Top Doctors Discuss The Art And Craft Of Surgery

Read Dr. Atul Gawande's Piece For The New England Journal Of Medicine, "Two Hundred Years Of Surgery"

Things that most people take for granted in surgery — the use of anesthesia, for example, or the way surgical tools are cleaned — were once cutting-edge discoveries in the profession. Dr. Atul Gawande and Dr. Sherwin Nuland discuss the changes they've seen over their long careers as surgeons.

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NEAL CONAN, HOST:

This is TALK OF THE NATION. I'm Neal Conan in Washington. In an article for the 200th anniversary issue of the New England Journal of Medicine, surgeon Atul Gawande defined his profession by its authority to cure by means of bodily invasion. He goes on to describe the advances that reduced the brutality and risks of that invasion: anesthesia, antisepsis, better instruments and training. And the piece prompted us to realize how much we don't know about the profession we all take for granted.

At the present rate, Dr. Gawande writes, the average American can expect to undergo seven operations during his or her lifetime. We've invited Atul Gawande and his colleague, the retired surgeon Sherwin Nuland. Both teach and write about their profession as well. And we want to hear from surgeons in the audience. Call and tell us what we don't know about your profession, 800-989-8255. Email us, talk@npr.org. You can also join the conversation at our website. That's at npr.org. Click on TALK OF THE NATION.

Later in the program: Musicians, what's it like to fly with your instrument? You can email us your stories now. That address again: talk@npr.org. But first the practice of surgery. Atul Gawande is a surgeon at the Brigham and Women's Hospital and professor at Harvard Medical School. His piece, "200 Year of Surgery," ran in the New England Journal of Medicine in May, and he joins us now from studios at the hospital. Nice to have you back on the program.

DR. ATUL GAWANDE: It's great to be on again, Neal, thanks.

CONAN: And as someone who is contemplating cataract surgery, I have to say I swallowed very hard at the description of the procedure from the New England Journal of Medicine and Surgery and the Collateral Branches of Sciences in 1812, which you describe on your first page.

GAWANDE: Well, and you can be grateful that that's not the procedure you're having now. The description was of John Collins Warren(ph), the son of one of the founders of Harvard Medical School, describing a technique he was using to remove cataracts, which of course starts with a person getting a knife put into their eye while being completely unanesthetized.

A cataract is a clouding of the lens of the eye, and the ancient technique of couching was to take a needle and push the lens towards the back of the eye, out of the way of the light, and he'd already had that done several times, unsuccessfully, blind in both eyes, and he was able to see at the end of it.

But I was startled as much by the mettle required of the patient and the surgeon as much as the technique that was involved.

CONAN: And it is astonishing to realize we are now at the stage where I'm looking forward to it. It's going to help me, and you know, it's something that until fairly recently you put off as a last resort.

GAWANDE: Yeah, it's probably a good - it is - let me put it this way: Surgery has become a necessary component of living a long and healthy life for most people - ranging from having a terrible broken bone to, you know, early in life to later on needing cataracts removed, and a simple cataract operation is routine for many people in life. It's 15 to 20 minutes, it's been so perfected and routinized that it can become part of your life.

And that has been an incredible journey over two centuries just to get there.

CONAN: Joining us now is Dr. Sherwin Nuland, a retired surgeon, clinical professor of surgery at Yale School of Medicine. He's the author of "The Mysteries Within: A Surgeon Reflects On Medical Myths," among many other books, and he joins us now from the studios at Yale, and Sherwin Nuland, nice to have you back on the program.

DR. SHERWIN NULAND: Well, what a pleasure. It's a pleasure to be talking to Atul Gawande again. It's been a while, Atul.

GAWANDE: It is a great pleasure.

CONAN: That normalization of surgery, that has to be one of the big changes since you started in the job.

NULAND: Well, absolutely. It was such a great undertaking, as a friend of mine who was on the faculty at Stanford wrote to me just a couple of weeks ago. Well, you know, they knew we were doing something to them after an operation. Now they're barely aware of it.

(LAUGHTER)

CONAN: Well, you'll get back - you'll get back at us. That idea that, yes, you had to not only have that surgery but then spend days, weeks in recovery in the hospital.

NULAND: And have a lot of pain and remember for the rest of your life what the entire procedure was. Of course I'm actually looking forward to the day when there's almost no surgery at all, except perhaps for congenital disease, trauma, reconstruction, things of that nature, certainly not for cancer, certainly not for a lot of the intestinal diseases we treat now or the stomach diseases.

