Surgeons and Other Physicians: A Cultural Divide

Are there intrinsic differences between how surgeons and physicians who are not surgeons see the medical world?  A pediatrician who reads this blog thinks so, and he e-mailed me to suggest that “The distinction matters because the dichotomy between doctors who perform procedures and those who practice ‘cognitive medicine’ [listening to and talking to the patient] is a major culprit in driving up the cost of American medicine.

His grandfather was a physician and his father was a surgeon, which puts him in a unique position to muse over “the cultural divide between surgeons and non-surgeons.” I’ll call him Dr. Y

Dr. Y begins with a disclaimer: Of course one must take all generalizations, including this one, with a goodly truckload of salt, and the moment I assert there is such a difference, particularly if I do it mostly with anecdotes, a flood of counter-examples roll in.”

In fact, he concedes: “There is much overlap in worldview between surgeons and non-surgeons: think of two circles of a Venn Diagram overlapping to a large extent, but still comprising regions that the two groups do not have in common. It is these outlying regions that matter and I think they exist. Are there data for that? Sort of.”

He points out that “there are a pile of studies that ask the question:  ‘Are there personality differences between surgeons and non-surgeons and, if there are, were these caused by the training or does the kind of training attracts the personality type?’ The results have been mixed, but the consensus is that medical students who choose surgery are no different from those who choose other things. Stuff happens in residency, which is to be expected, I think.”

                      

                                         Surgeons-in-Training

Over at HalfMD.com a student who is at the halfway point in his medical education offers a provocative window on the “stuff” that happens.

Last year, in a post titled “First Impressions he tried to prepare other medical students for what to expect in their first surgery rotation:

When rounding with the attending [physician] you will notice that he will only speak to the resident” (not to the intern) “and then only to criticize the resident. If the attending asks a question and the resident is wrong, prepare to get yelled at. If the attending asks a question and the resident is right, prepared to get yelled at, too. If you’ve ever seen The Devil Wears Prada, you’ll understand how the process works.

“The worst part of it all is that I haven’t been in surgery at all this week. I’ve done so much scutwork that I haven’t seen a single surgery. I don’t even know where the OR is. . . .

“Instead, I fill my time with useless conferences where the resident presents the week’s cases, and then a group of dinosaur attending [physicians] yell at him for two hours. They feel the need to participate in these conferences so that they can inflate their egos by belittling someone with less knowledge and experience. By the end of the conference, their egos have swelled so large that they begin insulting each other and the whole ordeal becomes an orgy with everyone trying to get on top by putting down the rest of the group. In addition to not learning anything during this conference, all hell broke loose on the floor during that 2-hour period.

“I got back to find that one of our patients suffered a seizure and another had a pulmonary embolism while we were gone. As I was on the phone trying to get a consultant to come take a look at one of the patients, my intern walked into the nurses’ station and announced “Some guy fell in the hallway out here… There’s a guy on the floor out here… He’s laying right over there.” The rest of that day and the next were filled with damage control to keep from being sued by every patient who gets annoyed with their nurses’ lack of lightning fast response.”

                                             The Stereotype

HalfMD’s experience seems to confirm all of the hoary old jokes you have ever heard about surgeons. (“How do you kill a surgeon? Make him climb to the top of his ego and jump. . . What’s the difference between a surgeon and God? God doesn’t think he’s a surgeon . . . .)

Indeed, Dr. Y observes: “if you Google ‘surgeon’ and ‘god complex’ you will get 34,700 hits, including, for example, the speech by the Alex Baldwin character in the movie Malice:

"I have an MD from Harvard. I am board certified in cardiothoracic surgery and trauma surgery. I have been awarded citations from seven different medical boards in New England, and I am never, ever sick at sea. So I ask you: When someone goes into that chapel and they fall on their knees and they pray to God that their wife doesn’t miscarry, or that their daughter doesn’t bleed to death, or that their mother doesn’t suffer acute neural trauma from postoperative shock, who do you think they’re praying to?

“Now, go ahead and read your Bible, Dennis! And you go to your church, and, with any luck, you might win the annual raffle, but if you’re looking for God, he was in operating room number two on November seventeenth, and he doesn’t like to be second guessed. You ask me if I have a God Complex? Let me tell you something — I am God."

                       A Brief History of How the Surgeons Became the Stars 

Dr. Y. believes that the history of medicine helps to explain why many (though certainly not all) surgeons do, in fact, possess such enormous egos: “Throughout the first 50-60 years of the 20th century, surgery was where the action was,” he explains. “Halsted, Cushing, and the Mayo brothers, among others, made huge strides in what we could do. Meanwhile, until the middle of the century and even beyond, internists had little to offer. Paul Dudley White, cardiologist to Eisenhower, though he pioneered the clinical use of the EKG, really had nothing to offer in the way of therapy.

“My physician-grandfather told my newly med student-father in 1942 that all he had was morphine, sulfa, digitalis (in the form of powdered foxglove leaf), and a bag full of useless nostrums. Dad started as a rural Minnesota GP. He told me for a heart attack one stuck a needle-full of morphine into the patient’s vein, pushed it until the pain stopped, and then waited to see what happened next.

