The thoughtful doctor, on the other hand, the one who knows the stuff cold but also realizes his or her limitations, tends to train harder, tries continually to learn, and is willing to entertain a wider range of treatment possibilities (and is more likely to treat you, not the symptoms). Because the thoughtful doctor prepares better, he’s more likely to pick up mistakes before they manifest themselves, thus avoiding them. In what amounts to an irony, then, the more modest doctor, the one who can imagine his own fallibility, will probably end up being regarded as more infalliable by grateful patients and staff than are doctors who ooze self-assurance.
There were several surgical and medical myths whose truth (or not) I was beginning to sift through. For example:
Surgeons are emotionally detached, even nasty.
Largely false – except for surgeons who specialize in cancers and are notoriously cold, not because they’re innately misanthropic but because they see so many people die. It’s a well-circulated opinion among surgeons that urological surgeons are easily the nicest among surgeons, and cardiac the most intense. Plastic surgeons are often called the “fairy surgeons” – mostly because our surgery is more aesthetic and largely elective, and non-life-threatening. We’re more artistic. And there tend to be, by my observation, more gay surgeons in plastic surgery than in other surgical disciplines.
Surgeons, particularly plastic surgeons, are in it for the money.
Some are, of course; most are not. It’s simply too brutal a life to do it primarily for the money. Dan Baker, a well-known New York plastic surgeon, told me he works harder now, in his mid-sixties, than he’s ever had to work before. We see each other walking to the local Starbucks at 6:30 A.M. on a Sunday – and that’s after we’ve seen our patients.
A nice office suggests a successful practice and a good doctor.
Plastic surgeons in particular are guilty of turning their offices and waiting rooms into palaces (gorgeous fish tanks, flower collections), often because they feel that their wealthy clientele expect it. Dr. Joseph Murray, a brilliant surgeon and the only physician ever to win the Nobel Prize for Medicine, had benches in a hall outside his modest office.
If a surgeon does lots of operations a day, he must be good.
Volume is not indicative of quality. There’s a balance between being quick and facile, on one hand, and really understanding the operation, on the other. When surgeons routinely take longer than usual to complete standard operations, it probably means they’re not as sure and prepared as they should be. I’ve heard women boast about how their plastic surgeon took seven and a half painstaking hours to do a face-lift, suggesting that he was especially careful. To me it suggests he’s probably not very good. The best plastic surgeons are neither too fast nor too slow.
The number of papers published or prestigious titles (e.g., department chair, medical society president) suggests a good doctor.
Not necessarily. In fact, there may be an inverse relationship. I have met several surgeons who published papers so often, they scarcely performed surgery anymore. That might not be a doctor you should go to.
Good doctors know a lot.
No – and yes. That is, we do know a lot – but about very, very little, and that area of expertise narrows over time, for two reasons: One, doctors get older and more experienced; two, the field of medicine becomes ever more specialized. I have come to know a great deal about the face, millimeter by millimeter, but less and less about hand surgery, a specialty that I, as all plastic surgeons, was trained in.
Residents (and interns and medical students) are so sleep-deprived it compromises their ability and particularly their judgment.
Myth – not that they’re sleep-deprived, but that they can’t function on little sleep. People make too much of this one. Yes, you can be exhausted and your thought processes change, but you compensate. When you work in a hospital, you cope. I’ve never failed in a case because I was tired, and God knows, as a resident I operated tired. You teach yourself to recognize when you’re too depleted. Hospital training is excellent for teaching residents that at the slightest sign of uncertainty, they should always seek backup. Or delay the procedure. Because this idea was beaten into my brain for years, now, in private practice, if I’ve been operating all day, and I don’t feel well or alert, and another operation awaits, I know to reschedule. Patients understand. As for being on your feet operating and concentrating sometimes for five, seven, ten, even sixteen hours at a time: It’s not a problem. You’re so focused on the patient and what you need to do, the body and mind transcend fatigue.
These are just a few lessons I’ve learned in medicine.
The invasive cancer had wrapped around the patient’s left carotid artery, threatening to slowly reduce the blood flow to the brain – in essence, to strangle it. (The left and right carotids are the two main arteries to the brain.) If I was one millimeter off, I would puncture the carotid, which would cause massive, rapid, gushing bleeding, and I would wipe out half his brain, paralyzing or killing him.
To get control of the cancer, I worked around the normal tissue to get at the abnormal tissue. I removed the left maxilla – the cheekbone – only to find that the tumor had invaded the back of that. I kept dissecting tissue, sending it to the pathology lab, and results kept returning with the phrase positive margins – that is, the cancer was continuing to show up. Without getting a result of clear margins, the patient would die.
I had yet to find the end of the cancer’s incursion. I removed the patient’s whole left face (essentially) to see that the tumor had infiltrated all the way to the base of his brain. I started going deeper, millimeter by millimeter, using scissors to cut away soft tissue, a drill with a bur when I needed to shave bone.
You know, if I screw up at all I thought, this will be very, very bad. I will kill him.
Finally, I got a pathology result of clear margins.
I leaned back. This was much bigger than I had anticipated. Now I had to close the hole in his face.
How the hell was I going to do that?
My thoughts raced through what plastic surgeons call “the reconstructive ladder.” The first option is simply to close the skin. I couldn’t do that here because too much was missing.
The second option is to apply a skin graft, usually taken from the leg. I couldn’t do that either, because the skin graft wouldn’t take to bare bone, and he was missing too much tissue.
The third option is a flap – which means to rotate skin, fat, and usually muscle from somewhere else on the body. In his case, I decided on a delto-pectoral flap from the chest.
Eventually, a couple short years after feeling inept, after having no confidence as a surgeon, I’d found it. Over time and numerous procedures, especially more complicated surgeries, I’d found it. Mentors covered me less and less. The responsibility and complexity of what I was given to do kept growing. No longer was I doing an appendectomy or taking out a superficial lipoma. One day I realized simply that I was now the one with the high-speed drill in my hands, I was the one screwing plates on to close a fractured cheekbone, millimeters from the eye. One slip and I was the one who would puncture the eye and blind him.
With each pass of the