CONAN: And Dr. Gawande, in your piece you look forward to the future - again, prognostication you say is difficult, but nevertheless you look forward to the day where - well, minimal invasion, what you're just talking about, what you guys are talking about, you say is as big an advance as anesthesia or antisepsis.

GAWANDE: It has been. The idea that something as potentially traumatic - removing your gall bladder, removing your appendix, being able to remove a breast cancer - could be turned into procedures with small, tiny scars, not always the case, but can be turned into that, and then go home the same day, is a startling advancement. And I hadn't realized it until, you know, we've seen the numbers where the death rates in surgery have really dropped precipitously during the last decade or so.

There would be 50,000 people who - more dead today compared to a decade - well, let me put it this way. If we had the death rates from surgery of a decade ago, there'd be 50,000 more dead people today than there are now. And that's been partly because we've made anesthesia safer, infection has been reduced, techniques have gotten better.

But it's also been because the trauma of the surgery has been reduced in size. So we're using laparoscopic, sometimes robotic, sometimes almost microscopic equipment to get at problems inside of each of our bodies.

CONAN: And when I do have the cataract surgery, instead of those - the scalpel, you talked about the knife, it will be stabbing beams of fire in my eyes.

(LAUGHTER)

GAWANDE: That would have been what it was. You know, I came this morning from taking my son for his annual check-up. He had a cardiac condition that - he is 17 years old now. Twenty years ago there would have - well, he was born 17 years ago with a heart defect that just a decade before him, it wasn't clear it could have been repaired at all.

At the time he had open-heart surgery to repair it as an 11-day-old, three years ago he needed it to be re-repaired. And that initial operation was a three-week recovery in the hospital, ICU, everything else. The second time around, when we went in to fix the repair, it was a catheter procedure. He could have it done on a Friday and be well enough that by Saturday he went home and Sunday he twisted his ankle playing sports. That is just how far and fast it is moving.

CONAN: Dr. Nuland, do you remember the first time you picked up a scalpel with intent?

(LAUGHTER)

NULAND: I not only remember that, but I remember the very first time a group of us from the Yale New Haven Hospital went down to Stanford to visit the American Surgical Company that was in the midst of developing the instruments and the clips and the cautery that made this amazing achievement possible. It hadn't yet been done on any human beings.

We would go down there about once every three weeks or so and work on pigs. We were helping them develop the instruments, and we were learning the technology, and I retired just in time to prove to myself that I could do this kind of thing, even though I never intended to do it for the rest of my life.

CONAN: It is astonishing just how far and fast we have come, but the profession itself, how has that changed in your lifetime?

NULAND: Well, I think the most important change that has occurred is one that seems to be forgotten when we speak about the development of anesthesia, 1846, the development of antisepsis in the, let's say 1860's up to 1880's, and that is the extraordinary change in anesthesia.

Somewhere in the 1950s, a group of four or five professors of anesthesia from various university medical centers made of anesthesia a true physiological specialty. They studied the functioning of the lungs and the heart and the saturation of oxygen and carbon dioxide in the blood, wrote some extraordinary papers, and by the end of the '50s, which is about the time I finished my residency training, early '60s, medicine had been transformed.

And that was when the beginnings occurred of the period of decreased complications - for example, cardiac-pulmonary complications. And then, of course, as Dr. Gawande pointed out, the amazing change since the advent of laparoscopic and similar techniques, people don't have nearly as many wound infections which can lead to death. They don't hang around the hospital in bed, so they don't throw blood clots, and all kinds of other reasons for the great decrease in mortality.

CONAN: And Dr. Gawande, you're a little younger, I think, than Sherwin Nuland, but I suspect there have been pretty important changes just in your career as well.

GAWANDE: Yeah, I finished my training about 10 years ago and joined the faculty at my hospital. And I'd say the biggest set of changes that have started to occur is concern about cost. We never defined what being great at what we do as taking into consideration the cost of what we do and its consequences for society.

And I would say in the last four to five years we're now being asked very hard questions, I think appropriately, at a time when I call it this phase we've entered of mass production of surgery - fifty million operations or more a year in the country, in a population of 300 million people. And are we doing the right ones at the right time? Have we made sure the knowledge of what we've discovered over the last few decades is really reaching everybody who could benefit and doing it in ways that don't waste resources? And I think we're just at the beginning of that conversation and that pressure.

CONAN: It's a conversation not just about surgery but about the vast majority of medicine, don't you think?

GAWANDE: It is. Surgery is about half of the spending in hospitals, and it is often the emblematic big-ticket item when someone, for example, is nearing the end of life, and a question occurs: Well, should we try this heroic operation, or should we in an emergency room late at night with someone failing go dive in yet again?

