Hurricane Jill has pinpointed it much better than I’ve ever managed: Surgery is black and white. Either the patient needs surgery, or they don’t need surgery. Either it happened, or it didn’t happen. Either you cut a particular structure, or you didn’t. Jill contrasts this with her pharmacy background, but I think it also contrasts with other medical fields: you can debate which antibiotic has the best coverage, or which beta-blocker works best for CHF patients, and apparently the medical interns at my hospital can even debate how much potassium to give a patient who’s hypokalemic (to me it’s a reflex that happens as soon as the labs come back); you can adjust the insulin coverage gradually, and experiment with different oral antihypoglycemic agents to see which work best for an individual patient. . .

Surgery is qualitatively different. Yes, there’s room for debate, and difference of opinion on the team, or between attendings, but in the end someone has to make a decision and act on it, and deal with the consequences; and usually that decision has to be made sooner rather than later. In the ER, that’s obvious; but even when a patient comes to the clinic, they and their PCP are not usually interested in spending a few months thinking about surgery. They come because they want to have a definite discussion, and make plans that day (or is that transference from our agenda? I think not; if the problem is one that can stand to be watched, the PCP has often done that already, and referred to a surgeon when the patient is tired of nonoperative management). If a patient gets started on a medication, and it doesn’t work out well, it’s not too much of a big deal to change to another one. But if the patient needed surgery, and didn’t get it, you don’t get a free pass back to the status quo ante by proceeding with surgery once you realize your mistake.

I guess it’s not so much that surgery is really black and white, or has hard, clear answers, more than any other medical field, but that even in the absence of scientific certainty, you have to make a decision. There is existential, if not epistemological, clarity. (Maybe that’s too many big words. . . tell me if I got them backwards.)

I always hated grey answers. Some questions I no longer consider important enough to be worth spending time or effort on finding the right answer to, but on the important questions, I have to have certainty. Does God exist? Yes. Is the Bible true? Yes. Should we do an appendectomy? Yes.