A Novice Surgeon Journeys Into the Unknown

Not everyone appreciates the attractions of surgery. When you are a medical student in the operating room for the first time, and you see the surgeon press the scalpel to someone’s body and open it like fruit, you either shudder in horror or gape in awe. I gaped. It was not just the blood and guts that enthralled me. It was the idea that a mere person would have the confidence to wield that scalpel in the first place.

There is a saying about surgeons, meant as a reproof: “Sometimes wrong; never in doubt.” But this seemed to me their strength. Every day, surgeons are faced with uncertainties. Information is inadequate; the science is ambiguous; one’s knowledge and abilities are never perfect. Even with the simplest operation, it cannot be taken for granted that a patient will come through better off--or even alive. Standing at the table my first time, I wondered how the surgeon knew that he would do this patient good, that all the steps would go as planned, that bleeding would be controlled and infection would not take hold and organs would not be injured. He didn’t, of course. But still he cut.

Later, while still a student, I was allowed to make an incision myself. The surgeon drew a six-inch dotted line with a marking pen across a sleeping patient’s abdomen and then, to my surprise, had the nurse hand me the knife. It was, I remember, still warm from the sterilizing autoclave. The surgeon had me stretch the skin taut with the thumb and forefinger of my free hand. He told me to make one smooth slice down to the fat. I put the belly of the blade to the skin and cut. The experience was odd and addictive, mixing exhilaration from the calculated violence of the act, anxiety about getting it right, and a righteous faith that it was somehow good for the person. There was also the slightly nauseating feeling of finding that it took more force that I’d realized. (Skin is thick and springy, and on my first pass I did not go nearly deep enough; I had to cut twice to get through.) The moment made me want to be a surgeon--not to be an amateur handed the knife for a brief moment, but someone with the confidence to proceed as if it were routine.

A resident, however, begins with none of this air of mastery--only a still overpowering instinct against doing anything like pressing a knife against flesh or jabbing a needle into someone’s chest. On my first day as a surgical resident, I was assigned to the emergency room. Among my first patients was a skinny, dark-haired woman in her late twenties who hobbled in, teeth gritted, with a two-and-a-half-foot-long wooden chair leg somehow nailed into the bottom of her foot. She explained that the leg had collapsed out from under a kitchen chair she had tried to sit upon and, leaping up to keep from falling, she inadvertently stomped her bare foot onto the three-inch screw sticking out of it. I tried very hard to look like someone who had not just got his medical diploma the week before. Instead, I would be nonchalant, world-weary, the kind of guy who had seen this sort of thing a hundred times before. I inspected her foot, and could see that the screw was embedded in the bone at the base of her big toe. There was no bleeding, and, so far as I could feel, no fracture.

“Wow, that must hurt,” I blurted out, idiotically.

The obvious thing to do was give her a tetanus shot and pull out the screw. I ordered the tetanus shot, but I began to have doubts about pulling out the screw. Suppose she bled? Or suppose I fractured her foot? Or something worse? I excused myself and tracked down Dr. W., the senior surgeon on duty. I found him tending to a car-crash victim. The patient was a mess. People were shouting. Blood was all over the floor. It was not a good time to ask questions.

I ordered an X-ray. I figured it would buy time and let me check my amateur impression that she didn’t have a fracture. Sure enough, getting one took about an hour, and it showed no fracture--just a common screw embedded, the radiologist said, “in the head of the first metatarsal.” I showed the patient the X-ray. “You see, the screw’s embedded in the head of the first metatarsal,” I said. And the plan, she wanted to know? Ah, yes, the plan.

I went to find Dr. W. He was still tied up with the crash victim, but I was able to interrupt to show him the X-ray. He chuckled at the sight of it and asked me what I wanted to do. “Pull the screw out?” I ventured. “Yes,” he said, by which he meant “Duh.” He made sure I’d given a tetanus shot and then shooed me away.

Back in the room, I told her that I would pull the screw out, prepared for her to say something like “You?” Instead she said, “O.K., doctor,” and it was time for me to get down to business. At first I had her sitting on the exam table, dangling her leg off the side. But that didn’t look as if it would work. Eventually, I had her lie with her foot jutting off end of the table, the board poking out into the air. With every move, her pain increased. I injected a local anesthetic where the screw went in and that helped a little. Now I grabbed her foot in one hand, the board in the other, and then for a moment I froze. Could I really do this? Should I really do this? Who was I to presume?

Finally, I just made myself do it. I gave her a one-two-three and pulled, too gingerly at first and then, forcing myself, hard. She groaned. The screw wasn’t budging. I twisted, and abruptly it came free. There was no bleeding. I washed out the wound, as my textbooks said to for puncture wounds. She found she could walk, though the foot was sore. I warned her of the risks of infection and the signs to look for. Her gratitude was immense and flattering, like the lion’s for the mouse--and that night I went home elated.

In surgery, as in anything else, skill and confidence are learned through experience--haltingly and humiliatingly. Like the tennis player and the oboist and the guy who fixes hard drives, we need practice to get good at what we do. There is one difference in surgery, though: It is people we practice upon.

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This article is excerpted from the book “Complications: A Surgeon’s Notes on an Imperfect Science,” by Atul Gawande. Reprinted by permission of Metropolitan Books, Henry Holt & Co., 2002.