A week of surgery – some impressions

One only has to be minimally involved in a surgical procedure to understand the appeal of this profession. It is instantly gratifying and very rewarding to be able to just fix something. That, working under time pressure and mixture of physical and mental skill make it a very exciting way to practice medicine.

So after a week of this, and just getting off call around 1:00 this AM after scrubbing in on a liver transplant I’ll tell you what has surprised me about surgery so far, and some of the things I didn’t realize going in.

Surgeons are famous for having little traditions and quirks about their profession that, while fading, still represent slightly fratboyish and conformist attitudes. I don’t begrudge them this, but they are amusing. So here’s some of the funny things I learned about surgeons my first week that I had no idea about, and maybe this will be embarrassing to expose my ignorance this way.

1. Surgeons always tuck in their scrubs.
2. Surgeons must never have their stethoscope around their neck, it must be in their pocket (their least valuable tool – haha).
3. Carrying anything other than a stethoscope, some gauze and supplies, and a pen light will lead to ferocious mockery. Pity the fool who would dare to bring a reflex hammer onto the surgical wards.
4. Surgery is almost always about the “most likely” or “most common”. They don’t spend a lot of time worrying about about diagnosing things to death, and the consequences are often too severe for delaying interventions. For instance, it’s considered normal for a good surgeon to end up removing about 20% normal appendixes in cases of suspected appendicitis. It’s better to be more aggressive for many surgical problems and rapidly intervene rather than dither around and over-diagnose.
5. Surgeons, despite their reputations, are avid scientists. They track the literature, cite a set of studies that justify their practices, and are interested not just in cutting but in the pathophysiology of what they treat.
6. It’s amazing watching some of these open procedures than anyone can survive such rough treatment of their insides. Seeing the force put on things like retractors, you wonder how people ever recover.
7. The music playing in the OR is frequently way too appropriate. Tonight “Cruel to be kind” came on, and it was a little eerie.

There is much more, but these were the kind of things I’ve noticed so far. These also might not be universals as I am at a major academic medical center, which can be quite different than the surgical practice in many other places.

There were also many pleasant surprises and amazing experiences I’ve had in one week.

1. Women, at least of the residents I’ve encountered so far, appear to outnumber the men. This is a pretty fantastic sign of progress, as surgery, for various reasons, has always tended to be a male-dominated field. The fratboyisms were certainly a part of it, but also surgery has traditionally been very difficult to combine with any kind of family life.
2. Everybody is polite and professional, and if a surgeon is brusque with you there is very little reason to be upset. It’s nothing personal, they’re under pressure, and a fast surgeon is a good surgeon.
3. The 80 hour limit is obeyed with few exceptions, and the impression is that even if it doesn’t improve patient care, it’s certainly cut down on the number of divorces.
4. A surgeon at UVA in the course of a single shift has an amazing set of responsibilities. Over the course of about 12 hours today I followed a surgeon who ran a trauma, a code in the ICU, and then helped in a liver transplant. All without breaking a sweat I might add.
5. As a medical student (not to mention away from medschool for almost 6 years) on my first day they handed me instruments and just said, “go”. You aren’t necessarily cutting and stitching, but going straight from the lab to having my hands deep within peoples bellies, and driving laparoscopic cameras is pretty startling.

You understand why they get a whiff of the superhuman about them.

This week, time permitting, I think I’ll discuss some of the surgeries I’m doing with my current team. We’ll start with the Whipple tomorrow as I have two cases.

Comments

  1. #1 Orac
    January 14, 2008

    Surgeons must never have their stethoscope around their neck, it must be in their pocket

    Indeed. If you wear it around your neck, it’s called a “flea collar” and will almost always produce a sarcastic comment.

  2. #2 SLC
    January 14, 2008

    “For instance, it’s considered normal for a good surgeon to end up removing about 20% normal appendixes in cases of suspected appendicitis”

    In fact, a surgeon whose normal appendix removal falls substantially below 20% can be reprimanded by medical oversight committees for risking burst appendixes.

