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The Hidden Costs Of Teaching Surgery: An Academic Surgeon’s Perspective

Discussion in 'Hospital' started by The Good Doctor, Feb 5, 2023.

  1. The Good Doctor

    The Good Doctor Golden Member

    Aug 12, 2020
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    I ran across one of those bordering-on-sappy Facebook posts that always pull me in, asking people to describe their job poorly and make it comically accurate. The photographer admitted she would flash clients, shoot someone, and then frame someone else. The bartender alluded to being a psychiatrist, marriage counselor, babysitter, and thirst quencher. You get the picture.

    I am sure that each specialty in medicine has its own pithy, confuscating sound bite that describes perfectly what they actually do all day that the public may or may not recognize as part of the job description.

    When I thought about my role in medicine and what I have primarily done in the last twenty-five years, I realized why my vocation has taken its toll on my mental and physical health.

    As an academic surgeon, I teach young people to do dangerous things.

    In the past, generations of surgeons have taught residents the art of surgery, like a driving instructor taught a sixteen-year-old to drive. There was a separate brake on the passenger’s side; the instructor could guide the operation with the neophyte. You often heard from the other side of the table, “There is no trouble you can get into that I can’t get you out of.” And by and large, that was true. Bleeding from the portal vein could be handled with deft forceps, a Prolene stitch, and a Yankauer sucker. A serosal tear on the bowel was easily stitched up, “no harm, no foul.”


    With the advent of minimally invasive surgery, this paradigm changed. Bleeders or bowel injuries often necessitate conversion to open surgery to control the damage. And that’s a big deal for the patient expecting a minimally invasive procedure or who might fare badly with a big open incision. The grizzled, gnarly gallbladder is a loaded landmine, a black box of booby traps and punji sticks even for the intrepid, experienced biliary surgeon. Even opening that patient and getting your fat, sausagey, dissecting fingers in there is no walk in the park. Now, attack that gallbladder with a pair of chopsticks. Even worse, watch someone else who was in diapers when you finished medical school attack that gallbladder with chopsticks with the patient’s health and your reputation in that young person’s hands. Nothing in my job evokes more coronary spasm or hemorrhoidal pucker than a second-year resident with the Maryland dissector coming around the cystic duct on a tough gallbladder.

    With laparoscopy, it’s difficult to take over when things get tight. You don’t want to be the helicopter attending surgeon who won’t let the resident operate. “Let me show you how I do this” requires the resident to switch places with you at the operating table to make the “walk of shame,” as we used to say when I was a resident. But it only takes a little bit of bleeding to quickly obscure the anatomy leading to more bleeding and stress for everyone involved.

    And it’s not that these young people are bad surgeons. Some are absolutely fantastic. Some need a little help. But that feeling of being on that precipice and not being in control takes its toll on a body. I’d be interested to see what my own adrenal glands look like on a cholesterol-glowing nuclear medicine scan. To quote the inimitable George Jones, I bet they’d be hotter than a two-dollar pistol.

    Robotic surgery might bring some of the control back to the attending surgeon. It’s expensive, especially the upfront costs, but I suspect with increased competition, the price points will continue to come down. With this platform, though, I can easily take over if the pucker factor gets close to the red numbers, and I can delineate exactly what I want to accomplish on screen. With the much-improved range of motion in the instruments, I am more and more confident that I can get out of trouble if something goes astray.

    Now, after five hundred-odd gallbladders, taken mostly from the stoic veterans who tend to ignore the colicky pains that send everyone to the ER, I am tired, jittery, and anxious about the next one. I have encountered most of Donald Rumsfeld’s unknown unknowns in the minefield of the cystic plate. I can’t sleep the night before very well, and I want to puke in the locker room getting dressed for the case. If I never did another damn gallbladder, it would be quite alright with me. It’s an irrational fear, perhaps, but it’s well-earned.

    Relax. Breathe. Exhale. Teach. One day at a time.

    What is your job description? What makes your adrenal glands hotter than a two-dollar pistol?

    Maybe we should get together and talk about it before we all burn out.


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