And so it's not the only place, by any means, but it's a big source of costs and fear.

CONAN: We're talking with two well-known surgeons about their art and craft in the operating room. We want to hear from other surgeons. Call and tell us what we don't know about your profession, 800-989-8255. Or drop us an email, talk@npr.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(SOUNDBITE OF MUSIC)

CONAN: This is TALK OF THE NATION from NPR News; I'm Neal Conan. Surgeon Atul Gawande wrote a recent piece in the New England Journal of Medicine marking the advances of surgery over the past 200 years. Among the most important: anesthesia. Dr. Gawande wrote: Before anesthesia, the sounds of patients thrashing and screaming filled operating rooms. No matter how swiftly the amputation was performed, the suffering that patients experienced was terrible.

Few were able to put it into words. Among those who did was Professor George Wilson(ph). In 1843, he underwent a Syme amputation, ankle disarticulation, performed by the great surgeon James Syme himself. Four years later, when opponents of anesthetic agents attempted to dismiss them as needless luxuries, Wilson felt obliged to pen a description of his experience.

The horror of great darkness and the sense of desertion by God and man bordering close on despair which swept through my mind and overwhelmed my heart I can never forget, however gladly I would do so. During the operation, in spite of the pain it occasioned, my senses were preternaturally acute, as I have been told they generally are in patients in such circumstances.

I still recall with unwelcomed vividness - and then he went on to relate the specifics, in horrifying detail, of his surgery. Our guests are Dr. Atul Gawande, professor of surgery at Harvard Medical School and practicing surgeon at Brigham and Women's Hospital, he wrote the piece, "200 Years of Surgery." Also with us, Dr. Sherwin Nuland, clinical professor of surgery at Yale and author of "The Mysteries Within: A Surgeon Reflects On Medical Myths."

We want to hear from the surgeons in our audience. Call and tell us what we don't know about your profession, 800-989-8255. Email, talk@npr.org. You can also join the conversation on our website, npr.org. Click on TALK OF THE NATION.

And let's start with Steven(ph), Steven with us from Scottsdale.

STEVEN: Hi there, Mr. Conan, I've been a fan of the show and of Dr. Guwande for many years, and I just wanted to talk about my field. My field is retinal surgery, and that's a field that's generally only about 40 years old. I've been in practice for about 16 years, and during those 16 years, I've seen dramatic advancements in my field, that have taken my patients from all being under general anesthesia and requiring hospitalization, to now, you know, being back in real life within just a week or so, even after retinal detachment surgery.

So it's quite an amazing and great feeling to be able to help people in a short space of time, rather than over months and consigning them to potentially, you know, terrible consequences for their retinal detachment surgery.

CONAN: And do you still find a sense of wonder about this amongst your patients?

STEVEN: I do, I do. I mean, patients come in, and they're upset, they're worried, they're scared. You know, this is something that they've heard their friends or relatives maybe go through, and they were never able to go back to their careers again. They sometimes could never drive again. And here we are with patients who are able to get back to driving, sometimes within two weeks.

And it's not the death sentence of their lifestyle that it was even, you know, 20 years ago.

CONAN: And with what instruments do you conduct this surgery?

STEVEN: We use a - it's a machine called a vitrectomy, and that machine was just only developed about 40 years ago by a professor at Bascom Palmer in Miami. And back then, you know, the instruments were much larger. Now they're the size of a 25- or 23-gauge needle. That's very, very small - instruments that don't require closing of the holes on the surface of the eye.

These people don't require stitches. So they're much more comfortable afterwards. And as a result, they actually see better a lot faster, as well.

CONAN: Hardly anything for you to do, then.

STEVEN: Well, I mean, actually, no - in fact, that's the irony of the situation is that because the instrumentation is smaller and finer, it actually is more demanding on us. We are - we have patients who they're expectations - you know, they're in their 60s, 70s, sometimes in their 40s, 30s, and yet - and they're active people.

And it forces us to be better. I think actually all of the demands on Lasik and things like that, these are, you know, refractive surgeries, have made all ophthalmologists, all eye surgeons, better at what they do because people expect to be able to go back to real life as quickly as possible.

CONAN: Well, thanks very much for the call, that's interesting.

STEVEN: OK, thank you.

CONAN: Go ahead.

GAWANDE: There's a fascinating part to what he just said, which my father described to me. He was a surgeon, a urologist, and he said that 90 percent of what he was doing in practice, he never learned to do as a resident in training, which meant that the field is changing so fast that you're learning on the job.