  3. #3 Matt Penfold
    January 14, 2008

    To your list of quirks you can add that in the UK surgeons are known as “Mr” rather than “Dr”. This dates back to when doctors were physicians and looked down on surgeons, who often only had a minimum of training. These days surgeons hang onto to their “Mr” titles as a form of inverse snobbery.

  4. #4 buckeye surgeon
    January 14, 2008

    The 20% negative appendectomy rate is an anachronism. Most patients get CT scans prior to surgical referral. I think if your negative rate is above 10%, you need to stop and re-evaluate your practice.

  5. #5 DermDoc
    January 14, 2008

    Astute observations. Witty remarks. Your a surgeon in the making.

    Just found your blog from KevinMD. I will certainly be back for more.

  6. #6 RedRice
    January 14, 2008

    Do you know how many interns would kill you for a shot at just holding a retractor on a whipple or a liver transplant?
    That’s it-You have to insult them to learn anything !!!!

  7. #7 Ian B Gibson
    January 14, 2008

    Is it true that most surgeons have egos bigger than the Sun? Most of the ones I’ve met were not so bad on that score, but I’ve heard from others that the stereotype is pretty accurate.

    N.B. I once knew a colorectal surgeon, but his ego was only as big as Uranus!

    (Sorry.)

  8. #8 Judy, Ph.D.
    January 14, 2008

    Dear Dr. Hoofnagle,
    Regarding survival of rough treatment of our insides, I have had two separate laparoscopic oophorectomies. The first by a private physician in a private hospital, after which I had almost no pain. The second in a teaching hospital, after which I had chafing of the skin on my abdomen, excruciating pain around the navel for several days, and a urinary tract infection. My first scar was barely visible; the second time, I must have been sewn up by a first year medical student. If the patient’s brain is not aware of the damage done, it is remembered by the body.

  9. #9 Amy
    January 14, 2008

    “It’s amazing watching some of these open procedures than anyone can survive such rough treatment of their insides. Seeing the force put on things like retractors, you wonder how people ever recover.”

    Oh, don’t I know it. Having undergone 6.5 hour open heart surgery my biggest post-op complaint was the bruising, stiffness and soreness that resulted from being tossed around and opened like a can of tuna. But I wouldn’t have had it any other way because my fantastic surgeon did a great job and my recovery was very speedy.

  10. #10 Morgan Garvey
    January 14, 2008

    Great blog–as the wife of a PGY 7 (that’s post graduate year 7…four years of med school plus five years of general surgery and two years of plastic surgery training), I found the comments about the 80 hour work week/ divorce rate interesting. I’d be interested in hearing more about the surgeons’ spouses and home lives. It takes an incredibly supportive spouse to create a happy home life for someone with such a stressful and time-consuming job. Not only does my husband work 80 hours a week, but he is constantly stressed out by impending certifying or board exams, presentations he has to give or cases he has to prepare for. I am incredibly proud of his accomplishments and want to do my part to help him succeed. In return, he does his best to be upbeat and present, even when he’s completely exhausted.

  11. #11 Phat Nguyen
    January 14, 2008

    “To your list of quirks you can add that in the UK surgeons are known as “Mr” rather than “Dr”. This dates back to when doctors were physicians and looked down on surgeons, who often only had a minimum of training. These days surgeons hang onto to their “Mr” titles as a form of inverse snobbery.
    Posted by: Matt Penfold”

    Actually I just watched a program which says that surgeons original background were barbers who didn’t have the “Galenic” medical training. Thus they were looked down by the medical establishments. And tradition endures. Today if you go to medical school in England, your title changes from Mr. to Dr. (Doctor) after receiving an M.D., if you decide to become a surgeon, your title comes back to “Mr.” again based on the “Barber” tradition.

