Surgical Training: Reform or Revolution

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I recent read with growing dismay a series of essays in the Bulletin of the American College of Surgeons. (Bulletin ACS, V99, No. 11) These were the first and second place essays from the 2014 RAS-ACS Symposium on the topic “The five year general surgery residency: revolution or reform?”
My dismay stems from the ideas put forth for changing the future of surgical training in this era of work hour restrictions, cost containment and advancing technology. The claim was often repeated through several of the submissions that surgical residents of today are asked to learn a broader range of surgical procedures due to the advent of laparoscopy, robotics and endovascular repairs. They also claim that the body of knowledge learned in training will become obsolete at an ever-increasing pace. This makes it incumbent that we train surgeons who cannot only do, bit also think. This last statement is one of the few in the series of essays with which I can whole-heartedly agree. I don’t subscribe to the view that the body of knowledge is too broad to be mastered. It has changed in nature, but is no broader that it was when I trained. What has changed is the ability to search and review specialized knowledge as needed. We need smarter surgeons, not surgeons who have memorized a body of facts.
The first place essay makes the statement: “Future endocrine, breast, or vascular surgeons should no longer need to acquire competency in hernia repairs or cholecystectomies. . . . (residents) should not have to demonstrate proficiency in managing conditions for which they will not bear responsibility in their careers.”
The other essays continue in the same vein – training should be more focused; career selection should be made earlier; the concept of the ‘General Surgeon” is obsolete.
I must ask: when did we, as a profession, lose our soul? I do not advocate a long rigorous, training program with no work hour restrictions just because I did it. This is not a case of “They did it to me, so I will do it to you.” We do not spend hours learning specific procedures to be duplicated step-by-step the way that our mentors taught us. What we spend hours learning is a set of manual skills, developing an intimate knowledge of anatomy in all it’s variations, and an intuitive understanding of tissue, its strength and weakness, its tolerances for traction and manipulation. You do hernias and cholecystectomies and colectomies even if your goal is to be a plastic surgeon so that you have an inbred understanding of how to handle and manipulate tissue, not so that you can master a particular procedure. A good surgeon who has a well-developed skill set can do most open operations, EVEN IF HE/SHE HAS NEVER DONE THAT PARTICULAR PROCEDURE BEFORE. There are some differences when it comes to the use of specialized equipment (e.g. Robots or laparoscopic instruments), but a good basic skill set will allow most surgeons to do any procedure. One may not be as fast or smooth the first time through a new operation, but the skill set is the same.
I don’t buy the assertion that the body of knowledge is too large to be mastered, not when the access to detailed information has kept pace with the amount of knowledge available. One may not have all the details on the tip of one’s tongue, but the ability to find the information is as close as the smart phone in your pocket. What is needed is a discipline that recognizes what information is critical and what can be looked up when needed. What is needed is a discipline that recognizes the value of broad understanding of surgical principles. What is needed is a discipline that advocates total responsibility for patient care and does not abdicates the diabetes care to the internist and the cardiac care to the cardiologist and rely on the hospitalist to handle the day to day inpatient care of the post-op patient.
I don’t advocate detailed training in all of those areas. Only enough basic knowledge to understand how they affect the care of the surgical patient.
In my day, (yes, I know that marks me as an old man), the surgeon was expected to be a passable Internist with superioir technical skills. That ideal has not changed. You don’t have to have the level of expertise that a specialist has acquired. You do need to know enough to know what they are talking about and decide if their care is good or bad for your patient.

