Sunday, March 30, 2008


Having explored what attributes help make a successful surgeon, I thought I'd add a word on what makes a good general surgeon. And that word is pucker.

No, not the "pucker up" kind of pucker.

Not the "best brown-noser in the world" kind of pucker (for those of you in the corporate world, these do exist in the medical arena as well).

Not even the "I'm so strange I walk around looking like this" kind of Dali-esque pucker.

I'm talking about good old fashioned tight sphincter tone. Anal retentiveness. An absolute obsession with getting the details, and getting them right. Maybe for me this comes from an abnormally young exposure to Vonnegut's Breakfast of Champions, which prominently featured a crudely drawn picture of an anus. Or maybe, I'm just anal retentive.

Freud, who must have been rather obsessed with these sorts of things himself, described those with an "anal character" were meticulous, parsimonious, and obstinate. Those qualities, as detrimental as they may be in interaction with others generally, are of particular help to a general surgeon.

Now, some nurses and physicians reading this may have just spewed their coffee on their keyboards; e-mail me, and I'll see about getting you a replacement. General surgeons? Those guys who walk into a patient's room and poke on their bellies for 12.6 seconds on average, and then announce it's time to head to the OR? "Surely, DocSurg, you're joking!"

Well, Lucy, let me do some splainin'. You see, before I waltz into the room in my oh-so-comfortable shoes, I have

  • read the chart
  • read the old chart, if it exists
  • reviewed the x-rays
  • found the lab results
  • talked to the referring physician
  • had a few martinis cups of coffee
Making a decision to go to the operating room is often fairly easy. What can be hard -- and I mean truly taxing -- is trying to decide when not to go to the operating room. I know that sounds a bit backwards, but sometimes a decision to hold off on opening somebody's abdomen means there is a potential to miss something. So, it's important to get one's ducks in a row, and that means preparing with all of the available information.

Note that I said "available" information. Sometimes, there's a whole lotta missing data, and a decision must be made about how to manage a particular patient. This is where the sphincter starts to pucker a bit. Because sometimes, after going through everything and examining the patient, what to do remains somewhat cloudy. There is an expression that surgeons use from time to time to describe this situation: "I don't know if operating now is the right thing, but it is certainly not the wrong thing."

Throw in a few compounding factors and it starts to feel like your next BM will happen on a cold night in August. Sick patient. Anticoagulation. Bad heart. COPD. Morbid obesity. You get the picture. It is important to make sure that nothing is missed or forgotten in the evaluation of a patient, or you end up feeling like the guy staring at Popeye Doyle at the end of The French Connection. Oh, merde!

But, to be honest, that is really only the start of the puckering process. In the OR, no stone can go unturned, no potential problem left unexplored. This is true for routine, as well as complex and emergent surgeries. And then, for the truly ill patient, all sorts of things need to be tended to after surgery--- and a general surgeon must rely on his or her own self, not abdicating things like looking at all of the labs or X-rays to other consultants that may be involved. This is where the "meticulous, parsimonious, and obstinate" personality comes to the forefront. Because if you make the decision to operate on a patient, in a sense you "own" them and it is your responsibility to get them out of the hospital in better shape if at all possible.

Pucker. Attention to detail. Rechecking the anastomosis before closing. Calling to check on the sick postop patient, even though you are not on call and you know full well that your partner, who is on call, is perfectly capable of dealing with anything that arises. Answering pages. It all leads up to pucker, pucker, and more pucker. And since we deal with the "end" result of too much pucker (sorry about the bad pun), as much as I love my dog, I have to say that a general surgeon's best friend comes in a jar:
Think you have enough "pucker" to be an anal retentive general surgeon? Find out with these handy dandy quizzes.