage. Before cutting anything, I always knew precisely what I was going to do and why and what to do should things not go as planned. In my view, it took a lot more courage to prescribe a pill, a slug of molecules that would pervade the entire body with effects only hazily understood and that could not be retrieved.

There are among us those who nurture that cognitive:procedural dichotomy. A moment of major disappointment for me came when a highly respected surgeon declared in open conference that he wanted to be a “toe-tag surgeon,” to stand in the operating room and do whatever was prescribed by the referring doctor without having to know the patient or think about the issues — the basest abdication of surgical responsibility.

It is true that we do not often initiate the diagnostic process, but that does not absolve us of coming to an independent diagnosis. We must also select from the variety of anatomic and physiologic solutions for the perceived problem, and we must judge whether the patient would enjoy a favorable risk:benefit ratio. We must also be prepared intellectually to scrap all that when the intraoperative findings do not correlate with the expectations and re-create the entire cognitive process on the fly.

Realization and validation of our ideas require technical capacity, and the greatest satisfaction results from a solution properly conceived and executed. There is no feeling like it: doing without thinking and its converse are equally sterile.

Richard Patterson is a surgeon who blogs at DailyDudley.

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  • James

    Given your point on the simplicity and ease of surgery (not many surgeons I talk to would agree with that) do you think it would be reasonable to reduce third party payments for procedures in order to increase E & M codes for cognitive medicine as part of a payment model for healthcare reform?

    • http://www.facebook.com/richard.patterson.399 Richard Patterson

      My point is that surgery requires both cognitive and technical ability and effort.

      • James

        I am not disputing that. Your article would seem to imply that surgery is the easy part. If that is the case in terms of making diagnoses (which you consider a large part of your daily life) and many physicians and organizations feel that there is an inappropriate weight placed on procedures for reimbursements, do you feel that there should be some reduction in reimbursement of procedures in favor of an increase in reimbursement for cognitive skills? As per your article, surgery requires both cognitive and technical ability and this could theoretically be done in a revenue neutral manner that would increase the number of medical students entering primary care. Few people enter primary care because of low reimbursement rates for cognitive medicine and it is a field that lacks the “easy” part of training for procedures.

        • Fletch

          It’s easy because he’s good at it. It’s easy for Tiger Woods to hit a 320 yard drive in the fairway but that doesn’t make it “easy.”

          • http://www.facebook.com/richard.patterson.399 Richard Patterson

            Thanks, Fletch. You said what I could not. After at least five years of intensive training, a surgeon should have a broad comfort range of “easy” operations. The better the surgeon, the broader that range, which should expand with experience and out of which the prudent surgeon will not operate.

  • http://www.facebook.com/shirie.leng Shirie Leng

    Refreshing candor. I have argued in my own blog that anesthesia, my field, doesn’t require a medical degree to PERFORM most of the time. The expertise comes in the decision-making around the anesthetic event. That’s where the cognitive part comes in. Anyone can perform the actions. You need education to decide what actions to perform

    • http://www.facebook.com/richard.patterson.399 Richard Patterson


    • Scott

      Or what to do when things don’t go smoothly or as planned. Often, descisions have to be made very quickly under these circumstances.

  • http://twitter.com/DavidGelberMD David Gelber MD

    Knowing when to operate and what operation to perform are the most difficult parts of surgery. The technical aspects are important, also, but doing the wrong operation at the wrong time is a recipe for disaster. Proper judgment is what separates great surgeons from good ones.

    • http://www.facebook.com/richard.patterson.399 Richard Patterson

      Well said.

  • T H

    The cognitive skills of MDs and DOs set us apart from the PAs/NPs/ODs. Whether we are family docs, surgeons, IM, ER, peds, or whatever, when it comes to our patients, we are the bottom line. And don’t sell technical skills short: the best person I know at central lines and intubation is an Family Medicine doctor who probably delivered Jesus and floated St. Peter’s Swan-Ganz….. but even he’d consult a surgeon for an appendectomy.

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