“Surgery was where it was at, so dad went back to do that. He was a surgery resident at the U of MN in the early 1950s, the early glory days of cardiac surgery with the Lillihei brothers (first users of the heart-lung machine that made it possible), the elder of whom once told dad to remember ‘who were the stars and who were the chorus girls,’ meaning all the non-surgeons.

“And it was true. Surgeons were the stars.

“A few other things led to the long reign of surgeons,” Dr. Y adds. “From the start health insurance plans favored things they could count, like operations, and which happened in hospitals, also like operations. There was also the matter of training. For a long time surgeons, with their 5 year residency, were far better trained than most physicians, the bulk of whom had done only a year of rotating internship.

“Fancy internists (and pediatricians) were only to be found in big cities, and they only trained for 3 years. Now, of course, a large number of non-surgeons have 6-7 years under their belts–residency plus fellowship. (It took me 10 years, but I tried a few things.) So the training time issue is now a wash.

“Lastly, there is the matter of American temperament, which, I think, is geared toward doing something, anything, rather than standing by. It goes against our grain. Americans have never favored (or highly respected much) thinkers. Consider Richard Hofstadter’s seminal book, Anti-intellectualism in American Life.

Thus surgeons, who are the doers, garnered far more respect than physicians practicing “cognitive medicine.”  And as the world saw the surgeons, so they saw themselves. Many viewed themselves as the “real men” of medicine. Perhaps this shouldn’t be surprising. At the beginning, surgery largely consisted of “lopping things off.”  Surgeons needed strong fingers and a stout heart. Often they lopped without access to anesthetics.

But today, a good surgeon must have great patience (just to learn his craft), a respect for fine tissue, and a keen eye for detail. Yet, as researchers wrote in The Archives of Surgery just two years ago:"Surgery remains a ‘macho’” culture. (This, of course, can make it very difficult for women surgeons to be accepted and respected in the culture.) And some surgeons do continue to view other doctors as the “chorus girls.”

                        Why Surgeons Are the Way They Are

While on his surgical rotation, HalfMD decided to interview the Dean of his medical school and ask him, point-blank: “Why do surgeons have to be such assholes?”

The Dean replies: “Surgeons are the playground bullies of the medical world. Any compassion and genuineness has been beaten out of them long ago. They’re so used to talking to others through screaming that their encounters with students and residents are rarely pleasant. That’s not to say that all surgeons are like that. Urologists and Ophthalmologists bring civility to the medical community.”

You have to hand it to the Dean—he didn’t dodge the question (even though he knew he was being interviewed for a blog). But he never quite answers it either: why are so many surgeons ‘macho bullies’? 

HalfMD himself may have stumbled onto the answer about ten days later, when he actually finds himself in an OR:

When the surgeon saw me enter the OR, she immediately removed the mechanical retractor that was automatically holding open the patient’s neck, handed me two manual retractors, and made me keep the surgical site open. If you’ve never seen retractors, they look like shoe horns and serve the purpose of reminding everyone in the OR that the medical student is the surgeon’s bitch.

“That procedure lasted nine hours. Imagine standing in place for an entire work day, not moving your arms, not eating, not peeing, and wondering when they’re going to sew this patient up so you can finally rest. The ophthalmologists are smart enough to perform all of their surgeries sitting down. No wonder getting into ophthalmology is so competitive. If other surgeons were that smart, maybe they’d realize that they don’t need to put every patient on Vancomycin prophylactically.

“This particular case involved a rare type of cancer called medullary thyroid cancer. The procedure was going well enough until our non-paralyzed patient started moving during the surgery. Her thyroid was partially hanging out of her neck when she started jumping off of the bed. As I tried to hold her down, the surgeon went right on cutting as if nothing was happening. Later, my attending also hit the jugular and blood went airborne with a perfectly vertical leap. As Old Faithful shot forth, I jumped back to prevent getting showered in HIV and hepatitis. The surgeon commented: ‘Look at how scared this guy is.’”

Here, perhaps, we see why a surgeon must be proud as Lucifer–even if that self-esteem borders on arrogance: “As I tried to hold her down, the surgeon went right on cutting as if nothing was happening.” The surgeon needs to be so supremely confident that no surprise can rattle her. As for ridiculing HalfMD for jumping back, while that may seem cruel, the truth is that if the attending who was assisting had jumped, her knife might have slipped, and the patient could have been killed. The weak must be weeded out.

This may explain why both medical students on surgical rotation and surgical residents are consistently abused, both mentally and physically.  If a student doesn’t have the physical stamina to stand in place for nine hours, the self-confidence to persevere while being taunted for each and every mistake, and the self-control to endure constant hazing, then perhaps this is not the field he or she should choose.

                                   A Military Culture

Looking back on his experience a year later, HalfMD is still trying to prepare others students in a post titled: A Life Raft for Surgery

“Few rotations are as anxiety-producing as this one. . . .In addition to the general etiquette that was discussed earlier, there are several new behaviors you will have to acquire on this rotation.

“First, you should address everyone as “ma’am” or “sir.” That includes the nurses, the techs, and all of the residents and attendings. For some reason, surgeons believe that medicine should be run like the military. Granted, none of them had ever served in the armed forces, but I certainly heard a lot of attendings say, ‘This is just like the military.’