A Question About the Standard of Care

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A Question About Standard of Care

To all of my medical friends and colleagues, especially to PA’s, NP’s, and Nurses, I need some guidance.
Is it acceptable for a specialty surgeon, for example and orthopedic surgeon, to leave routine postoperative care to a PA and Hospitalist and never see a patient postop until the office follow up one to three weeks after discharge? I ask because there are surgeons at one of my primary hospitals who maintain that they do not need to round on patients after routine elective surgery as long as the Hospitalist is dealing with the patient’s medical issues and the surgeon’s PA sees the patient and keeps the surgeon informed.
The question has arisen because regulation language has been proposed at one of my primary hospitals requiring the surgeon to follow the patient for at least 48hr after surgery. The fact that I am dismayed by the need for such a regulation tells you where I stand, but I am an old dinosaur. Perhaps the modern standard of care has changed and it is perfectly acceptable for a surgeon to delegate routine postop care to a PA as long as the patient is doing well and there are no complications.
What is the current practice? Say a healthy 70 year-old has an elective hip replacement. Is it acceptable for the postop care to be handled by the surgical PA with medical management by the Hospitalist? Does the operating surgeon have any duty to see that patient in the hospital if the PA is able to tell him/her that the patient is doing well with not surgical related problems?
I was trained in an older, harsher school that required hands-on care of any patient, no matter how routine the procedure. But in those days, we didn’t have surgical PA’s. The Physicians Assistant was a new concept. Most of the PA’s I knew were military and were involved in outpatient care on isolated duty stations, not seeing routine postop surgical patients.
Times and practice has changed. Mid-level providers are given much more responsibility now than when I was in training. I am married to a Nurse Practitioner and am cognizant and sensitive to the issues of their scope of practice. Still, I have difficulty in embracing this idea that a PA can be the only one responsible for postop care in any surgical patient, no matter how stable. Am I wrong? Am I simply behind the times?
Contrary to popular belief, I can change with the times. If this is the way of the modern world, I will accept it, albeit reluctantly.

Lifeguard

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There was a time, during my training and early in my career when the trauma surgeon was the fighter pilot of the surgical world. We were the Top Knives, the Master Surgeons, of our respective hospitals. Certainly the surgeons who trained me in the craft embodied that, and it was something I aspired to.
The nature of trauma has changed over the thirty years since I finished my residency. Penetrating trauma has fallen off to less that 15% of our total evaluations at the same time that non-operative management of liver and splenic injuries has become the norm. Cars are safer than they were two decades ago and the injury patterns have changed as a result.
I recently reviewed my trauma experience for the past year in preparation for applying for the ABS recertification exam.
I attended 518 Level 1 trauma activations in the past year. Of those, 294 were admitted as Trauma Service patients. Out of that total I did 21 major surgical procedures (not counting sewing up lacerations or chest tube placements in the trauma bay).
Those numbers seem to be in line with reported national averages. Operative intervention is now only a small part of what the trauma surgeon does, although I would argue that the acuity of those operative cases is higher than it was twenty years ago.
I reviewed the charts of the trauma admissions with which I was involved. 86% presented with a blood alcohol level in excess of 0.8 g/dl, or legally intoxicated. 47% returned a positive urine drug screen for other drugs such as opioids, benzodiazepines, methamphetamine, or marijuana. 76% were uninsured or underinsured (meaning that without the stop-loss portion of my trauma contract, I would not have been paid for my work).
The trauma service these days consists mainly of baby-sitting recovering orthopedic and neurosurgical patients. That’s not to say that these patients don’t have ongoing problems that are best managed by a team of surgeons, but they are not patients that we as trauma surgeons have operated on. All too often, the operating service signs off on day three or four and we are left doing the bulk of the postoperative care, rehab care and discharge planning.
Not terribly exciting to a fighter pilot personality. I fear we have gone from being the Master Surgeons, to the lifeguards at the shallow end of the gene pool.

