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(Illustration: Tom Nick Cocotos/Pacific Standard)

Is the Quest to Build a Kinder, Gentler Surgeon Misguided?

• July 14, 2014 • 6:00 AM

(Illustration: Tom Nick Cocotos/Pacific Standard)

Surgery is a fundamentally messy and stressful activity. When being a few millimeters off target can be life-changing, a surgeon needs to possess fierce concentration, unrelenting perfectionism, and, above all, staunch self-assurance.

My profession is filled with exceptional individuals who do amazing, lifesaving work. Many of us are jerks.

This is the trouble with surgeons. We are a sub-tribe of doctors who have long been celebrated for our abilities yet reviled for our personalities. In movies and TV shows, we are egomaniacal, hostile, and even mentally unstable. A low point came in 1993 with the film Malice, which featured a scenery-chewing turn by Alec Baldwin as a gifted but evil cardiac surgeon who denied having a God complex. “I am God,” he clarified.

Behind the caricatures lies some truth. Many surgeons are abrasive, abusive, and wildly self-centered—so much so that observers have speculated that they suffer from psychiatric disorders. In 2012, British psychologist Kevin Dutton published The Wisdom of Psychopaths: What Saints, Spies, and Serial Killers Can Teach Us About Success, a controversial book arguing there are certain benefits to being ruthless, cunning, and indifferent to the feelings of others. Dutton included a list (based on an Internet survey) of professions with the highest proportion of psychopaths. Surgeons landed at number five, barely trailing CEOs and lawyers.

Within the past two decades, though, the surgical profession has attempted a wholesale revamping of its image and ideals. Compassion, communication, and collaboration are now strongly emphasized during training. It’s been a rapid and turbulent metamorphosis that has undoubtedly led to improvements for patients, hospital co-workers, and even surgeons themselves. Nonetheless, in the process, surgery may have created its own identity crisis. We want to believe we’re better off with nicer surgeons. But what do we lose?

There will still be occasions when getting the best treatment requires enduring a rude, insensitive surgeon.

SURGERY HAS ALWAYS BEEN, at its core, a brutal undertaking. Prior to the introduction of anesthesia in the mid-19th century, surgeons often worked to a sound track of screams. Writing in 1812, British novelist and playwright Frances “Fanny” Burney provided a rare patient-centered account of the horrors of a mastectomy without anesthesia. “When the dreadful steel was plunged into the breast,” she wrote, “I began a scream that lasted unintermittingly during the whole time of the incision—& I almost marvel that it rings not in my Ears still! so excruciating was the agony.”

No surgeon could inflict such anguish for long without developing a tough shell. Thirteenth-century French surgeon Henri de Mondeville wrote that two of the most important requirements for a surgeon were a strong stomach and the ability to “cut like an executioner.” Samuel Cooper, a British surgeon of the early 19th century, identified the surgeon’s most valuable quality as “undisturbed coolness, which is still more rare than skill.”

Because of their grisly work and perceived lack of refinement, surgeons lagged far behind their medical counterparts in social status, on a par with blacksmiths or barbers. Then, with the invention of anesthesia in the 1840s, followed a few decades later by the introduction of antiseptic techniques, surgeons began to achieve success upon success in invading the body and curing disease. Their profession skyrocketed in prestige. In 1904, New York surgeon Frederic Dennis delivered an exuberant keynote address at the Universal Exposition in St. Louis and lauded the “conspicuous grandeur” of surgery’s ascendance and the “self-reliance, principle, independence, and determination” of those who could perform it.

While surgery grew somewhat less gruesome, surgeons of the 20th century retained many of the personality traits of their pre-anesthetic forebears: detachment, resolve, and a thirst for action. Many viewed themselves as heroes on a par with military leaders, fighter pilots, and political figures—and, not coincidentally, gained a reputation for being prima donnas. Still, the public appeared willing to accept some self-centeredness as compensation for miraculous work. In May 1963, legendary Boston surgeon Francis “Franny” Moore appeared on the cover of Time magazine, with a pithy accompanying caption: “If They Can Operate, You’re Lucky.”