  12. #12 lights n steel
    January 14, 2008

    Great post! And so true about the stethoscope thing. I really don’t care one way or the other, but I like to tease my medical students. If they show up to rounds with it around their necks, I tell them they look like an internist. ;-)

    You have a lot of women in your program? That is a rarity as a general rule. Even still. The reputation persists.

    Oh, and I’m glad to have learned about the Mr. thing in England. I heard it once, but couldn’t confirm. Not that I spent a huge amount of time trying… Good to know. So, women surgeons are Mrs.?

  13. #13 Misanthrope
    January 14, 2008

    The funny thing about stethoscopes is that most of the time they’re really not that useful. In my practice as an anesthesiologist I’m much more concerned with functional status. If a patient can go up down a couple flights of stairs without difficulty then they have enough physiologic reserve to withstand a surgical insult. If they can’t lie flat without getting short of breath then there are better tests available to help sort it out. But, as useless as stethoscopes are, patients expect to have their chests listened to, so for psychological reasons I still tote one around. Still, it cracks me up when I see an orthopedic surgeon auscultate a patient.

    By the way, I tuck my scrubs in.

  14. #14 Elux Troxl
    January 14, 2008

    I hope that you get to spend at least 20 minutes with Herr Dr Ladislau Steiner while you are at UVA. It could be the most interesting 20 minutes of your education.

    Elux

  15. #15 William the Coroner
    January 14, 2008

    Surgery is loads and loads of fun. Myself, I don’t like the hookers and blow lifestyle that attendings lead (and I like to sleep to darn much)

  16. #16 hopkinsmed
    January 14, 2008

    UVA must be running a strong affirmative action program for female surgery residents, because I’d say at least 70% of all surgery residents across the country are male. The only surgical field that women dominate in is ob/gyn.

    I also dont agree with you that surgery residents routinely meet the 80 hours rule. I’ve rotated in 5 different hospitals with gen surg programs, and at every single one of them the residents were outright lying about the hours they worked. On paper, they wrote down 80 hours but I knew they were lying when I’d come in at 4:30 AM and they would already be rounding on patients, and when I left at 9 PM at night they would still be there. Thats not just once in a while or on call days, thats EVERY SINGLE DAY, regardless of whether they are on call or not.

  17. #17 ggg
    January 15, 2008

    I think that this blog was pretty blatantly misrepresented in the nytimes.com link;

    http://well.blogs.nytimes.com/2008/01/14/the-mysteries-of-surgeons-revealed/

    I really don’t like the frame of “uncovering the dirty underside of medicine” when this post was really more of an innocent observation. That feeling of betrayal seems to come from a misunderstanding of medicine as a whole. It seems like its perceived as infallibly exact and when that mistaken perception is violated, people feel they’ve been misled. Medicine is a science. It isn’t based on a moral right and wrong. Its based on what works the best right now in our still incomplete body of knowledge. Moreover, its based on the individual doctor’s experience of what works the best which makes every decision relative to some degree – but still a product of an intricately refined education system. But that isn’t effectively communicated to people and so they see mistakes as a product of negligence in an otherwise infallible system. That mini-article seemed to pick and choose every line to create a picture of haphazard cockiness to the layman.

  18. #18 Grodge
    January 15, 2008

    Stethoscope: one buddy of mine cut off the earpieces from his stethoscope in March after having matched into an Ortho residency. He would keep the just the earpieces in his labcoat’s side pocket, peeking out of the top just for show. “Well, I won’t be needing this thing anymore,” he said.

  19. #19 Tara Pope
    January 15, 2008

    Hi — This comment is not for posting but to invite you to comment on the New York Times Well blog. I’m a New York Times reporter who wrote a blog post about your blog and it has created quite a stir on my end, including comments from some who feel my post misrepresents your full piece. I thought your original piece was interesting and wanted to share it with readers. I think my readers would love to hear from you, and I’d love to hear a comment from you responding to some of the reader concerns.
    I look forward to hearing from you.
    rgds
    Tara Parker-Pope

  20. #20 Hildy
    January 15, 2008

    lightnsteel: It’s always ‘Miss’, even if you are married. I love your blog, btw.