Reconnecting

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Reconnecting

I got an e-mail recently from a Dr. Tim Race, MD, FACS. I didn’t remember knowing a Dr. Race and almost deleted it. I’m all over the Social Media these days and have gotten some increased notice because of some columns I’ve written for Physician’s Weekly. I’m happy to respond to friend requests on Facebook, and often respond to comments on my PW posts. But e-mails from people who aren’t on my friend list are uncommon and I don’t usually open them. As I said, I almost deleted the message until I noticed the subject line. “NMCB-5” it said.
That brought it back to me. I’d known a Petty Officer Race when I was the battalion surgeon for Naval Mobile Construction Battalion Five during my operational tour, the year after my internship. I had been a naïve, young (very young) doctor who went from playing at being a Naval Officer to thinking I might one day actually become one. For the first time in my life, people expected me to lead, to take sole responsibility for potentially life or death decisions and to be the expert that others turned to with questions about my area of responsibility. It was transformative.
Tim Race had been the Public Health technician for the battalion, a Third Class Petty officer, just out of C-school and a bit of a troublemaker. He took his duties seriously enough, but was smart and cocky. He had little patience with the regulations and protocols of enlisted life in the Navy. My first act as a division officer when I reported to the battalion was to convince the Master-at-Arms to let Race out of the brig so that he could do the monthly galley reefer inspection on time.
Race used to volunteer for the unpopular ‘midwatch’, the midnight to four AM watch, at the dispensary, mostly because there was no one else there to tell him what to do. I had a bad case of recurring insomnia during that deployment and used to hang out in my office rather than disturb my hut mates. Race and I often talked. I don’t recall those conversations being particularly deep or overly friendly. To me he was a bright 20 year-old kid with a bit of a chip on his shoulder. I did know that he was working on a degree in biology but not much about any future plans. Neither of us was looking much beyond the end of that deployment. Race left the battalion when we returned to Home Port and I didn’t hear from him for almost 35 years.
He finished his degree and went to Medical School on the GI Bill. He trained at Virginia and did a Colon Fellowship in Pittsburgh.
In his e-mail he told me he’d seen my column on the Etiquette of Help in Physician’s Weekly and got my e-mail from my Facebook page. He then surprised me by thanking me for setting him on the path to Medical School. He recalled our late night conversations in the dispensary on Diego Garcia and told me he’d been impressed by my commitment to going back to Bethesda to finish my training. Apparently at some point in what I though was a casual conversation, I told him that he was smart enough to be in my position one day. No one had ever told him he was a smart person. I’d earned his respect by getting him out of the brig and then letting him do his job without a lot of intrusive oversight. When I told him he could make it to Medical School, he believed me.
I struck me as I read his note that we never know how much influence our everyday actions may have on others. I recall mentors and teachers who had a profound affect on me. That isn’t unusual. But I also know that some of the people who inspired or motivated me may have had no idea that they had done so. I recently reconnected with an old high school friend whose father inspired much of my own ideal of how to be a good husband and father. I think she was surprised to hear he’d had such an affect on me, since he and I weren’t particularly close. I’m not sure he even liked me. But he became for me a sort of ideal to aspire to. I know he had no idea that he’d affected me so, but a large part of who I am as a family man is down to his example.
Dr. Race and I will try to get together sometime in the future, maybe at the ACS Clinical Congress this fall. I’m a bit humbled to have learned that I had a role in shaping his career, and wonder what effect, good or bad, I may have unwittingly had on others.

