Abstract

In lieu of an abstract, here is a brief excerpt of the content:The Practice of SurgeryKaren DevonThere’s no one on the snowy road driving beside me. It’s Christmas Eve, the night the newest attending surgeon on staff gets to be on call. Tonight feels like an anniversary of sorts. The first time I performed an appendectomy “alone” was on Christmas Eve. I can’t recall if it was snowing back then since I hadn’t left the hospital in days. I had assumed that while I was operating on that 26–year–old woman with new abdominal pain that moved towards the left lower quadrant, my attending staff on call was sleeping soundly. I didn’t even know where he lived, or how long it would take if something catastrophic were to happen. I phoned the white–haired man to get his blessing just before midnight. “Have you done this operation before?” he asked. “Yes, several, but not completely alone” I confessed. “Go for it and call me when you are done. Oh, and be safe!” Click. Gulp.As I drive in tonight, again past midnight, I reflect upon that night. Was it practice? A right of passage? The most appropriate treatment for the patient? Perhaps it was even safer this way since my attending really had never done this operation the way it is now done—laparoscopically—by residents. I clearly recall telling the patient and her mother, “We do this all the time! The staff surgeon on call will come in if I need him, but the chief residents always do this operation and I feel comfortable taking care of you.” Sign on the dotted line and make sure you read the part where you are told this is a teaching hospital. Not only was independence an expectation, but I was also supposed to teach the more junior house staff how to emulate what I was so expertly performing.That night I took out the rotting appendix without incident and called the grey haired surgeon in the wee hours. “Merry Christmas Doctor. Sorry to bother you. I just wanted to let you know that the patient is awake and doing well.” “Yes I know. Good work” he replied. “I was in my office. Just in case.”As a resident, I was often torn between the need to gain independence in order to learn and grow as a surgeon, and the idea that I was practicing. As most budding surgeons do, I wanted to be the person doing the surgery. Working on my technical skills was clearly an important part of expertise. Surgery is inherently different than other types of medicine. It seemed slightly more difficult for someone to stop my cutting, than to catch the error in a prescription, before some damage is done. Perhaps a little more like driving a car, than learning to use a calculator. Recently a more modern surgical education is evolving, whereby students practice by simulations on machines. Yet educators know that ultimately many “firsts” need to occur with real patients. That proficiency and expertise are more than a diagnosis, a steady hand, or even the two combined. If the experience of operating as the primary surgeon without immediate supervision, on a patient with acute appendicitis never occurred until we passed licensing exams wouldn’t that be more harmful? I may have been the least legally responsible for outcomes, that night of my own first, when the grey–haired surgeon took the [End Page E1] responsibility of trusting me. But in fact, the obligation I felt was enormous. We cannot simulate the weight of responsibility that comes when responsible for another human being, who you have met and who provides their trust in you. Furthermore, as the teachers of this art and science, we need to balance our obligations to each individual patient with our obligation to society to train competent and caring future surgeons. Surgery would have no history if the “practice” of surgery had nothing to do with practice, defined in its simplest form, yet how do we cover all of this during the late night conversation that is called informed consent. Interestingly since that December evening and for the next 200 laparoscopic appendectomies before my graduation in to...