“Second, do not speak unless spoken to. If you have a question, you should keep it to yourself and look up the answer later. I cannot stress this point enough. Do not ask your attendings any questions regarding any disease is that you may encounter. Your attending will very likely turn the question around and either pimp you or force the resident to answer. Then you’re going to be stuck with the resident that dislikes you and a comment on your evaluation that says ‘The student needs to read more.’”

In this boot camp, the surgical resident is never right. He never knows enough. This is a hell where the Sergeant is in your face. Conceivably, sthis is a way of teaching humility—the humility that anyone who cuts into human flesh must possess. After all, most surgeons probably know, in their heart of hearts, that someday they may well make a mistake that kills a patient: just one moment’s loss of concentration, that’s all it takes. The guilty and bitter knowledge that they are , after all, fallible human beings may be what lies underneath so much pride.

                        But Do They Really Need to Be This Way? 

     Dr. Carol C. Nadelson tackles this question in a review of A Surgeon in a Woman’s Body, by Joan Cassell, published in Psychiatric Services in February of 2000. She begins by observing that “although we have seen many studies and much literature about the culture of medicine, and especially surgery, over the last four decades, this book is an insistent reminder that not much has changed.”

Then Nadelson asks the crucial question: “ Should it change?”

Her answer lead to more questions: “In what way? We would undoubtedly say yes to change and proceed to present a more humane training process and practice approach. But why hasn’t it changed? Is it the insistence of the authoritarian ethos, or is there a down side to making what seem to be obvious changes? What would it cost to the patient, the surgeon, and our society? What would we gain?”

I’m not going to try to answer these questions: but they are, I am convinced, the right questions. For my part, while I believe that surgeons need to be strong, and extremely disciplined, both mentally and physically, they do not need to be bullies, and they do not need to be macho—with all of the contempt for women and “chorus girls” that the term suggests.

                      How the Surgeon’s Starring Role Has Shaped U.S. Medicine

Moreover, I am persuaded that Dr.Y is onto something when he notes that the surgeon’s status in the world of American medicine may help explain some of the problems with the way we practice medicine: “A good share of our tendency to favor expensive procedures (and high utilization),” he suggests, “ is bound up in how our insurance system was constructed, in the long dominance of proceduralists (epitomized by surgeons.)

“Discussing this whole issue is crucial,” he adds, “because I truly believe that it explains part of the skewed and crazy nature of our health care system. My European physician friends are amazed at the dominance of surgeons here, both in terms of income and political clout. I think it helps explain a lot. It’s also,” he acknowledges, “ an incendiary topic.”

I would like to invite surgeons as well as other physicians and patients to respond to some of the ideas in this piece. I’m hoping to publish one or more surgeons’ comments as a post. (Please, no rants.)

35 thoughts on “Surgeons and Other Physicians: A Cultural Divide

  1. That was a very fascinating post. As a patient who has been through five surgical procedures between 1994 and 2005, I’ll offer my perspective.
    I also perceive surgeons as the fighter pilots of medicine. The most significant of my five procedures was a CABG (quintuple bypass) in 1999. I’m quite sure that it significantly extended my life expectancy from what it would have been if I didn’t have the procedure. I also needed a DES six years later to resolve another significant blockage that developed. One of the other procedures fixed an issue that caused periodic severe pain that felt similar to a heart attack while the remaining two resolved problems that interfered with my ability to function day to day. All five were very significant issues to me and I was grateful to the surgeons for their skills and for the miracles of modern medicine including prescription drugs. Issues that I consult non-surgeons about should be addressed too, but they just don’t seem as important if they are not immediately life threatening or causing significant pain or discomfort. Moreover, a mistake by a surgeon can cause a material adverse outcome, including death, right then. That’s a stressful burden to live with every time you enter the operating room.
    From a business perspective, surgical procedures performed in a hospital, especially those for commercially insured patients, are big financial tickets and the most profitable segment of a hospital’s business. Outpatient procedures produce higher profit margins but inpatient procedures bring in many more dollars per case.
    The worst aspect of the culture, however, is that it discourages anyone, especially nurses, from speaking up if they see something wrong, a mistake being made, or a procedure not followed. A lot of preventable errors could probably be avoided if surgeons were not such bullies. The question I have is: would their outcomes be as good (or maybe even better) if they were civil team players? I have no idea.

  2. Barry,
    It’s interesting that you use the fighter pilot analogy. While the ratios have changed with the greater use of fighter-bombers, quite a few bomber pilots, with some justification, say fighter pilots’ job is protecting them while the work gets done. Even in a two-seat fighter-bomber, one can argue that the pilot’s job is getting the weapons system operator to where the WSO will do that which the aircraft flew to do.
    Taking aviation a bit farther, one can contrast two flights, United 232 and Air Florida 90. The first was a catastrophic systems failure in flight, which, when presented in simulators to test pilots knowing what was to happen, invariably led them smashing into the ground within a minute or two. In the actual flight, the captain having the responsibility kept the plane flying for close to an hour, and then brought in for a semi-controlled crash landing at Sioux City, about half the people aboard surviving. Al Haynes, the captain, however, said it was a total crew effort, especially when an instructor pilot, who had been a passenger, joined them.
    While that instructor pilot had made a study of something close to what happened, although not quite as bad as reality, now contrast it with Air Florida 90.
    That aircraft was still on the ground at Washington National, where there were marginal icing conditions. The cockpit voice recorder tells the tale of the copilot diffidently warning the captain that it “felt wrong”, when the takeoff still could have been aborted. It scraped across traffic on the 14th Street Bridge and then into the Potomac.
    The difference is what the aviation industry calls Crew Resource Management, a specific discipline to make sure that while the captain is responsible, crew are required to speak up.
    When I was recovering from my CABG, and my surgeon trooped in with his entourage, a few days later, I gave him a severe look. “Are you sure you’re board certified cardiothoracic?”
    He gasped.
    I continued, “You are incredibly patient and courteous to your residents. You called me a couple of nights before the surgery, and, when you found out I wanted the details, spent 90 minutes on the phone with me. Everyone in the nursing and support staff loves you.
    “What if your board finds out?”