WHEN I STARTED MY surgical residency in the summer of 1999, toughness and swagger pervaded all levels of my program. Ground Zero was breakfast in the cafeteria with the trauma surgery team after a night on call. We’d exchange yarns of high-speed car crash survivors with mangled limbs, head-trauma victims with eyes popped out of their sockets, and assorted saves and misses in the ICU and operating room. The ultimate prize for the trauma surgery resident was to perform an emergency thoracotomy, which involves cracking open the chest of a dying trauma victim and literally massaging life back into the heart. My fellow residents and I thought nothing of yelling at nurses, bullying the internal medicine and emergency room docs, and complaining about the incompetence of anyone who was unfortunate enough to not be one of us. On more than a few occasions, I witnessed senior surgeons throw instruments in anger, leaving the staff cowering.

kinder-surgeon-1(Illustration: Tom Nick Cocotos/Pacific Standard)

As I progressed in my training, though, I became increasingly uncomfortable. Instead of gaining more confidence and emulating the cool, imperturbable surgeons and residents in my program, I found myself growing less and less sure of myself, always afraid of causing harm to my patients. Everyone around me seemed so certain in their judgments and abilities, while I spent a lot of time second-guessing my decisions and feeling apprehensive about my technical skills. My insecurity was in gross violation of the surgeon’s credo: Sometimes wrong, never in doubt.

My worst fears were realized midway through my third year of training. During a routine gallbladder operation, despite close supervision by an attending surgeon, my novice hand slipped a few millimeters from its intended target and I poked a sizable hole in my patient’s bile duct. We had difficulty repairing the damage I’d caused, and my patient would later require a major salvage operation. In the aftermath, racked with guilt and shame, I became convinced I was an impostor. Surgeons were supposed to be fearless, cool under pressure, heroic. I was sensitive, introspective, self-doubting, maybe even (shudder) nice. Several times during the months after my mistake, I stood outside my department chair’s office, ready to walk in and hand her my resignation.

TODAY, MORE THAN A decade later, I’m a practicing surgeon at a busy academic hospital. I love my job, especially operating. In the aftermath of my error, I suffered many sleepless nights and even sought therapy to help me work through my conflicted feelings. Still, I recovered. The numbing fog of fear and self-doubt gradually lifted.

I spent a lot of time second-guessing my decisions and feeling apprehensive about my skills. My insecurity was in gross violation of the surgeon’s credo: Sometimes wrong, never in doubt.

The culture of surgery has changed dramatically. Many of the personality traits we used to consider “the right stuff” are now viewed as outdated, misguided, and even dangerous. Yelling at underlings buys you an incident report. Throwing instruments in the operating room is grounds for suspension. From their first days of residency, the surgical trainees in my program receive instruction in non-technical skills such as team leadership, effective communication, and situational awareness.

Numerous factors have contributed to this overhaul. Many previously heroic operations have been replaced by targeted medications, molecular therapies, and minimally invasive procedures, edging surgeons off their pedestal at the top of the medical hierarchy. The public has learned more about preventable complications and deaths in U.S. hospitals, and the media has paid particular attention to surgical mistakes: wound infections, retained sponges, and wrong-site surgery. The rise of multidisciplinary medical care and systems-based practice has highlighted the importance of effective teamwork. A slow but steady shift in the gender and racial make-up of the surgical workforce has resulted in a welcome influx of new perspectives and leadership styles. And, what is perhaps most important, patients now demand more kindness and respect.

So many of these changes have been positive. A 2011 study suggested that patients who perceive higher levels of empathy in their surgeon actually have better outcomes. Nurses, anesthesiologists, and other hospital co-workers are beginning to enjoy calmer, less toxic working environments. Many surgeons, too, seem ready for this newer mind-set. University of Toronto surgeon Carol-Anne Moulton has spent several years conducting anonymous, probing interviews of surgeons of varying specialties and levels of experience, and her work has revealed that many of them suffer in silence, unwilling to admit fear, doubt, or grief. Underscoring Moulton’s findings, the American College of Surgeons released data in the late 2000s from a nationwide survey of surgeons’ job satisfaction and emotional health. Utilizing the Maslach Burnout Inventory, a standardized psychological evaluation tool measuring emotional exhaustion, depersonalization, and personal accomplishment, the survey reported a staggering 40 percent burnout rate in American surgeons. In short, the overconfident, misanthropic persona that has long been associated with surgeons often masks a roiling set of insecurities and hidden pain. During the darkest days of my residency, knowing that I wasn’t alone in my struggles would have given me great solace.