Acceptance

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Acceptance

I wrote a few weeks back about a death in the trauma bay, a young man with gunshot wounds to the chest. We knew nothing about him at the time, but the paramedic report and the police presence implied he was involved in some kind of drug deal. I have recently learned that this wasn’t a drug buy gone bad, but a random shooting. The victim wasn’t even the target, but was simply in the wrong place at the wrong time.
Most people want death to be sensible. We want a reason for someone to die that satisfies the mind’s need for cause and effect. Lung disease – must have been a smoker. Heart attack – red meat, obesity, no exercise. We look for some sort of causality, no matter how feeble. We imagine a clockwork universe where everything is rational and mortality plays by the rules. The secret wish behind that desire is the belief that there is also moral justification to death; that somehow we get what we deserve.
It isn’t true. The monumental stupidity that we see daily in the trauma unit still doesn’t explain why some live and some don’t. We take comfort in the mantra that “There are no victims”, that drink or drugs or stupid decisions account for the apparent randomness of trauma, but even that is a fairy tale.
We can catalog the injuries and say this or that was the fatal trauma. We can dissect our decisions and our care and say here or there is where we could have done something differently, maybe turned things around and saved rather than lost a life. None of it is true or real.
The truth is that even when people do stupid things, injury and death follow no rational or logical pattern. We are comforted when the patient is intoxicated, or when they have taken a stupid risk, and been injured. It reinforces our desire to see cause and effect. But when the injury, or worse, when death is completely random, when a patient is literally blindsided by a random event, those comfortable illusions are destroyed. We are left with the unanswerable “Why?” Perhaps it is true that God is watching over us and maneuvering us like chess pieces. I don’t know. His ways are not the ways of man.
Meanwhile, I am praying for and working on acceptance. It is hard, but that’s why it’s called work.

Suicide Ain’t Painless

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Suicide Ain’t Painless

Some of the best advice I ever received as a medical student was from my chief resident when I was an eager young fourth-year on my first trauma rotation. “Never run to a gunshot wound to the head,” he said. “They’ll either survive until you get there or they won’t survive no matter how fast you run.” The corollary to that axiom is “Think donor. The life you save may not be the one in the trauma bay”.
Gunshot wounds to the head are a particularly difficult type of trauma to deal with. When self inflicted, they automatically create a lot of ambivalence for the trauma team. It’s hard to work to save a life that the patient himself didn’t think was worth living. And shooting yourself in the head, unlike taking pills or cutting your wrists, is a statement of a fairly serious intent to end your life.
Mostly it is an act of despair, although sometimes it seems understandable. Not a choice I would make, but understandable for the patient. I am not a psychiatrist for a reason–I have little patience with neurotics and depressed people whose only purpose in life seems to be inflicting their own misery on everyone else around them. So depression, despair, loneliness, all the usual reasons people cite as the cause of their suicidal motivation don’t strike me as particularly valid reasons to put a gun to your head. In those cases, it’s an act of supreme selfishness.
On the other hand, a patient faced with a long and debilitating and ultimately fatal illness may see suicide as a rational act to avoid a futile and costly struggle that will have the same outcome in the end as a bullet in the brain. Again, not necessarily my choice, but understandable. I’m a firm believer in property rights. The ultimate property right is the right to decide what to do with your own life. If suicide seems a rational decision, I support your right to make that choice. Just get it right the first time and make sure no one else is hurt in the process.
That last part is the real problem with suicide. It may seem right to you, but even the most rational suicide harms those whom you leave behind. Death and grief go hand in hand, but sudden death leaves little time for the survivors to prepare or accept the loss. The thought that you would deliberately choose death over staying with people who care about you is doubly hard for the survivors to accept. It’s a very personal type of rejection and all the rational arguments about why you did it don’t change that.
As a trauma surgeon, I give families bad news on a regular basis. It isn’t something that I’m particularly good at. Although I try to put things in terms that are easily understood and give an honest assessment of the patient’s prognosis, I’m not good at offering comforting words or expressions of sympathy. Harder still is the discussion of brain death and organ donation. I believe in donation. I encourage everyone to become an organ donor. But I’m lousy at broaching the subject with families, even though it’s supposed to be part of my job. Thank God for the nurses at Donor Network who do that sort of thing very well.

