October 5, 2011


last night I was on call and around 4pm, a young guy came in with a gunshot wound to the knee.  Before I knew it, I was four hours into my first vascular surgery with the young guy on the table, both legs sliced open on the medial (inside) side).  The two surgeons I was working with were using a vein from one leg to take the place of the severed artery on the other leg, called "grafting" an artery for a bypass.  

I learned many things last night about vascular surgery and about vascular surgeons.  In their own words, these attendings said that vascular surgeons have to have the biggest egos, secondary only to cardio-thoracic surgeons (the men and women who operate on hearts and lungs).  They also are perfectionists - and need to be.  So I was surprised when near the end of the case around midnight, I was handed 0 nylon on a needle driver and forceps (big tweezer-like things that surgeons use to pick up skin to suture; suture = to put in stitches) and told to stitch up one of the groin incisions.  But I did.  The entire time, one of the attendings asked me questions about the physiology of the vascular system (for example, "what would I feel if I had accidentally attached this vein graft to the popliteal vein instead of the popliteal artery?"**)  while the other coached me on better technique for suturing.  Both of them were incredibly focused on details (appropriately for their profession) which is not typically my strength.  However, paying more attention to the details (where  your shoulders are facing, how far onto the needle driver you arrange the needle, locating each layer of fascia before creating a fasciotomy) ended up making such a huge difference.  
They say in surgery, if it feels like you're struggling to do something, you need to change something - because the best surgery is when everything is in line.  The change can be something as easy as switching the angle of your wrist or walking to the other side of the table or adjusting the light.  There are millions of things we can adjust but sometimes we think that they're just details.  But surgery has definitely taught me that the details truly matter.  Especially when learning, it's so important to learn the details before getting a gestalt.

On that same note, a few great friends sent me an article from the NewYorker by Atul Gawande, another one of my favorite doctor-writers: Atul Gawande, who writes about  how after their training is complete, surgeons (and maybe all doctors, maybe all professionals) operate without much supervision, without much continued assessment, and miss out on much improvement simply because no one is watching them and coaching them on how they can be better.  He relates this to professional athletes - who even though they are deemed the top of their fields, have other people who watch them as they cannot watch themselves, and help them improve.
Dr. Gawande also talks a lot about teaching styles and coaching teachers, another profession that is trained and then sent off into the world to manage on their own.

A great excerpt:
"Expertise, as the formula goes, requires going from unconscious incompetence to conscious incompetence to conscious competence and finally to unconscious competence. The coach provides the outside eyes and ears, and makes you aware of where you’re falling short. This is tricky. Human beings resist exposure and critique; our brains are well defended. So coaches use a variety of approaches—showing what other, respected colleagues do, for instance, or reviewing videos of the subject’s performance. The most common, however, is just conversation."
In the vascular surgery last night, it took so much of my brain power to both answer the questions and try to suture correctly that I don't think I even breathed the whole time, but afterward I felt like I had a greater understanding of what I need to learn to be a better doctor, moving more comfortably into "conscious incompetence".

**answer: no pulse because pulse is created by the resistance in arteries - and veins don't have very much resistance.  You would feel a thrill, which is a whooshing of blood past really quickly, instead.  If you listened to the graft, you would hear bruits, which is the sound of blood going by very quickly.

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