  3. I’m surprised to see that I was cited so much in this article. I should point out, however, that the interview with the dean was made up. I fabricated a story to show what the dean would say if I ever got a chance to interview him.

  4. Half/MD, Barry and Howard
    Half/MD thanks for clearing that up about the interview with the Dean.
    I did wonder what was going on in his mind. It occurred to me he might be close to retirement, and was now just saying things he had thought for many years . . .
    Howard and Barry– Yes,
    I believe that the OR is much like an airplane, andthat if people in the OR worked together the way airline pilot and co-pilots are supposed to, everyone would be safer.
    I do suspect that the fact some surgeons are such bullies does explain why others in the OR don’t speak up–especially if they’re not entirely sure that they’re right.

  5. Half M.D. was forced to hold the blogging retractors on this post – well done.
    These stereotypical surgeons are the “alpha males” of the medical world.
    From wikipedia”
    “Some animals live in a social structure where the more powerful male in the group is decided by either simple play-fights or even very aggressive battles. The current alpha male must defend his ranking from younger members. When he is too old or not strong enough to win, he loses his position in the group.
    The result of this is that the alpha male usually has more opportunity to mate with the available females. This system evolved because strong males will produce young which have a better chance for survival.”
    However, the beta males get to be with the females while the workaholic alpha males are busy with work.

  6. Maggie,
    I enjoy reading your blog and usually find the topics enlightening and well reasoned but this one is really over the top. It caused me to wonder if you had truly run out of substantive issues to pursue.
    As a recently retired surgeon with more than 40 years of up close and personal exposure to the species you attempt to describe I can only conclude that you may have fallen pray to colorful imagination indulged in by TV script writers or other practitioners of the art of fiction. Even your source, HalfMD, admits to the fictional nature of his contribution and Dr. Y is careful to caution readers not to get carried away by generalizations and vague impressions.
    Is there really a difference between a person who becomes a surgeon and someone who chooses to pursue another branch of the healing art? No, not in the real world. As Dr. Y confirms, there is no objective evidence that medical students who choose surgery as a career are any different in academic achievement or identifiable personality traits. Perhaps there should be additional testing for endurance or manual dexterity or hand eye coordination but so far the professional has not seen fit to impose these standards. Anyone who is motivated and interested enough to pursue the training is welcomed. In the end it is a personal choice. Some folks like to drive a car and others like to ride. And as you report, “today, a good surgeon must have great patience (just to learn his craft), a respect for fine tissue, and a keen eye for detail.” And a surgeon must have the practice and experience to establish the confidence to commit to a course of life threatening action that will be effected for the patients benefit
    The type of conduct and behavior that you would imply as characteristic of surgeons has not ever been the norm and was considered unprofessional and unappreciated even in the days when DeBakey, Lillehei, and Sloan walked in the corridors of the OR. I was there and that is my personal experience and testimony. Tyranny in surgery or in relationships with patients and staff is not now nor ever was an optional career choice. While there will always be boors and ignoramuses in this world, they are not suffered gladly.
    The overwhelming majority of my colleagues are well intentioned human beings who try to be patient and courteous to their patients, co-workers, residents and students. Sometimes they are not as successful as at other times, but, no, they are not one or two standard deviations away from normal human behavior as this blog would imply.

  7. Surgeons and FPs/internists definitely come from different parts of the solar system.
    Whether that has anything to do with driving up health care costs is questionable.
    Most people first encounter a surgeon because a non-surgeon made a referral, or they came through the ED.
    There is nothing more fun than spending a couple of hours in a board room with a dozen surgeons.

  8. Surgeons and FPs/internists definitely come from different parts of the solar system.
    Whether that has anything to do with driving up health care costs is questionable.
    Most people first encounter a surgeon because a non-surgeon made a referral, or they came through the ED.
    There is nothing more fun than spending a couple of hours in a board room with a dozen surgeons.

  9. Surgeons and FPs/internists definitely come from different parts of the solar system.
    Whether that has anything to do with driving up health care costs is questionable.
    Most people first encounter a surgeon because a non-surgeon made a referral, or they came through the ED.
    There is nothing more fun than spending a couple of hours in a board room with a dozen surgeons.