Year’s End

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Year’s End

Over the past few years, I have reflected each New Year on the state of my profession and on life in general. Forgive me my hubris. I’m just old enough to think that I have something of value to say. This year I have struggled to not have this post sound like some sort of Jeremiah-like rant against the state of surgery and the profession’s abandonment of its own core principles. While I proudly claim the title of “Dinosaur”, facing one’s own extinction is hard, although obsolescence may be a better term than extinction.
First, the good. There has never been so much information available to the average surgeon. Through the Internet, multimedia presentations, online conferences and various university programs we have access to the latest research, evidence based protocols, and expert opinions in a quantity and quality unmatched in history. Critical examination and pooling of experience has improved our understanding of some very basic surgical diseases, replacing some of our most treasured (but erroneous) ideas about how to treat them.
Technology has continued to advance making new tools, treatments and techniques available at a breakneck pace.
The core of surgery, the commitment to technical excellence in the operating room, remains strong. I am gratified to see this strong commitment in my younger colleagues despite the changes in surgical residencies that have limited their experience and exposure to many clinical situations.
Personally, I am in better physical condition than I’ve been in years. I continue to be healthy enough to take Trauma Call, and although it takes me a bit longer to recover from nights without sleep, I can still hang in there with the younger surgeons. Age and cunning can give you an advantage over youth and enthusiasm.
I continue to write, both fiction and memoir. I have been honored to have met some very good authors and have the opportunity to talk to them as an equal about the craft and profession of writing.
My wife and I continue to have a strong and intimate partnership. She has nearly finished her Doctorate and together we can make a powerful force for change. She is a smart, passionate, and compassionate woman, and I am daily amazed that she picked me.
Our family has endured some stresses this year as all families do. But we have found the strength that resides in love and will persevere. We have two sons who have become good and kind young men and a grandson who is the new light of our lives.

Then there is the not so good. Change may be inevitable, but that doesn’t make it good. At this stage in my career I had anticipated coasting to the finish. Instead, changes in the way medicine is practiced and paid for have left me scrambling to maintain my practice and my prerogatives as an independent surgeon.
The big hospital systems continue their drive to consolidation, buying up facilities, building competing trauma systems that duplicate rather than complement each other and generally creating an environment that is hostile to the solo practitioner.
The same drive to monopolize the marketplace is leading to restrictions on our choices of specialists and facilities. Exclusivity in contracting can create synergy and simplify referrals, but only if the contractor is at least as good as the rest of the available specialists. Unfortunately, exclusivity tends to lead to mediocrity and we who depend on certain specialists for consultation are left with no alternatives.
Meanwhile, protocols and procedures continue to take precedence over thoughtful evaluations. Process has trumped outcome as a measure of our competence. We continue to spend thousands of man-hours and huge sums of money documenting compliance with protocols that have been demonstrated to be at best clinically irrelevant. All to ensure a continued flow of money from CMS. Many of my issues with the ACA and Medicare have little to do with reimbursements or insurance, and much to do with medicine by bureaucratic fiat. The agencies tasked with ensuring the quality of medical care no longer listen to those of us in the trenches who actually provide that care.
Some of my colleagues have surrendered to the creeping mediocrity of healthcare in the 21st century. Management by committee, healthcare by protocol, fragmentation of routine care to multiple specialists in the name of a care ‘team’, have replaced for them, the core concept of the surgeon as the captain of the ship. They limit themselves to the operating room and leave the rest of the patient’s care to the dubious skills of the Hospitalist. The have succumbed to the pressure to be little more than technicians and in doing so abandon the singular skill of the general surgeon – the ability to meld good medical care with surgical skill and take total responsibility for the care of the surgical patient.
I am not given to conspiracy theories, but the direction of healthcare in this new century seems to be on a steady course to eliminate the private, independent practitioner and replace him or her with a vague ‘team’ of healthcare managers. Decisions are to be made by consensus under the umbrella of standardized protocols and care delivered according to best practice guidelines. The thoughtful, sometimes inspired diagnosis will be a thing of the past, replaced by high tech imaging and computer diagnostic programs.
As I said, pretty much of a Jeremiad this year. Still, I will continue to do the best I can to preserve a way of life and practice that I was trained for. If you are a surgeon, it isn’t something you choose. You don’t look at a list of medical specialties and say, “I think I’ll give surgery a try”. You just know that this is the life for you; that there are few thrills or pleasures greater than the time you spend in the operating room perfecting your craft. The long hours, the missed holidays and events become burdensome at times, but in the end, the craft itself is the greatest reward. As Miyamoto Musashi says in The Book of Five Rings, “The Way is in training. Do nothing that is of no use.”