NEVERTHELESS, I FIND MYSELF worrying that the reformation is going too far. It is wonderful that our new trainees are more humble, self-aware, and communicative. After all, I was a resident who for much of my training felt out of place in the field, not hard-core enough to make it. But instilling these new ideals should not lead us to misrepresent the challenges inherent to the job. Surgery remains a fundamentally messy and stressful activity. When being a few millimeters off target can be life-changing, a surgeon still needs to possess fierce concentration, unrelenting perfectionism, and, above all, staunch self-assurance.

Friendly customer service is a worthy goal, but, to quote Stephen Sondheim, “Nice is different than good.” Putting likability before surgical outcomes is like judging a restaurant by the waiters and ignoring the food.

While I have a hard time buying Kevin Dutton’s claim that ours is a profession filled with functional psychopaths—since one of the hallmark features of psychopathy is a lack of empathy, and surgery is a profession built upon helping others—I won’t deny that surgeons exhibit tendencies that come awfully close to qualifying as personality disorders: narcissism, obsessive-compulsiveness, paranoia. Researchers have made several attempts over the past few decades to psychoanalyze our profession, with only modest success, but some findings have been consistent: Surgeons are action-oriented perfectionists with little tolerance for ambiguity, and we tend to push ourselves to the limits of our stamina and personal comfort. A common, perhaps inevitable, by-product: behavior that is offensive by usual societal standards.

In his 2012 book Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, Johns Hopkins surgeon Marty Makary describes two very different attending surgeons whom he encountered during his residency. One was nicknamed “Dr. Hodad” and was universally beloved by patients for his warm bedside manner. The “Hodad” nickname bestowed upon him by the residents, however, stood for “Hands of Death and Destruction,” because the man was a terrible technical surgeon with poor results. Another surgeon on the same faculty was nicknamed “The Raptor” for his cold, abrasive personality. This surgical bird of prey frequently infuriated patients, staff, and co-workers, but, as Makary recounts, he had amazing technical abilities, and his patients did far better than those of the kindly Dr. Hodad. Unaccountable is largely about health care transparency and how better public reporting of outcomes will create an environment in which bad surgeons like Hodad can no longer thrive. However, when I look at the other half of Makary’s duo, I suspect he’s in trouble, too.

Insurance companies are increasingly linking reimbursement to patient satisfaction scores, and this could make the Raptor an endangered species. Surgeons now can expect to find themselves rated by patients on Yelp, HealthGrades, or any of the burgeoning panoply of consumer-feedback websites. Friendly customer service is a worthy goal, of course, but to quote Stephen Sondheim, “Nice is different than good.” Putting likability before surgical outcomes is like judging a restaurant by the waiters and ignoring the food.

Surgical residency programs now place great emphasis on communication, teamwork, leadership, and other non-technical skills, and the modern residency curriculum is incorporating new training modules that attempt to impart these qualities. This is admirable and potentially beneficial, but at the same time, we may be losing ground in teaching the most fundamental skill of surgery: how to operate. Surgeon Pauline Chen discussed this troubling trend in a recent New York Times blog post. According to a 2013 study in Annals of Surgery, directors of surgical fellowship programs nationwide are dissatisfied with the technical abilities of new residency graduates, estimating that fewer than half of them are able to perform even the most basic operations independently. In a recent survey of graduating U.S. surgical residents, 26 percent reported that they did not feel comfortable with their skills and needed further training. The next generation of surgeons might be better behaved, but worse at their job.

