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.”
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.”
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.)