And what I never expected is that a fundamental part of being a surgeon is learning how to learn, even after your training is done, and it's an uncomfortable discussion, often, with patients because we're very often needing to change and perfect and learn techniques.

I'll watch videos online to get a sense of what I might be doing, you know, in the next operation, how I might be tweaking and changing what I am doing. And he mentioned expectation because it clashes with that view of expectation, that this is all set to go. Surgery was a miracle in the 1950s and 1960s, and now it's so routine that we expect it to be perfect, and it's not by any means.

CONAN: Let me ask you, Dr. Nuland, a question about speed. I was fascinated by a bit of Dr. Gawande's article, where he said that eventually, anesthetic made surgeons realize they could take their time. How important is speed?

NULAND: Well, that's always been a question that surgeons have been fighting about, as Dr. Gawande pointed out earlier. Amputations, he mentioned Syme. When Syme did his amputation at the ankle, he could do it in about 35 or 40 seconds, and there were reasons for that.

One obviously was that there was very insufficient or no anesthesia; and the other was that the major theory of infection was that oxygen came from the air, got into the wound and oxidized the tissues and killed them, so the faster you work, the better off you are.

I have never been convinced, in the era of modern anesthesia and modern surgical techniques, that except for very few patients who have specialized needs, speed was, at all, of any consequence. We have been taught, I think Dr. Gawande and I, although I am a generation or two older than he is, were taught in what's called Halstedian technique, being very meticulous about tissues, being very, very careful to do the least bit of damage. The old Hippocratic dictum of primum non nocere, first do no harm, extends to actual surgical operation.

If we can sneak in and sneak out without the body being totally aware that we're around and destroying things, I think our morbidity, our mortality rates will be - continue to improve.

CONAN: It's interesting, Dr. Gawande, in your piece you describe British surgeon Robert Liston, who may be the only surgeon in history to have a 300 percent mortality rate in one case.

GAWANDE: Yes, that's right. He was doing an amputation, one of his classic 25-second amputations. The assistant has to hold the leg and the patient down. And he went so fast he cut through the assistant's hand, as well as the patient. The patient died of infection, the assistant died of infection, and a - someone in the gallery was said to have died of shock, fainting straight away at the sight of it all.

(LAUGHTER)

GAWANDE: It's morbidly...

CONAN: Morbidly funny.

GAWANDE: Grimly funny.

(LAUGHTER)

NULAND: That's one of those medical myths we talk about. Atul, you know it never did happen.

GAWANDE: Is that right?

NULAND: It's a great story and could easily have happened, yes.

CONAN: Oh, darn it.

NULAND: But the way I heard the story was that the assistant was emasculated, and the fellow up in the balcony died of shock.

GAWANDE: And I even had a reference in that - in the paper on it. Well, just goes to show.

(LAUGHTER)

NULAND: We ought to get together and talk about it.

(LAUGHTER)

CONAN: Let's get Jana(ph) on the line, Jana with us from San Jose.

JANA: Hi. I wanted to make a comment about a patient I saw this weekend, where we were able to diagnose an ectopic pregnancy in 48 hours, using rapid turnaround (unintelligible) transvaginal ultrasound. And it actually crossed my mind during the operation, it's amazing that we can treat this with laparoscopy. She's home the same day and back to work in five days.

And I wanted to make one other comment, and the two of you may be familiar with this saying, as well. But a colleague of mine, Dr. Della Garland(ph), told me: You can teach many physicians to operate, but the mark of a great surgeon is knowing when to operate.

GAWANDE: It's completely right, and...

JANA: (Unintelligible).

CONAN: Go ahead, Dr. Gawande.

GAWANDE: It's completely right, and what you just described is also a description of how complex it's become. There is highly technological ultrasound or imaging techniques. There's testing that can reach the genetic level. There is the procedure which can be done, and you have to get it all orchestrated in the right way.

And so we've become a field of numerous specialists who either have their act together or don't. And what can get lost in the middle of that is: Are we making the right decisions?

Are we working together with and for the patient? And that sense of - that fundamental decision. Are we doing the right thing? And do people feel that they know somebody is in charge and helping make sure the care goes the way it needs to? I think a common complaint now is there are so many pieces of care that many times people don't feel there's anybody paying attention to the big picture for them.

CONAN: Janna, thanks very much.

JANNA: Thanks for the program.

CONAN: Dr. Gawande, take us into the operating room, the modern one, the one you work in these days. Who's in there with you? Who are the members of your team?