  10. Sorry for any multiple posts, some blogs do not work well with Firefox – grr.

  11. Dr. John,
    No, I haven’t run out of substantive issues to write about–just finished a 40-page white paper on Medicare and I have a backlog of about 6 posts I want to write here.
    I’m sorry you didn’t like the post, but it isn’t fantasy. Not according to the Archives of Surgery
    (see reference in post) which says that surgery
    still represents a “macho culture.”
    The book review (from another medical journal) makes the same point.
    My guess is that this varies by hospital, depending on who is in charge and the culture.
    In some hospitals, doctors tell me that “rainmaker surgeons” who bring in a great deal of business are allowed to act out.
    Consider the story below about how Maimonides Hospital in Brooklyn New York has decided to “Rein In” Rude surgeons and other doctors.
    “The nurse later said she sensed the surgeon was in a bad mood when he walked into the operating room. Things did not improve when she handed him the wrong size gloves, and they deteriorated further when he began shouting at her and then dismissed her from the procedure.
    “She came out very, very upset,” the executive director of perioperative services at Maimonides Medical Center in Brooklyn, Pamela Mestel, recently recalled, sharing details of the spat that emerged when the nurse and surgeon faced each other again during a mediated discussion monitored by hospital officials.
    “While such disputes occur regularly in hospitals, Maimonides has adopted a “Code of Mutual Respect” that requires medical staff to treat colleagues well or face peer review and possible discipline.
    “High-powered physicians, some with bad tempers, are not new. But increasingly, hospitals such as Maimonides are attempting to curb the reputations of rude or arrogant surgeons and doctors by instituting policies that hold all employees accountable for their behavior.
    “There’s the God complex people talk about when they talk about surgeons. Medicine, fortunately, is changing for a lot of reasons. No longer is that kind of behavior acceptable,” the vice president of perioperative services at Maimonides and author of the hospital’s “Code of Mutual Respect,” Dr. David Feldman, said.
    At Maimonides, hospital staff credit the medical center’s president, Pamela Brier, who made clear during staff meetings that she would hold everyone to the same standard. “I said, ‘Look, I’m going to commit to you that nobody at the medical center has a title so senior or is a doctor that brings in so much money that they’re exempt from behaving properly,'” Ms. Brier recalled recently..
    “Even among hospitals that do not prescribe specific codes of behavior for physicians and staff, several have implemented mechanisms to promote safety. Beth Israel Medical Center’s “red rules” give every hospital employee the right to stop a procedure if they see something they think is unsafe.
    “According to the hospital’s president, Dr. David Shulkin, if a surgeon rushes into an operating room and urges others to skip certain procedures, such as marking the body part that is to be operated on, nurses and technicians may stop the surgery in its tracks. “In the past, some physicians got away with that” when hospitals adopted the position of “we don’t want to offend the doctor, he’ll take his cases somewhere else,” he said.
    Dr. Shulkin, who has prioritized patient safety since taking over at Beth Israel three years ago, said the appropriate attitude starts at the top.

  12. Let’s be clear that while I made up the interview with the Dean, the rest of my stories really did happen while I don’t necessarily think that all surgeons are a bunch of bastards, there are certainly enough to sour the reputation of the whole group.
    There are certainly personality differences between the medical students who decide to go into surgery versus other fields. To this day I have never encountered a timid surgeon.

  13. Culture of surgery

    Interesting post. Maggie Mahar explores the hierarchical, and sometimes abusive, environment that pervades surgical training. Will it change?
    Not likely, as long as payments continue to be tilted towards surgical procedures. Surgeons are the main prof

  14. Not authoritative and studies vary, but, a) done at Baylor–some cred, b) the differences in folks seeking a career in surgery are likely not accidental, and it will be reflected in their personalities:
    Curr Surg. 2003 Mar-Apr;60(2):210-3.
    Factors influencing career choice among medical students interested in surgery.
    Azizzadeh A, McCollum CH, Miller CC 3rd, Holliday KM, Shilstone HC, Lucci A Jr.
    Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA.
    PURPOSE: The number of applicants to general surgery programs has recently declined. We set out to determine factors that influence career choice among medical students. METHODS: Design: survey; Setting: university medical center; Participants: fourth-year medical students; Intervention: distribution and completion of the survey. Participants ranked 18 items coded on a Likert scale from 1 (not important) to 8 (very important). These factors were career opportunities, academic opportunities, experience on core rotation/subinternship, role model(s) in that specialty (mentors), length of training required, lifestyle during residency, work hours during residency, ability to obtain residency position, concern about loans/debt, call schedule, lifestyle after training, work hours after training, financial rewards after training, intellectual challenge, patient relationships/interaction, prestige, future patient demographics, and gender distribution in the specialty. Students were asked to provide gender, career choice, number of programs they applied to, and the number of programs at which they were interviewed. RESULTS: A total of 111 of the 160 surveys distributed were returned (69%). A total of 48 of the students were men, 31 were women, and 32 did not identify their gender. Nineteen students were interested in pursuing a career in surgery or a surgical subspecialty. Factors predicting surgery as a career choice were career opportunities (p < 0.04) and prestige (p < 0.003). Lifestyle during residency (p < 0.0007), work hours during residency (p < 0.008), and quality of patient/physician relationships (p < 0.05) were all significantly negatively correlated with the choice of a surgical career. Students pursuing a surgical career applied to greater than 31 programs compared with 11 to 15 for the nonsurgical students (p < 0.0001). CONCLUSIONS: Prestige and career opportunities are more important to students seeking surgical residencies. Concerns about lifestyle and work hours during residency and perceived quality of patient/physician relationships were deterrents to surgery as a career choice. These issues may need to be addressed to increase the number of applicants to surgical programs.