Late Life Change

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Late Life Change

There’s an adage in surgery that change is bad; the only thing worse than change is change you don’t control. As with most such aphorisms, there is a hard core of truth about how surgeons view the world contained within it. We must deal with risk, both predictable and unpredictable, every working day. The tendency is to spend a lifetime doing things the same way because it is safe, it works for you and it reduces the unpredictable risks to a minimum.
Sometimes change is forced upon you, whether you planned for it or not. This is nothing remarkable. Everyone experiences unpredictable shocks, large and small, throughout their lives. Some of the biggest changes are sometimes the least predictable – the unexpected death of a loved one, the unanticipated loss of a job, the unwanted pregnancy, the discovery of a personal betrayal – are among the biggest life stresses that anyone will experience. And there is nothing unique about any of these things. We’ve all been there. And yet the personal experience of such a stress is unique, at least to the one experiencing it. It doesn’t lessen the emotional turmoil to reflect on the fact that many others have gone through the same sort of thing, or even worse things, and survived them.
Recently, the trauma center where I have worked for 23 years informed me that my services on the inpatient trauma team were no longer required. My contract to round on the trauma inpatients and provide ICU and ward care was canceled with a letter informing me that the hospital was invoking the 30 day notice off non-renewal built into the contract. Privately, the trauma director was quick to point out that this had nothing to do with my performance, but was a business decision. The hospital system that owns the trauma center is moving to an all-employee physician model and all of the independent contractors like me are being let go. I will still be doing three or four 24-hr trauma shifts in the ER each month ( that’s a different contract) but will no longer be involved in the inpatient care of the patients I admit to the trauma service.
I’ve tried to be objective about this and see it in a businesslike fashion, but it is still a personal blow. It’s like a veteran starting infielder being suddenly relegated to the role of pinch-hitter. I realize now that I have defined myself professionally for so long as a trauma surgeon that I am not sure what my identity will be going forward. My reaction isn’t unique. Millions of workers have had to deal with the loss of a job, often the loss of an entire career, because some manager decides they don’t fit the new business model being rolled out. In that, I am no different than many other middle level executives that have had to find new directions at a time in their lives when they expected to be coasting.
And, although I am not so naïve as to expect loyalty from an institution (that’s a rare enough quality to find in an individual), I realize that I expected something more than a form letter telling me of my demotion to second string. To be fair, the trauma director did make a very welcome personal effort to explain the move and reassure me that he still held me in high regard, but he doesn’t make the decisions about how the contracts are handled.
I still have my separate private surgical practice and can still be involved in the emergency care of trauma patients. The financial consequences of losing the contract will be significant but not crippling (I hope), and there are opportunities to expand my surgical practice now that a significant chunk of time is no longer committed to inpatient care. I hope to be able to take up the slack, but have no guarantee that increased availability will mean increased work. I won’t hurt for basic income even if it doesn’t.
Some other things will need to scale back, mainly commitments to free care. I will continue to set aside about a fifth of my volume as unpaid care and remain committed to the charities I already support, but medical mission work will not be practical for the time being. A planned West Africa trip was already canceled by the sponsoring organization due to the Ebola epidemic, but I’ve had to turn down a request from Canvasback Charities to accompany a surgical team to Majuro in March because I can’t afford four weeks off right now. And I’m debating whether to start looking for exit strategies a few years earlier than I had anticipated. I had always anticipated slowing down as I neared 65, but had figured it would be on my own schedule and not someone else’s.
Of course, I can always find another trauma center to take me on – they seem to be sprouting like weeds in the Phoenix metro area these days. Actually, that is pretty unlikely. Most of those centers are also looking for employees, not troublesome independent surgeons. And many are too far from my home to be practical in terms of response time (less than 30 minutes for back-up call). I could relocate, but don’t really want to start over again this late in my career. There are many options and I am ruling some out just because I don’t like them, not because they aren’t workable.
For now, I am doing nothing. I tell myself it’s because I’m waiting to see how the practice works out without the regular trauma work, that I’m ‘keeping my options open’. But I suspect there’s a big element of inertia and fear behind it. It’s not a feeling I am accustomed to. As they say, ‘A surgeon doesn’t have to be right, but he does have to be certain’. Right now, certainty isn’t in my repertoire.

