Saturday, March 4, 2017

Ten Years In

My first day as an attending general surgeon in Cleveland, Ohio was August 7th, 2006.  I saw one patient with a hernia in the office that day and then, around 430 pm, the call came in from the pediatric ER about a kid with abdominal pain.  Some healthy 17 year old boy with obvious early appendicitis.  I booked the case, tip-toed my way through the laparoscopic appendectomy uneventfully and went home feeling awful proud of myself.  It was exactly how I envisioned a life as a general surgeon.  I had been a confident 5th year resident.  I hadn't done a fellowship.  I had felt ready.  I was ready to take on the world.

A whole hell of a lot has happened since then.  Ten years have elapsed in the blink of an eye.  Thousands of cases.  Thousands of patients.  I have two beautiful kids now, 5 and 8.  I was married, then divorced, and now married again.  Life rolls on--- you don't realize how it slips away in the accumulative moments, the episodic nature of consciousness, the way we compartmentalize chunks of time. As Auden said:
‘In headaches and in worry
   Vaguely life leaks away,
And Time will have his fancy
   To-morrow or to-day.
Nowadays I'm busy as all hell.  My clinics are jammed.  My OR block times are filled far in advance.  I did 900+ cases last year.  I'm on ER call pretty much 180 times a year.  I've built a career and a reputation in a pretty competitive market.  I drain abscesses and hemorrhoids in the office.  I whack out lipomas and epidermoid cysts.  I do bread and butter laparoscopy (gallbladders, hernias).  I use the robot.  I get to do enough of the more complex stuff (colons, Nissens, etc) to stay sharp.

And I love it still.  I can't imagine doing anything else to fill the hours of my days on Earth.  I was made to do this job.  Certain personality quirks come in handy: obsessive compulsiveness, work ethic bordering on the pathological, single mindedness, a baseline anxiety only partially quelled by work and more work, an innate desire to please, to prove one's worth to strangers. It isn't a life for everyone.  It can be brutal and exhausting and self defeating.  But I was born for this.  The idea of a community general surgeon with a wide armamentarium of skills may be a dying paradigm in this era of super specialization, but the life I am living now was always my vision.

Older surgeons, as a way of passing on sage advice to residents, used to resort to tired cliches like: "Know the 3 A's of a successful practice--- Ability, Affability, and Availability".  Those things are still in play.  You can't be a dick to everyone.  You have to be nice all the time, now---not just when you see referring docs at medical staff meetings.  You can't throw scalpels around the OR.  You can't tell a PCP "no" when they call you about a hemorrhoid on Friday at 445pm  And you can't be a hack.  You can't be the guy everyone talks negatively about in the PACU or SICU when you're not around.  The most truthful component to your reputation is the way the staff at the OR where you work  feels about your talents.   The 3 A's still hold sway.  But there's more to it than that.  A truly satisfying life as a general surgeon is not so easily distilled by just three letters.  I'm a grizzled, gray bearded old vet now.  I think I've earned the right to weigh in with a few of my own thoughts.

1)  Humility, and being humble, is universally lauded as a personality characteristic of the "well adjusted".  No one really likes a pompous dick (well, except for the 40 million Americans who somehow voted for the current POTUS).  Nothing will turn off a patient, a nurse, a physician colleague, a hospital administrator, any goddam regular-ass human faster than behavior that is perceived to be "arrogant" or "lacking in humility".  This is tangentially related to the Affability component in the 3 A's but it's deeper, more complex.  You can't just decide one day that you are going to be a swell humble guy.  It cannot be a persona one dons.  False humility, humble-bragging, lightly cloaked self-effacement is all too transparent to people who have experienced actual loss and trauma and despair.   At least that's the way I have always felt.  You can't fake it.  It's not that easy.  True humility can only arise out of something real and true and lasting.

 And in my mind, the provenance of authentic  humility is humiliation.  The life of a general surgeon, especially in the nascent years is a series of humiliations.  I mean this in the best sense, the most edifying sense of the word.  It has always been humiliating to fail in front of others.  Forgetting your lines in a grade school play.  Showing up for a first date with your zipper down.  Missing a penalty kick to tie the game with seconds left.  Humiliation is painful and demoralizing; for the first time you begin to honestly doubt all your preconceived notions of who you are.  Am I worthy, do I even belong on this stage?  A general surgeon experiences humiliation on a near daily basis early in his/her career. The 2.5 hour laparoscopic cholecystectomy, the moment during an anorectal case when you inexplicably aren't exactly sure of the anatomy and you make the circulating nurse call your senior partner in for help, the cut ureter and the sheepish call to a urologist, the anastomotic dehiscence, the Lushka leak, the recurrent hernia 6 months later, the flubbed lines of an inexperienced doctor trying to offer final parting words to a dying patient's family, the poor judgments, the complications, the sleepless nights replaying surgeries and decisions over and over in your mind.  The alarm goes off early.  Your eyes flash open.  Another day to face.  Another chance to make it better.  To get better.

Three things can happen at this point.  You can ignore the humiliations and become a false person, a shitty surgeon, a sell out.  (More opt for this  than we'd care to admit.)  You can quit.  I mean, sometimes it's just not worth it.  Get out when it becomes clear you've lost the will.  But you can also just accept it, the humiliations.  You can own them.  You can accept that you have failed both yourself and all those previous patients who trusted you with their lives.  You can accept it.  And then you can show up for work the next day and when you walk into that next patient's room, something seems different.  You feel relaxed.  You smile before you have spoken.  It just happens.  You feel blessed and calm and grateful. You experience for the first time true humility.  And the patient who meets your gaze knows it instantaneously.  It's what they've all been been expecting all along.  Finally you can get to work.  You can do what you were meant to do.

