by Richard Patterson, MD

“If you can’t do this drunk, you shouldn’t be doing it at all.”

The eminent professor was speaking to a friend of mine about heart surgery.  He was not advocating Operating Under the Influence, nor am I.

The point is that the technical component of surgery--the cutting, the sewing, the rearranging--is pretty easy.  It is true that in the OR, as on the golf course, some are more gifted than others, some more experienced.  But almost anyone can get through an operation or a round of golf, given training and equipment necessary to the act.  In more than ten years as surgical faculty, I worked with only one resident whom I considered technically hopeless, and he proved me wrong.  We don’t speak of this ease very often, if at all, within the fraternity or without.  The aura of technical virtuosity distances and distinguishes us from those who do not operate, just as the rites of the temple did the priests from the laity.

That distinction cuts both ways, though, and lends credence to the claim that we are mere doers and not thinkers.  One of my gastroenterology colleagues would tell patients in my presence that he would put “the X on the spot” and tell me what to do about it.  The disparagement goes much broader, even into the US Congress, with talk of “cognitive” versus “procedural” physicians and their relative value to society.

One of my more admired professors became a friend, colleague, patient and occasional adversary.  He had entered a surgical residency but left after a year to pursue sub-specialization in internal medicine.  He once confided his awe at “the courage” it took to be a surgeon, to transect the aorta for instance.  My counter was that it took no courage.  Before cutting anything, I always knew precisely what I was going to do and why and what to do should things not go as planned.  In my view, it took a lot more “courage” to prescribe a pill, a slug of molecules that would pervade the entire body with effects only hazily understood and that could not be retrieved. 

There are among us those who nurture that cognitive:procedural dichotomy.  A moment of major disappointment for me came when a highly respected surgeon declared in open conference that he wanted to be a “toe-tag surgeon”, to stand in the operating room and do whatever was prescribed by the referring doctor without having to know the patient or think about the issues—the basest abdication of surgical responsibility.

It is true that we do not often initiate the diagnostic process, but that does not absolve us of coming to an independent diagnosis.  We must also select from the variety of anatomic and physiologic solutions for the perceived problem, and we must judge whether the patient would enjoy a favorable risk:benefit ratio.  We must also be prepared intellectually to scrap all that when the intraoperative findings do not correlate with the expectations and re-create the entire cognitive process on the fly.

Realization and validation of our ideas require technical capacity, and the greatest satisfaction results from a solution properly conceived and executed.  There is no feeling like it; doing without thinking and its converse are equally sterile.