Risky Business

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Risky Business

I wasn’t always as conservative and risk averse as I am now. I blame my work. Anyone who can see the carnage caused by stupidity and risky behavior that I deal with on any trauma shift and still engage in high risk activities is either stupid or isn’t paying attention. But really, the process started before I became a trauma surgeon.
As a young man, I did a lot of risky things, beyond the usual drinking and driving and tempting fate that all 18 year olds do. I took canoes and kayaks down rapids that gave experts pause. I did free climbing in the Red River Gorge of Kentucky and in the Canadian Rockies. I engaged in the illegal sport of building climbing while an undergrad at the University of Illinois. Champagne-Urbana is a pretty flat place and climbing walls were a rarity. Our climbing wall was the bell tower of Altgeld Hall. Had we been caught, we’d have been arrested and likely expelled, but we weren’t.
By the time I started medical School, my risky behavior tapered off. I was too busy with studies and clinicals to do much. As a resident, sailing had become my favored passion and I spent my free time at the helm of a sailboat whenever I could.
So I wasn’t concerned when, as a new surgeon, I was assigned to a Marine Corps Surgical team. Part of our training was in rappelling. How they thought a bunch of surgeons and corpsmen needed that skill is beyond me, but I didn’t question it at the time. This was old hat to me.
We started on the 30-foot rappelling tower. I had done this so often, I could rig my harness in my sleep. I helped several other guys rig up and we followed the instructor’s lead and rappelled to the ground. I did it on a single jump, braking to a stop a few feet above the ground and stepping down as if stepping out of my car. Showing off, I know, but it felt good to be climbing again.
After the tower, they took us to Mangilao Cliff, a shear 150-foot basalt outcropping on the main Naval base on Guam. There was a road to the top, and one at the base, so it was perfect for training. I rigged up and confidently stepped off. After my second drop, I realized I was hyperventilating and my heart was racing. Halfway down, I was panting and my palms were sweaty. I was afraid. This had never happened to me on a rope before. I made it to the bottom and got control of myself. I felt weak and worthless, but hid it from the other team members, some of whom got stuck or wouldn’t even make the first drop.
I went home at the end of the day and told Michele of my fear and my feeling of weakness.
“Of course you were afraid, you idiot,” she said. “Unlike before, now you have something to live for.”
I realized she was right. My oldest son had been born just three months before. He would need me unlike anyone else ever had before.
Years later, as an assistant scoutmaster, I was able to teach my son and the boys in our troop some of my paddling and climbing skills. I still got a shiver of fear as I watched my 13-year-old firstborn make his first rappelling descent of Coon Bluff on the lower Salt River. His grin of accomplishment as he touched the ground was worth it.

The Way for Surgeons, with a bow to Miyamoto Musashi

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THE WAY FOR SURGEONS

DO NOT THINK DISHONESTLY

THE WAY IS IN TRAINING

BECOME ACQUAINTED WITH EVERY ART

KNOW THE WAYS OF ALL PROFESSIONS

DISTINGUISH BETWEEN GAIN AND LOSS IN WORLDLY MATTERS

DEVELOP INTUITIVE JUDGMENTAND UNDERSTANDING FOR ALL THINGS

PERCEIVE THOSE THINGS WHICH CANNOT BE SEEN

PAY ATTENTION, EVEN TO TRIFLES

DO NOTHING THAT IS OF NO USE