WE WANT IT ALL: brilliant technical surgeons with outstanding interpersonal skills. In trying to shape our trainees to be all things to everyone, however, we run the risk of creating a workforce caught somewhere in the middle, not doing anything well. Residents already face increasingly stringent limitations on work hours and therefore have fewer opportunities to hone their operative skills. We worsen the problem by piling on multiple competing priorities and then getting upset when residents don’t meet our expectations.

kinder-surgeon-2(Illustration: Tom Nick Cocotos/Pacific Standard)

As it is, surgeons are expected to master two faces, a game face in the operating room and a milder face everywhere else, and toggling between the two can be extraordinarily challenging. In my specialty, endocrine surgery, I rarely deal with significant bleeding, life-threatening complications, or true emergencies. All the same, I often have difficulty ratcheting down the intensity after a taxing case or when a patient suffers a complication. I find myself distracted during conversations, and my responses to questions become clipped. It can take some time to decompress and rejoin polite society. My colleagues in blood-and-guts fields like trauma or transplant surgery have much vaster emotional chasms to cross whenever the turmoil of the operating room abates. Even on a good day, experienced staff members know to give their surgical colleagues a wide berth if there is a challenging operation to be performed. If things go sour, watch out.

And to some extent we must accept this. While several of the most gifted surgeons I’ve come to know—the surgeons I would want operating on me or my family members—are kindhearted, thoughtful people who fit right in with the new ideals of the profession, a nearly equal number are charm school dropouts: prickly, stand-offish, awkward, arrogant. Raptors. Their results are outstanding, but if these surgeons were in training today, many of them would be severely disciplined or even weeded out entirely. We might not love them, but we would miss them.

SOME SURGEONS BELIEVE THAT the solution to our current identity crisis is to return surgery to being a purely technical, back-room occupation, one that involves minimal face-to-face interaction with others. Let the surgeon fix the problem; make someone else do the talking. Adopt the mind-set of auto mechanics and airline pilots who are focused only on their job and have limited personal contact with customers. This would be an extreme interpretation of surgeon Atul Gawande’s recommendation that, in this increasingly complex health-care environment, doctors start considering themselves members of pit crews, not solo cowboys.

We want to believe we’re better off with nicer surgeons. But what do we lose?

While Gawande’s concept of a pit-crew mentality emphasizing teamwork and collaboration has a lot of merit, the back-room approach—relegating surgeons back to their days as technicians and tradesmen—is seriously flawed. Not only is this model unrealistic in our current practice environment, most surgeons would chafe at such a radically circumscribed role. While we may not always show it, or like to admit it, surgeons thrive on human connection. Restrict our opportunities to engage with our patients and their families, and the profession would lose much of its joy.

We can all agree that surgeons must meet a minimum behavioral standard that values respect for others and a willingness to engage and listen, and puts a lid on outbursts of temper—perhaps not always worth a full five stars on Yelp, but at least more reasonable than what existed before. As professionals, we need to do a better job of shifting between psychological states—kind-hearted to cold-blooded and back again.

Surgeons would benefit tremendously from simply identifying more effective coping mechanisms for the stresses that are inherent to our occupation. That in itself might decrease the likelihood that bystanders get their heads bitten off when trouble ensues. Researchers at Imperial College in London have developed a novel training module for improving stress management in surgeons, with ideas borrowed from other high-pressure fields such as aviation, athletics, and the military. The techniques include visualization, simulation, debriefing, and relaxation maneuvers like controlled breathing. One of my colleagues (who might kill me if I named names) has started meditating as a means for improving his focus, energy, and emotional well-being.

At the same time, our co-workers, colleagues, and patients must be realistic. There will still be occasions when getting the best treatment requires enduring a jerky, insensitive surgeon. We shouldn’t passively accept condescension and rudeness, but we must also remember that kindness and a good bedside manner don’t always tell the whole story. Tame the Raptor, but don’t lose his results.

Surgeons have a delicate operation to perform. Can we carve away the toxic personal qualities that have plagued us for centuries while retaining the guts and perfectionism that are the foundation of our professional ethos? The answer lies somewhere in the uncertain space between confidence and arrogance, leadership and dictatorship, harmonious teamwork and taking charge when chaos erupts. I, too, get lost sometimes in the gray area between humane and hard-ass. It’s a delicate balance, and we know we can do better. But any surgeon will tell you that the scalpel doesn’t cut as well when it loses its edge.


This post originally appeared in the July/August 2014 print issue of Pacific Standard as “Bloody Nice.” Subscribe to our bimonthly magazine for more coverage of the science of society.

Wen Shen
Wen Shen is a surgeon at the University of California-San Francisco.

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