Academic OB/GYN

When I was a high school math nerd I looked forward to the AP calculus class I would take my senior year, because once I had done that I really would have achieved the tops that mathematics had to offer.  Once I finished that class, I remember thinking “now I really understand math.”  When I studied mathematics and computer science in college I realized how wrong I had been.  I realized then that calculus was not the end of the mathematics – it actually was just the beginning.  In fact, it was the first thing I ever learned that could even be called mathematics at all.  The rest was just arithmetic.

As an academic gynecologic surgeon, I often get asked a question that reminds of me of my calculus realization, and that question is “Who will be doing my surgery?”

Patients at a teaching center who are going to be having surgery often ask this question, wanting to make sure that the attending physician will be doing their surgery and not a resident or other trainee.  The answer that works the best is that we operate together, and that the attending is involved in every step of the way.  This sometimes works, but sometimes people don’t like that answer.  Often they ask “but who will be actually holding the knife?”

The truth is that in teaching centers, residents do most of the physical work of surgery, and typically it is they who are holding the knife.  Though attendings are involved and are usually scrubbed into the case, residents usually do most of the physical work.   Residents don’t do things they are not yet ready to do, but once they have amassed enough experience and knowledge to physically perform a surgery, they will typically be doing it.    Some patients find this alarming.   But they shouldn’t.

The problem is a misunderstanding about what doing surgery actually is.

Just like my high school mathematics misunderstanding, patients sometimes think that holding the knife is the top of surgery, the ultimate task.  The truth is that it is just the arithmetic.   When a resident operates, they are honing the physical skills they will need to one day operate without supervision, while the attending does the important work of deciding what needs to be done.  Attendings may not place every clamp and cut every pedicle, but they help the resident to do those things the right way, and when needed to redirect them away from the wrong things.  Sometimes that is just a gentle “why don’t you try doing it this way…” and sometimes its “lemme show you how to do that better.”  Sometimes its “you rock!” or “that’s great!  Now keep doing it that way the rest of your natural life.”

When senior residents struggle, it is rarely because they can’t physically do something, but rather that they do not know what should be done.  That’s when the attending steps in and redirects.  It is this intellectual work that is the core of surgery, what “doing surgery” actually is.  The physical task of cutting tissue, placing suture, and controlling bleeding is the arithmetic, not the calculus.   It is the building blocks that surgery is based on, not surgery itself.   Only once those buildling blocks have been mastered can the real learning of surgery begin.

I love teaching my junior residents the physical tasks of performing surgery, when I can wrest that work away from my senior residents.  It is great to see a third year resident that has taken those formative years and come out with great physical skills.  Still, it is even more satisfying to watch a senior resident who not only operates with good physical skills, but also makes good decisions in the operating room, and deals with an unexpected situation successfully.  But when they can’t, another attending or I will be there to help them make the right decision.   And because of that, when a patient asks me who will be operating, I can honestly say “Me”.

PS – To my residents and residents all over the world.   Learn the physical tasks of surgery outside of the operating room as much as you can.  Read one or more surgical textbooks cover to cover and know the material.  Understand suture materials.  Know the names of every instrument.  Tie knots at home five minutes every day until you can do it one and two handed, left or right dominant, in your sleep.  When an attending has to spend a case teaching you how to do these things, your chance of learning real surgery in that case goes way down.  But when you walk into the OR holding a knife right, understanding where sutures need to be placed in fascia, knowing where  figure of 8 should go to stop a bleeder, you can have the best cases ever.  If you work hard outside of the operating room, that will happen early in your residency.  If you don’t, it may not be until late in your third year or even fourth year, which hurts your ability to come out of residency as a solid surgeon.  If you are a medical student who wants to go into a surgical residency, its never too early to start.