2)  I wrote a piece 7 years ago about what the recently deceased JD Salinger could pass on to new doctors.  I'm a different man now than what I was back then.  But the sentiments I expressed in 2010 still hold up after all these years.  There are two components to making the best of this gig.  One, you have to do everything patient-related with all of your damn heart.  You have to check those labs every day and follow up on x-rays.  You make your rounds and you sit down in that pleather chair bedside and listen to them even when they bore you.  You have to sit in that chair long enough until it stops being boring or annoying and then, inexplicably, before long, you won't want to leave, you'll want to order a bottle of fucking Beaujolais and listen to them all morning long.  You have to call the ones you're a little worried about on their cell phones with your own cell phone without doing the "star 67" thing.  You change your own dressings. You put an NG tube in when the nurses can't get it.  You prep your own patient on the table.  Put a damn Foley in when the young new PA can't seem to get it to go.  Call your referring doctors.  Text them.  Send emails.  They know and love these patients more than you will ever know.  God I hope they do.  I barely know these people and I'm always sad when they walk out satisfied, healed, never to return.

The other part is more difficult to explain.  It resides in the realm of the poets and painters and artists.  It's a little more abstract that just work ethic and dedication.  You have to make sure that, every time you walk into a patient room or glove up in the OR, no matter how tired you are, how much stress you're feeling, no matter how much work you have left to do that night, you have to strive to make sure that most of your stars are out.  Stay above the fray.  Keep that bird's eye view.  Find that sliver of darkness between the silvered clouds where your stars are always shining.  They will guide you through the toughest of moments.  When your stars are out it's never really all that dark.  It will sustain you.  Remember always, this is what you worked so hard to attain.  You are doing the very thing you hoped would happen when you were young.  Rise above the desultory drudgery of EMR charting and high maintenance patients and 3am ER calls about nursing home patients with fecal impaction.  You won't always find all of them.  Some will hide behind clouds.  But most will be there.  Just make sure you look up every day and every night.  You will find them by looking.

3)  Once as a fourth year resident I was making rounds with Ted Saclarides, MD on the colorectal service.  We were talking about how demanding and all-encompassing our chosen field could be.  The residents were grumbling and whining about how we never saw the sun that month.  Sac just sort of smiled and shook his massive head.  He told us he worked harder as an attending than he ever did as a resident.  That he spent so much time in the hospital he had missed a few of his kid's birthdays.  It didn't seem to bother him.  He said that he was a surgeon.  That this was what he had always wanted to do.  He liked being busy.  He liked being in the hospital, taking care of patients.  He was a surgeon, first and foremost.  It was his identity.

At the time I just sort of felt sorry for him.  It seemed ghastly.  Missing your kid's birthday?  Defining yourself by what sort of work you did during the day?  How sad and provincial--- a life abridged, it seemed.  Instead, I saw a future that was broad and more diverse.  I had so many other interests and goals and dreams.  To be a good husband.  To be the sort of father I wish I had.  To travel the world.  To write stories, maybe even the next Great American Novel.  To learn about all the millions of non-medical things I didn't yet know.  To read and think and grow as a simmering human soul.  This poor middle aged sap, I thought.  He has no idea what he missed.

But of course, life happens to us all.  We get bogged down, thrown off course.  Time has its fancy.  Books we meant to read collect dust on shelves.  Marriages break down.  You find out that being a father is harder than you ever imagined.  A few short stories get written but you realize they're all for shit.  The novel hibernates in notebooks for years, stashed in a desk drawer.  But one thing doesn't change.  Every day the alarm will go off at 430am.  Every day you find yourself at the hospital, making rounds, meeting patients for surgery, writing notes, dictating, rushing off to see someone in pain in the ER.  Most days your efforts and exertions will be directed toward fulfilling your duties as a doctor, a surgeon.  Those days will add up.  In the end that's all there is.  We simply become the person who has lived the life we have had.  And that's OK.  We do the best we can.  There's only so much time.  We read those books at night when we're not too tired, albeit more slowly.  We know we won't get to them all.  We enjoy those moments with our families when we can.  We find ways to unwind without ever completely disconnecting from the essential source of our identity.  We become surgeons without even really intending to.  You can't hide from it.  At some point you have to embrace it.  Let it seep into you, let it be quilted into the fabric of your being.  You'll wake up one day and realize that you are indeed, first and foremost, a surgeon and you will not regret it.    


Margaret Polaneczky, MD (aka TBTAM) said...

This is hands down, the best thing I've ever read about what its like to be a doc. The section on humlity alone should be required med school reading. Thank you for writing this.

Colin said...

From the other side of the fence, it fits my wife's orthopedic oncology surgeon to a T.


Anonymous said...

you have a good way with words

Unknown said...

Wow !!! What a great piece!! I miss working with you at Lake West!! I hope you are well!!!

Anonymous said...

I started reading you years ago after coming across Sid Schwab's blog. Came back today to see if you were still around. You're writing is as powerful as ever. Glad to see you are still going strong. Your views are today more valuable than ever. Ad multos annos.