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Surgery as a Specialty

An impromptu lesson in the finer details of suturing at the end of a case brought back memories of childhood violin lessons in which my violin teacher would explain the finer mechanisms of producing a spiccato. “Relax your wrist,” he would say while demonstrating. I would go home and practice the same bowing technique hundreds to thousands of times, gradually taking incremental steps towards improving the technique until eventually, it became second nature.

In some ways, it was an odd payoff. I would spend months, equating to thousands of minutes, practicing the same musical piece for a single 10-minute performance at a recital. Yet, there was immense satisfaction at the end. I imagine surgery is much the same. Surgeons too take time to develop, which might explain why there is a sense of order and hierarchy innate to surgery. Experience and effort matters. I find the order and structure calming.

Someone asked me recently whether it was tough making it through a Whipple procedure, a notoriously long surgical procedure used to treat pancreatic cancer. I was somewhat caught off-guard by the question as I had never really considered the issue. The act of actively participating in the case made time pass faster than the clock on the wall would suggest. The field of surgery is not for everyone, but for those who do love it, it has an irresistible draw.

Relaxing after shelf exam at Tomukun Korean BBQ

The third year of medical school is a truly unique experience in which students get to sample a variety of medical specialties. While on service, I often like to ask residents and attendings why they have chosen a certain specialty. It can be incredibly informative. I asked my resident how he knew surgery was the right choice, expecting to hear that he had known from the very start that he wanted to be a surgeon. I was surprised by his answer.

His journey into medicine began innocuously enough, he explained. He had studied economics in college and while completing a summer internship discovered that it was not for him. Coincidentally, his roommates who were both pre-meds recommended shadowing a surgeon. On a whim, he decided to check it out. Even 10 years later, he vividly recalled his first encounter with Dr. X. While he had no idea what the surgery was about, he loved how simple the explanation for the heart worked. I listened enthralled as he described the technical intricacies of fixing a child’s aortic valve. As he talked passionately about how this experience led him to think that at age 40, he wanted to be like Dr. X, and I couldn’t help but to think that in 5 years I wanted to be like him.

Surgery is a paradox in some ways. Despite requiring more years of training and working longer hours than most specialties, I’ve yet to have seen people more passionate about the work they do. If you ask a surgeon about why they chose surgery, they will tell you that there was no other option for them – that nothing else would satisfy them. Perhaps this makes sense. It requires intense study and practice!


“Feedback is the breakfast of champions.”

“Don’t contaminate the surgical field,” I repeatedly thought to myself as I entered the OR. Over the first 3 weeks of my surgery clerkship, I had made more than a handful of mistakes. The first day, I forgot to take off my watch prior to putting on gloves to place a Foley catheter. The second day, the patient bed brushed the corner of the scrub nurse’s blue sterile table as I was wheeling it out of the OR. The third day, I cut too close to the end of the surgeon’s knot – thus undoing his work. Day 4, I touched the handle of the surgical lights with my sterile gloves and so the list goes on. Throughout the clerkship, I made a list of all the mistakes I’ve made, partly to remind me not to make the same mistake again since as Confucius would say, “a man who has committed a mistake and doesn’t correct it is committing another mistake.” But it also serves to document how far I’ve come within even the year and even a month. On a day to day basis, I am constantly humbled by how much more there is to learn. As with many activities, the more I learn, the less I realize I know.

One of the many corridors in the hospital early in the morning

The smooth confident motion in which I saw the attending and surgery resident swiftly tie the knot with seemingly minimal effort belied the amount of technique that goes into the motion. I quickly learned this when towards the end of the case, my resident handed me a suture.

“Do you know how to tie a subcutaneous stitch?” he asked me. During my first two years, I had attended multiple suturing sessions and had practiced with pig feet. I felt reasonably confident. “Yes,” I concisely told him. I soon learned that there is a skill in doing this.

“Turn your wrist more,” he admonished. I rotated my wrist.

“Pinch less skin with your forceps”, he told me, “that way you’re better able to see where you’re going.”