  21. #21 Beth P.
    January 15, 2008

    Loved your posting. I’m looking forward to reading about your experience with the Whipple procedure. Will it be on the Denialism site, or do you have a separate blog?

  22. #22 Chris H.
    January 15, 2008

    What the Times comments show is that many doctors need a sense of humor implant!

  23. #23 David C.
    January 15, 2008

    Origin of “flea collar”:

    It is a subtle jibe at the nemesis of the surgeon, the internist. An internist is known as a “flea” because, finishing the joke, the flea is the last thing to leave a dead body.

  24. #24 KATIE
    January 15, 2008

    My husband too just finished the PhD part of his MD/PhD and went straight to a surgical rotation after being out of med school for 4 years. He is struggling with being on the bottom of the totem pole after reaching the top of his lab work, but I think he’s actually enjoying being back in med school. What’s really interesting (and maybe frustrating) is to work under residents who were either in his first two years of med school or even younger but also I think he finds it disheartening that he doesn’t use his PhD despite spending 5 years slaving away on it, it’s like the degree doesn’t matter. Do you ever feel that way?

  25. #25 N.B.
    January 15, 2008

    Loving the blog. I read a lot of Sb, but somehow I missed yours!

    I’ve got a lot of respect for surgeons; surgery is one of those things I don’t think I could ever do. Half the reason I opted for pharmacy school over med school is that I never wanted to have to do surgery!

  26. #26 PalMD
    January 15, 2008

    My memories of my surgical rotation are of the best and worst few months of my life. We had no work hour restrictions, but we learned like hell. The surgeons (well, the one’s we were with the most) were evil bastard, but generally fair.
    What was interesting was that, despite hating it, by the end I had gotten good at it, gotten into a rhythm, and was almost seduced by it. It just goes to show that human beings are nearly infinitely adaptable.

  27. This blog reads like a blog rather than carefully thought-out observations.

  28. #28 mph
    January 16, 2008

    Your comment reads like a comment rather than a treatise on postmodern sculptures of cuttlefish.

  29. #29 pathmd
    January 16, 2008

    As the medical director of a blood bank, I obviously interact alot with surgeons (and, almost became one after my surgery rotations in med school), and found your observations dead on, with the exception of the preponderance of women in your residency program–we have 3 or 4 here and NO FEMALE ATTENDINGS (that speaks more volumes than having trainees–many programs don’t mind training you, they are just not going to hire you). What I have always found most amusing in terms of portrayl of MDs on TV, is that the show Scrubs gets the interactions among us right far more often than say ER or Greys Anatomy (yes, I have TiVo). What do you think?

  30. #30 mandy
    January 17, 2008

    mph: lol

  31. #31 Mo
    January 17, 2008

    Isn’t it appendices rather than appendixes?

  32. #32 surg_prof
    January 18, 2008

    ***1. Surgeons always tuck in their scrubs.

    Maybe in Virginia. I’ve never tucked mine in, and I’m a tenured professor of surgery.

    ****2. Surgeons must never have their stethoscope around their neck, it must be in their pocket (their least valuable tool – haha).

    Most attending surgeons don’t have stethoscopes. In fact, for infection control purposes, you should be using the stethoscope at the patient’s bedside. Otherwise you are carrying germs from patient to patient.

    ****3. Carrying anything other than a stethoscope, some gauze and supplies, and a pen light will lead to ferocious mockery. Pity the fool who would dare to bring a reflex hammer onto the surgical wards.

    You forgot the obligate cellphone/PDA/Blackberry, and the cool Montblanc-or-other upscale pen. Pocket jewelry.

    ****4. Surgery is almost always about the “most likely” or “most common”. They don’t spend a lot of time worrying about about diagnosing things to death, and the consequences are often too severe for delaying interventions. For instance, it’s considered normal for a good surgeon to end up removing about 20% normal appendixes in cases of suspected appendicitis. It’s better to be more aggressive for many surgical problems and rapidly intervene rather than dither around and over-diagnose.

