(The real surgeons out there will please excuse my perhaps romantic explanation of a profession I’m coming to respect more and more.)

The female surgeon who knits everywhere (25+ years of surgical experience) was this morning discussing with the chief the different kinds of errors in judgment that surgeons can make. She said, “I’m watching myself, because I want to stop before I get so scared that I choose not to do surgeries which turn out to be necessary. That’s what old surgeons do. You can only see it in the ones who were really great to start with (with the mediocre ones, you never notice when they get worse). After a while, they remember so many patients who had something bad happen, that whenever they look at a patient, they see some extraneous detail that reminds them of one of those past cases, and they’re scared, and they don’t operate. And then the patient becomes septic, and anyone else could have seen that they needed an operation. I want to stop before I get that old. There are errors of omission, and errors of comission. With old surgeons, it’s always omission.”

Which is kind of funny, because surgeons seem more likely to err on the side of operating too often. But she was speaking from having worked in the same hospital for a quarter of a decade, and having watching many surgeons grow old and retire.

There’s a secret surgeons are keeping (maybe not too well): surgery is fun, surgery is a high, surgery is almost the only thing worth living for (I don’t know where different people rank spouses and children). It has a tremendous cost, because the rest of the world vanishes into nothing; but the life inside the OR, when the patient is unconscious, and the nurse gets out that shiny iodine scrub, and blue drapes are ready – that awareness and sharpness and readiness is like nothing else in the world. Yes, it’s partly about power; but that’s not all. There’s a unique drama in the careful ritual of scrubbing, and walking into the OR with hands raised and dripping, and then drying and gowning, assisted by three other people. Where else would getting washed and dressed be a community event? But here, everything is focusing in on the – not the patient, per se, but the body and anatomy on the table.

And then, the careful choreography of spreading layer after layer of blue cloth and paper, each piece just so, tacked in place; and stretching overhead to twist the green handles onto the lamps, pulling that brilliant light in, finally reducing the universe to a few square inches of brown-dyed skin. Those lights are so bright, even in the well-lit OR it hurts to look at their target, at first; but after a few minutes, your eyes adjust, and everything else looks dark, washed-out. Moving the lamp even a few inches, as the case progresses, seems to create simple visibility. You can’t see without that glaring light now.

[editorial intervention: something tells me most people would really rather not hear my further fantasies on the theme of red blood, and pink bowels, and yellow fat, and bovie smoke.] So we’ll skip to the end, where at least for the moment (complications may show their ugly heads later) the job has been done, the perilous vagaries of individual anatomy have been navigated, the problem has been fixed – the patient is cured. You sew up carefully, always repeating, like a mantra, “The only thing the patient sees is the incision; that’s how they know you did a good job.” Then, winding down, recklessly breaking out of sterile field (like a new infraction of the rules every time) to pull the drapes away, and wash the iodine prep off the patient, and tape dressings over the incision. And the secret relief when the patient wakes up, breathing, moving their arms and legs, mumbling a little incoherently. (It worked again, that anesthesiologist is a miracle worker. No one knows how the anesthetic gases work. We’re so scientific nowadays.)

The residents acknowledge it, half-secretly, in empty hallways: “I’d rather be in the OR than anywhere else in the hospital.” “Perhaps, if xyz happened, we would have a reason to go to the OR.” “Clinic was busy today, next week will be great – lots of surgeries to schedule.” And the looks of well-repressed joy (maybe that’s why surgeons have such expressionless faces) when there’s a busy schedule, and no clinic for the day, and everyone can be in the OR, and scrub.

The medical students all know that, if you’re talking to surgeons, at least one of the preferred modes of treatment of any disease is going to be surgery. It’s a proverb among doctors: “To a man with a hammer, everything looks like a nail.” “If you refer to a surgeon, he’ll recommend surgery.” Because deep down inside, existence is just the search for a way back into the OR. And yet, there are horrendous morbidities and complications that can come from surgery. So it is a point of honor among surgeons, never to allow themselves to proceed to the OR, until it is well and truly indicated. They compensate for the tremendous temptation of the OR by developing the strongest sense of responsibility that I’ve seen in any specialty so far. Partly it’s the anesthetized patient’s absolute dependence on the surgeon (and anesthesiologist). Partly, perhaps, it’s that surgery is so far out of the realm of normal life that most people have a hard time understanding the options, the pros and cons of going to surgery, and of different procedures. So the surgeon has an even stronger responsibility to explain fairly, not to weight the story in one direction, unless it’s really definitely best. And if you’re going to take a knife to another person, you have to know everything: everything about their disease (causes, microscopic appearance, complications, natural course, medical treatments), everything about the anatomy (every single artery big enough to see; every fold of omental tissue; every little duct – they all have a special name, and sometimes two or three); everything about the surgery (what procedure you’re going to use; all the possible instruments; other options; when they might be good and when not); everything about what to do when something goes wrong; everything about preop care, how to prevent the five major causes of post-op fever. You have to know everything.

And then people say surgeons are cocky. Well, if they know (almost) everything, and they can cut sick people up and put them back together again healthier, a little swagger might be indicated. They pay for it, with infinite care.

(I’m not being brainwashed, honest.)

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