COMMENTARY

Surgery May Be the Most Noble Choice of All

Sidney M. Schwab, MD

Disclosures

September 06, 2011

It's a saying that was probably never as true as we claimed it was, but it still might contain a shriveling kernel, a raisin, of truth: a general surgeon is an internist who can operate. Unlike other surgical specialists who may run for the hills after finishing an operation, when I admitted a patient for surgery, I always wanted to (and, more often than not, was able to) take care of all their needs.

Before my retirement, the breadth and depth of my practice -- caring for problems of the thyroid, parathyroid, esophagus, breast, stomach, gallbladder, pancreas, adrenal, small and large intestines, appendices, herniae, abscesses, hemorrhoids and other anal maladies (there's no happier patient than one cured of an anal fissure), not to mention countless cysts and lumps and unnamed ditzels -- made me "surgeon for life" for many of my patients and their families. I was as close as I could have been to the good ol' Doc Jones that I erroneously imagined becoming when I arrived at med school.

Being a surgeon, inexplicably given the trust to literally enter the body of a fellow human, gave me a sense of intimacy that no one but a surgeon can ever fully grasp; it was something that never stopped stopping my breath. It never dulled me to its stark newness, its privilege; I never stopped saying to others in the operating room, Come look at this! Isn't it beautiful? Isn't it amazing? How do you explain running your hand across the surface of a liver, sensing its slippery smoothness; or the pleasure of sewing bowel together in a way passed down by generations of pioneering surgeons, then laying it back in place, knowing no one else may ever see your work?

With that trust extended by patients comes a unique responsibility. The ability to cure a disease (not "owned" by all specialties!) carries the potential to do great harm as well. Surgical training gets a lot of bad press: too hard, too demanding, too... well, nasty. But -- at least in my time, the days of the iron men (and only a few women) -- it inculcated what are perhaps the most important characteristics of a surgeon: knowing your limits and accepting responsibility. The doctor who doesn't know when he is in over his head is dangerous. The doctor who won't accept full responsibility for the outcomes of her care is not a true physician.

My career straddled 2 very different eras. The easy rotations were those where I had to be in the hospital every other night; on the others, it was 12 nights out of 14. As chief trauma resident, I went 2 months straight without seeing the light of day, or the fog of San Francisco. I won't argue it was sensible, or even justifiable; but I came out of it well and fully trained -- or so I'd like you to believe. (Now it seems less likely to be true, with "graduates" increasingly feeling compelled to seek subspecialty fellowships.)

For better or worse, I finished my residency with a need to be there for my patients. I rounded at least twice daily, more for the sick ones; whether on or off call, I felt better seeing my post-ops every day. Toward the end of my career, I was still the one who'd find time to see a woman referred urgently, frightened by a mammogram report. My younger partners stuck to their schedules.

And I burned out, quitting 10 years earlier than I'd ever imagined I would.

Which is a point I'm trying to make. The new era of reduced hours and less screaming isn't all bad. I imagine new surgeons nowadays aren't as likely to burn out like I did. The pleasures of surgery will always be there: the beauty of the human body, the knowing of some of its secrets, the planes and nooks and crannies, the hidden pathways where you've been allowed entry. And it will always be a binary world: you succeed, or you fail, for all to see. But the exhaustion? Maybe not so much. These days, surgeons can actually expect to have a life, to have their cake, and eat out occasionally.

In my community, we now have both medical and surgical hospitalists, 24/7. Calls from the emergency department, which were the bane of my existence, no longer interrupt the schedules of these office-based surgeons, nor their sleep. They have predictable work hours, and freedom from much of the administrative hassles that drove me nuts. (I spent 6 months as the first and only surgical hospitalist in town, and other than the lack of follow-up, I loved nearly everything about it. It was nearly the opposite of how I'd practiced for my entire career before that.)

It's said that medicine is a calling, and to do it right, it should be. I'm proud to have been a general surgeon, and I'd argue that there's no other specialty that demands the same breadth of knowledge or range of skills. Surgery encompasses the breathtaking pleasure of accomplishment and the heart-rending failure to cure, the ability to do much good while balancing on the scalpel-edge of the potential for irreparable harm. I felt it every time I walked from the OR to talk to waiting families, with good news or bad; I felt it in every office consultation where I tried to instill hope and confidence, to allay fears, to map a path from where we were to where we wanted to be.

Surgery is a noble choice; maybe the most noble of all.

Editor's note: Dr. Sidney Schwab is author of Cutting Remarks: Insights and Recollections of a Surgeon.

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