    Really out of date, as a previous poster noted. In the era of preop imaging, a 20% negative rate is quite problematic.

    ***5. Surgeons, despite their reputations, are avid scientists. They track the literature, cite a set of studies that justify their practices, and are interested not just in cutting but in the pathophysiology of what they treat.

    Of course. That’s why in the leading institutions, lots of surgeons run basic research labs.

  33. #33 blogger
    January 27, 2008

    Is a fast surgeon a good surgeon?
    I’d challenge you on that notion that within reasonable time limits for surgeries the fast surgeon is the good surgeon.
    What makes the great surgeon?

  34. #34 MarkH
    January 27, 2008

    I’d challenge you on that notion that within reasonable time limits for surgeries the fast surgeon is the good surgeon.

    I absolutely agree. It depends on the patient, the operation, and the situation. Within reason, faster is better. Complications and morbidity increase with operative length however, and in many surgeries involving difficult hemostasis (liver wedge resections, transplants, trauma etc.) that I’ve seen it’s important that a surgeon also be pretty fast. But you have a point that speed isn’t everything, and clearly attention to detail and care has its place as well. I took that as a given.

  35. #35 observer
    January 30, 2008

    I have noticed one characteristic of surgeons that other specialties do not necessarily exhibit…the know that each task has a beginning, a middle, and an end…and that you have to do all three.

  36. #36 mcs
    January 30, 2008

    As a UVA School of Medicine graduate and a female general surgeon, I am glad to hear that you are meeting lots of surgery chicks but I don’t think that is a true representation of general surgery in the U.S. It is still very much of a boys club. That being said, I got a kick out of your blog entry and think you hit the nail on the head for the most part. Too bad some of my colleagues have a hard time laughing at themselves but I say rock on!

  37. #37 Nat
    January 31, 2008

    Phat

    The basic medical degree in the UK and some other commonwealth countries is not an MD, it’s a bachelor of medicine and a bachelor of surgery (MB ChB or MB BS). The title ‘doctor’ is therefore just a courtesy title as they don’t have an actual doctorate. The MD is awarded but it fairly rare and it’s usually a research degree for practicing physicians (like a PhD). A surgeon doing a research degree might however avoid doing a PhD or an MD because this would make them a doctor. So surgeons sometimes do a Master of Surgery, which is, confusingly, just as much work as a PhD.

  38. #38 rongrimm
    February 2, 2008

    Read mark Kramer’s book “Invasive Procedures”
    Then you will really know what it is to be a surgeon.

  39. #39 Burt Humburg
    February 4, 2008

    A few thoughts:
    1) Don’t let Orac or any of the others give you the business about not wearing your stethescope around your neck. If that’s where it’s comfortable, wear it there. Just have the fortitude to handle the mockery when it comes.
    2) There was a great book that taught not so much surgery but how to learn surgery. I can’t recall the name of it or the author, whom I believe is deceased now. It was a great book that began with an epigraph, a paraphrasing of a Heinlein quote: Learn everything; specialization is for insects. Anyway, in that book, the author discussed traits of surgeons, how some are erudite and others consider grunting to be high conversation. Some are researchers and some can’t be bothered to read even their own journals. Some are tall, some are short, etc. etc. But the one trait that every surgeon who was good shared was that they were impatient. Not to paint with too broad a brush, but my survey of attendings was consistent with that. From the best to the worst and everyone in between, they were all generally impatient people. And I was not.

    Great post. Good luck on the rest of your rotation. Remember your three rules of surgery:
    1) Sleep when you can.
    2) Eat when you must.
    3) Don’t fuck with the pancreas.

    BCH

  40. #40 Cook
    March 4, 2008

    They are just “Supermen of Standard Procedure” (especially in USA),type of manual workers… What is so special???

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