“You can’t come out where you grab the skin. Grab another piece”.

I struggled to perform these steps correctly. The resident was very nice about it. But it seemed as though I was doing every possible thing wrong. Ironically, I had tied a subcutaneous suture previously with another resident, during which I had received no commentary. Was it that my technique had gotten much worse over the past week? Or that the previous resident was too polite to comment? Or that he simply wanted to quickly finish closing the patient up after a long case? Or maybe it is that the farther we go in our training, the more confident we feel in teaching others. It’s hard to know exactly why.

Finishing the day, heading home

A view of the hospital on the walk back to my apartment

I have however found that good feedback can be hard to come by. Feedback that is both specific and actionable is rare. This is often due to limitations in time as, understandably, patient care takes priority. Furthermore, giving good feedback can be difficult too in itself. Prior to entering medical school, I had taught as a high school teacher and found while grading chemistry lab reports that it can be incredibly difficult to give constructive feedback. While one can often see that something is wrong, it takes a more thorough understanding of all the finer details of a process to be able to explain not only “what” is wrong, but also “how” and “why” it is wrong. So when a resident, nurse, attending, or even fellow medical students are able to give useful feedback especially things that I’m doing wrong, I am incredibly grateful. I will always bear in mind the feedback and things I’ve learned here as I continue this journey!

M3 is Hard

Well, as a seasoned M3 (who is totally qualified to call herself this by dint of surviving almost one full week on Surgery), I have a bit of advice for those who are starting clinical rotations: it’s hard.

While I admit the hours are comparable to those used to study for Step 1 a month ago, the energy (physically, mentally, and emotionally) expended during the day are far greater. From the outsider’s perspective, I did not do much of anything during my study period – I sat on my couch and stared at my iPad for hours on end.

Now, I’m racing from pre-rounds to rounds on the floor, then down to the OR where I stand, maintaining the retractor in exactly the right position or even being asked to two-hand tie a knot (which makes my heart rate jump to over 100), and so on. The amount of action makes it patently obvious why there are multiple medical dramas focusing on the hospital and not on the preclinical years.

In short, I’m exhausted. I come home ready to collapse on my bed – I torture myself by prolonging sleep at least until I’ve showered and ate dinner – and I sleep, as my family calls it, “like a rock” (as in, like I got hit over the head by a rock). In the morning, I stumble around my apartment like a zombie, trying to collect everything I need for the day.

But, when I’m at the hospital, I don’t think about any of that. I’m exhilarated. I am actually doing something to help improve other people’s lives, even if my part in this better life is reasonably small. Especially on Surgery, it’s easy to see the impact on people’s lives.

This month, I’m rotating on the Vascular surgery service, which means that a lot of the OR cases are some form of endarterectomy. Over time, atherosclerosis causes plaque buildup in major arteries and can lead to inadequate oxygenation of important tissues. If these arteries feed the heart, the result can be a heart attack. If they are any other artery, that’s where vascular surgeons come in. For example, femoral artery stenosis can lead to claudication (essentially angina in your calves, or leg pain after walking a given distance that subsides after rest) and difficulties moving from place A to place B. Or, there’s carotid artery stenosis, which leads to a higher risk for stroke.

In an endarterectomy, the surgeons clamp off the vessel above and below the stenosis (usually at least 50-70%, and sometimes even 100%, of the vessel is occluded), open up the artery, take out the plaque, and close everything up. The procedure takes 2-3 hours, but what a difference it can make. People can walk farther than they have in a long time or are less likely to have a stroke. It can change their life.

And that’s what I came to medical school to do.

So yes, it’s hard. And yes, I’m exhausted. But, even playing a tiny part in improving someone’s life makes it all worth it. It just takes time to get used to the change in my own life. No more streaming lectures for me; now I have to be up front and center. It’s definitely an adjustment period, but it’s a bit like starting a challenging exercise regime – my whole body is sore and I want to quit. But, when you stick with it, you become a much stronger and better person than you ever dreamed possible.