  15. Maggie–
    I think you’re correct that exploring this question, land mines and all, can help us understand how American medicine got to where it is. Our system is far more expensive than that of other countries and we need to examine all the ways it might have gotten that way, and this is one of them. That’s not a criticism of surgeons, other procedure-oriented physicians, or anybody else — it’s just an attempt to understand. You’ve done many, many excellent posts about medical economics that more or less go over the same ground. This one is a bit of a tangent, but I think it is an interesting and potentially fruitful tangent.

  16. As a doc myself I greatly admire surgeons for their technical skill and especially their courage.
    But my observation over 35 years of medical practice is that generally they are more aggressive,more paternalistic and,by definition, more interventionistic than their non-surgical counterparts.
    Also in many cases their world view is a mechanistic one- the body parts need to “be fixed”. And they tend to see the world as dichotimized into black or white (good/noble or bad/evil.So disease-the enemy- needs to be surgically repaired/removed and death-the ultimate enemy- needs to be vanquished with their ” special sword”- the scalpel.
    Dr. Rick Lippin
    Southampton,Pa

  17. My life was saved by a wonderful, kind, pediatric surgeon. I grew up thinking that I’d follow in his footsteps and become a surgeon myself. However, when I realized what the culture of surgery was like, I changed my mind. I wrote an article for JAMA called, “Why aren’t there more women surgeons?” in February, 2000. After interviewing 3 very successful female surgeons and listening carefully to what life was like for them – I decided against becoming a surgeon.
    There is a true cultural difference between medicine and surgery. Each medical student has to decide for herself which culture she likes better. As for me, I’ve never regretted changing my career plans – and I still look to surgeons as mentors and friends… My clinical work is devoted to the disabled, and I’m preparing to volunteer at Walter Reed. Maybe I don’t get to operate on people – but the joy of helping them walk again is really fulfilling.

  18. Dr. R , Save the rustbelt , Half MD, Brad, Chris, Dr. Val, Dr.J., Dr. Rick —
    Thank you all.
    Dr. R wrote: “However, the beta males get to be with the females while the workaholic alpha males are busy with work.” Score one for the pediatricians!
    Save-the-rustbelt– you are right, someone refers the patient to the surgeon. But then the surgeon decides how much surgery to do. And once you’re in the hosptial, surgeons sometimes decide to do a little “exploratory surgery” . ..
    HalfMD–No, I didn’t think you made it up. “Never met a timid surgeon”–a good way to put it. I’d add that “strong” and “aggressive” doesn’t have to be obnoxious.
    Brad F wrote: “Prestige and career opportunities are more important to students seeking surgical residencies. Concerns about lifestyle and work hours during residency and perceived quality of patient/physician relationships were deterrents to surgery as a career choice. These issues may need to be addressed to increase the number of applicants to surgical programs.”
    Very interesting. I’d add that concerns about a macho culture is probably not the only reason that fewer women choose surgery –concerns about hours and lifestyle” would rank high for many women.
    Chris–
    Yes, I think the history of medicine is very important to how we got where we are now. And, as you say, this is not a matter of “blaming” anyone. We’re all very glas that surgeons like the Mayos became stars when they did and blazed trails in medicine.
    Dr. J– Thanks (and welcome)
    Dr. Rick– very well-put
    Dr. Val– interesting. So often illness as a child (or a sibling’s illness) seems to lead people into medicine. The way you changed your career path–by talking to successful women surgeons– sounds very wise.

  19. I have lived in LA/OC, NJ/NYC and now Western Michigan.
    I have NEVER been treated as badly by any dr. as I have been here. I have suffered many horrible illnesses, i.e pulmonary emboli, hypo/hyper thyroid. I was once put in place for a urinary exam and left for over 30 minutes before the dr came into the room! I felt uncomfortable physically and mentally so I sat up and waited for the dr. When he walked into the room and saw me sitting on the exam table, he threw a fit. I am not a side of beef to be left hanging on a hook!
    I believe that the archaic behavior and mentality described in this article is not only for surgeons but ALL medical professionals in the Midwest.
    The arrogance of the medical professionals here is mind numbing and dangerous. We are leaving the state as soon as we can safely / financially mainly because of the lack of professional health care.
    It is common knowledge in Western Michigan that the medical care available here is basically worthless. I am bitter that because my doctors provided poor care, I suffered emboli and now I am nearly unable to be insured. the week that I threw the emboli, I called the dr. 3 times and asked to be seen but was refused! I was so dizzy that I fell to the floor.
    The type of behavior described above is not only surgeons, but all drs. as far as I can tell in the midwest. MSU, U of M, butchers and buttheads.

  20. Sort of hard to comment on all the ‘flaming’ going on here, having devoted my career to surgery since residency started in 1981, but I have found it interesting that surgeons kids usually pick another non-surgical specialty, and if a surgeons’ s dad was a doc, they were usually not a surgeon. Also I’m here to say just because a doctor or surgeon is female doesn’t guarantee 2 doses of compassion. I don’t think the compassion gene is on the X chromosome!

  21. Rich–
    Your comment about surgeons’ kids picking another specialty could be tied up with the demands, in terms of long hours, that take the surgeon away from family. It could also be connected to what some describe as the “authoritarian” side of the surgeons’ culture.
    Since boys are more likely to become surgeons, they may be differentiating themslves from their somewhat authoritarian fathers. . .
    BTW: Aa a woman, I don’t think that compassion is tied to the “X” chromosome–I think many of the differences have to do with socialization. As a child, I received approval for being sympathetic and compassionate. Boys around me received approval for being athletic and smart. If they failed to be sympathetic–or were even cruel (laughing at a friend who fell down, threw up in class, etc.) they were not criticized.
    That said, when I became the mother of a boy and a girl, I was shocked to discover how different they were from birth. (I firmly belived that all gender differences were a result of nurture.)
    My husband and I took care of them almost equally; when they first learned to talk at 10- to 12 months sometimes they would call me “dada” and call him
    “mama.” I fed them milk(and they clearly recognized that difference) but otherwise, we were just the two faces/people they knew where their protectors.
    It was only as they could differentiate us as people that they were clear on who was dada and who was mama.
    Nevertheless, when they were very, very young, you could see the gender differences.
    Myy son would use blocks to build very tall towers.
    My daugher used the same blocks to build parking lots.
    Then, when she was barely able to walk, she dragged a chair to the kitchen sink, got up on it, turned on the water, took a cup that was next to the sink, filled it with water, emptied it, filled it again, emptied it.
    She would do this over and over–and I always let her do it (making sure she had a plastic cup that wouldn’t cut her.)
    Call me a Freudian. But that day I realized that, for many kids, there is a real gender difference that doesn’t see to have much to do with nurture/conditioning.
    I’m not an expert about any of this, but would be interested in any leads to good resarch that might let me write a post about this.

  22. I think most assholes learn they can’t survive in the private world when their referral base is based on being nice. I have worked with assholes. I would never ever ask one of them to see my patient, even if they were the best surgeon in the world (how ever you measure that)

  23. For Happy Hospitalist, given the way you characterize certain disagreeable people, may I suggest…well, tongue-in-cheek is not the right metaphor…http://f2.org/humour/songs/crs.html
    (Warning: do not have liquids in mouth when reading/listening)
    On a more serious note, it sometimes can be a difficult call. A family member needed a brain biopsy, and we went for a preoperative visit to the neurosurgeon. He asked if there were questions, and I inquired if the procedure would be stereotactic, and which specific structures he would biopsy.
    With a rather demented expression, he said “Structure? THE BRAIN.” I turned to the patient and asked “are you sure we weren’t supposed to go to podiatry?”
    Chatting with one of the neuro ICU nurses, there was a consensus that he did have the best pair of hands in the department, but if any of them were a patient, they demanded all conversation would go through a fellow or senior resident. Frighteningly, he’s now chief of neurosurgery at a different major teaching hospital.
    During WWII, Churchill spoke of the Germans as “at your feet or at your throat”. There may be a twisted medical truth there; most of the podiatrists I know are much more pleasant than the otorhinolaryngologists.

  24. Those of us in health care administration often refer to managing physician groups at “herding cats.”
    And the first time I heard the phrase “alpha wolf” was at a seminar focused on trying to introduce the concept of management to surgery practices. Still trying on that one.

  25. Thanks Maggie,
    As a general surgeon, who trained at the Harvard Surgical Service affiliated with the New England Deaconess Hospital, I did not face the humiliation that others have decried.
    My chairman, Bill McDermott embodied the gentleman surgeon and hired people who behaved respectfully toward their teams. I felt the same way at Roosevelt Hospital in NY where I did my surgical subinternship during medical school.
    Caring for surgical patients with teams is a long and proud tradition that continues to this day with surgeons thanking the nurses and anesthesiologist at the end of the procedure.
    I know that I will be drowned out by the voices of many others who feel that they have been abused. I do not deny that surgery has abusive people. I just wanted to say that my memories remain full of the camaraderie of taking care of patients under trying circumstances, such as multiple admissions, long nights and weekends, and dynamically changing physiology.
    For those convinced that there are two distinct camps of surgeons and cognitive physicians, please comment on my post, Collaborative Distinction,
    http://healthcarecollaboration.com/collaborative-distinction/.

  26. The domination exhibited by physicians, particularly surgeons, is about far more than verbal abuse and yelling. I don’t doubt those defending their experience who say that they haven’t seen many angry tantrums by surgeons. But I think we’re getting distracted by the most extreme displays so that we miss the very real and dangerous power dynamics here.
    I happen to have just been in the OR a couple of weeks ago with my wife, who was undergoing an emergency C-section. It was performed by obstetricians, as most are. There was one attending and one (I’m guessing) resident who was being trained during the operation. Their tone of voice and demeanor was perfectly pleasant throughout.
    But here’s the thing: as far as they were concerned they were the center of the universe and everything in that room revolved around them. The patient and the nurses had the status of objects. They were oblivious to my wife and I as human beings, and never once spoke to us in the OR. That would have been fine if they were so focused on the operation that they didn’t want distractions, but in fact they gabbed with each other throughout the procedure. I couldn’t believe how many different things they found to talk about while cutting open and sewing up my wife. Some of it had to do with training, which is appropriate though a bit unnerving. Some of it had to do with office gossip, friends in common, etc., which is quite unprofessional. How many airline pilots do you know who make a habit of gabbing with their crews over the intercom throughout a flight? Or imagine that only the pilot and co-pilot would speak to each other, treating the flight attendants as worthy of communication only to issue orders.
    But all that was a minor annoyance to me, and I would not have commented on it except for the following: the nurses quite clearly lived in fear of the doctors. This was cemented for me when I saw two nurses counting up the sponges when it came time to start sewing up my wife. They went through …17, 18, 19… one is missing. So, they count again. Same number. Count again. Same number. They talk to each other about a missing rag in perfectly normal voices 6 feet from me. I hear their concern. The doctors do not, though they hear each other loud and clear.
    Then, rather than make sure to get the physicians’ attention, the nurses keep counting. I lost track of how many different times they poked and rearranged their piles of bloody sponges to try to make the final one appear. I could see the them laid out in rows on the floor, and it wasn’t long before their behavior appeared pathological. After the 7th or 8th counting (who knows) with the exact same result, a nurse looks up at a doctor plaintively and starts to say something. She panics and it catches in her throat to make an inarticulate sound, but since she is only 3 feet from the doctors I still expect one of them to turn and ask “what is it?” Doesn’t happen.
    So, the nurses go counting again. And again. Meanwhile, the physicians are busy sewing up my wife. They are probably half-way done when finally a nurse summons the courage to speak up and say a sponge is missing.
    The doctors don’t yell at her. They calmly start digging around in the uterus to find the final sponge. After some effort, they find it. There is no “thanks for pointing that out.” Or, “glad we caught that.” They went on as though nothing had happened. Now, you can say the nurses were just doing their jobs and didn’t need thanking, and that if either of the physicians were thinking “Shit, I almost screwed up” they wouldn’t want to admit it in front of everyone, including the patient. I’m OK with that.
    What I’m not OK with is that the nurses are afraid to speak up and correct physicians even when it is essential to their job. One nurse finally overcame her fear this time, but I am not confident that it will happen every time at that hospital.
    I look back and wonder why I didn’t say anything. It didn’t even occur to me, because I saw myself as just a spectator and provider of support to my wife. In retrospect, I should have taken a different attitude, but it’s hard when you are suddenly thrown into that environment. (Mother and child are both doing fine now, by the way.)
    The two physicians, I am sure, saw themselves as the paragons of civility and good manners. How they had their effect on the nurses I don’t really know. Were they imperious outside of the OR? Did the attending have a reputation for blowing up when interrupted even if they didn’t this time? If a nurse interrupts and she is wrong, does she get punished in more subtle or indirect ways? For all I know, the physicians are always civil to the nurses’ faces and their intimidation came from an ability to to give them low marks or decide that they don’t want to work with certain nurses. I don’t know. All I know is that we had a near miss that came closer to being a hit by the fact that the nurses were too intimidated to do their jobs efficiently.

  27. I am a surgeon, a woman, and a human being. Your RANT is why I am unwilling to ‘come out ‘ in public with my profession away from the hospital. Sometimes I tell people at parties I am a gardener, so I can have a peaceful social evening. There are as many reasons to become a surgeon as any other profession.
    I am lucky to work in a group (Kaiser Permanente) where my colleagues are people I deeply admire, doing very hard, necessary work to keep people alive.
    Someday you or someone you love will need surgery. It is likely to be 2AM, you may be in excruciating pain and no other treatment will be effective. Remember, a third of people with appendicitis died a century ago. I or one of my colleagues will be there for you. Am I a bully? Is that what you want to call individuals strong enough to step up to this type of challenge? With the fortitude to hold life and death in our (nearly) bare hands? The integrity to do whatever it takes alone in an operating room to solve a problem? The commitment to put our personal lives aside at a moments notice for the endless emergencies. The strength to face a family when we come out of the operating room with bad news. Think about it. Could you do it?
    Keep your heart and mind open.

  28. >The nurse later said she sensed the surgeon was in a bad mood when he walked into the operating room. Things did not improve when she handed him the wrong size gloves, and they deteriorated further when he began shouting at her and then dismissed her from the procedure.>
    so when a nurse can’t even get the right sized gloves for a surgeon (usually on the preference card) do you think they are providing the right equipment when asked for? probably not. when does repeatedly correcting the incompetent become “behaving improperly”? And is it passive aggressive behavior on the nurses part, lack of caring about the case or just ignorance? I’ll tell you that when staff repeatedly show they don;t know what is going on in a case, I feel very justified in dismissing them from a case. “she was very upset” – yeah, I’ll bet he was too – people not having the stuff you need, dropping things, handing you the wrong stuff, making you wait for stuff when the patient is opened up under anesthesia – it puts you in a pretty bad mood…

  29. to dr. human:
    would you still do all that if you weren’t paid so well and worsiped for your skills? THAT is the question and true measure.

  30. The worst aspect of the culture, however, is that it discourages anyone, especially nurses, from speaking up if they see something wrong, a mistake being made, or a procedure not followed. A lot of preventable errors could probably be avoided if surgeons were not such