GAWANDE: Yeah. It's upwards of half a dozen people. You have yourself and a surgical assistant that may be a resident in training or a physician's assistant. You have the anesthesia team, which may be a certified registered nurse anesthetist and a physician anesthesiologist or, again, a resident if you're in an academic place. You have the scrub nurse who is sterile gloved, gowned and in the field. And then you have a circulating nurse whose job is to be outside the field and make sure that everything comes into it that's needed.

And then you have even more people that come in and out. The biotechnologist who - the bioengineer who makes sure that the equipment is - you know, many, many pieces of equipment that have to be working properly. And when it goes down and fails, you need someone to come right in and fix it or address it promptly. You have the computer IT specialist because, now, so much of our information about the patient and also just the running of the operating room is off of software systems that are very complex.

And then you have, you know, leaders in the pod, as we call them, who make sure that the beds are available and the recovery room is ready to go. It's a whole flight crew, in many ways. And then, of course, me as a surgeon, I get to go out, talk to the family and take credit for it all, but it's a - it's an incredible number of people.

CONAN: We're talking with Dr. Atul Gawande, professor of surgery at Harvard Medical School, practicing surgeon at Brigham and Women's Hospital, author of "Two Hundred Years of Surgery." That piece ran in the New England Journal of Medicine last spring. Dr. Sherwin Nuland is clinical professor of surgery at Yale School of Medicine, author of "The Mysteries Within: A Surgeon Reflects on Medical Myths." Dr. Gawande's more recent book is "Better: A Surgeon's Notes on Performance." You're listening to TALK OF THE NATION from NPR News.

And could I ask, have there been moments in the middle of surgery, both of you, when you didn't know what to do?

GAWANDE: Dr. Nuland, do you want to take a stab at that? I can tell you that it happens to me all the time.

NULAND: Since my career is longer than yours, I must tell you have there been moments when I knew what I was doing? There were so many moments over the years - since every patient is very, very different than every other patient, every form of pathology is different than any other form of pathology - that I had no idea what the next step was going to be.

I think this is why it takes us five, six, seven, eight, sometimes, depending on the specialty, 10 years to train so that we can prepare ourselves for those many, many moments when we aren't quite sure what to do and for those very few but nevertheless present occasions when we're scared out of our minds for fear of what's going to happen in the next three or four seconds. And we must strive to keep total equanimity and calm, not only to control the situation, but that - so that no one else on our team is infected with an epidemic of fright or panic.

CONAN: Panic, Dr. Gawande?

GAWANDE: Yeah. The - that sense of not sure what to do next and not letting it escalate into panic is critical because nature doesn't serve things up the way the textbooks claim that things are supposed to go, and you find yourself in situations of doubt; unclear what you're looking at, unclear whether you're making the right next move. And what confidence, I'm slowly learning, looks like is the confidence to ask for help and to get advice, call someone on the phone, hey, can you come down and take a look at this with me? You know, I'm heading down this path, and I'm not sure it's the right one.

NULAND: I think Atul would agree that the greatest skill a surgeon can have, the epitome of his or her art, is not the technical or manual skill, but judgment. The secret of all good medicine is judgment. Hippocrates told us that 2,000 some odd years ago. And anybody who's been in the OR for more than 10 minutes recognizes that judgments are being made every single minute during the course of an operation that can obviously change the outcome - and the outcome for a patient's life - as a matter of fact.

GAWANDE: Yeah. This is the interesting part to me. Surgery, people assume, is about the technical skill. And one of my professors, as I was training, said that if you can write in cursive, you have the technical skill to do surgery. The judgment comes from the fact that what you should be doing is - at each step along the way should never be something that has a - gives 50-50 chance of failure. It shouldn't be like Shaquille O'Neal standing at the free throw line, hoping he could hit the net. It should be 99 percent every move, even better than that, faithfulness that it's going to be predictable.

And so the judgment is what's always the crucial part. Am I going to get into bleeding here if I make this move? If I do get into bleeding, what are my ways that I bail out of it without hurting myself or the patient? And being able to set it up so that it feels like in this game I'm shooting 99 percent at every step along the way is the interesting and tricky part of it; rarely the physical dexterity of it.

CONAN: Do you miss it, Dr. Nuland?

NULAND: I loved it. I used to wake up every morning virtually - and this is not really a joke - wondering how anyone could justify his life if he was not a surgeon, feeling sorry for those who couldn't be surgeons. But when it was over, it was over. I recognized that the time had come to turn my attention elsewhere. And every once in a while I have a little fantasy in which I'm back in the operating room with that wonderful camaraderie and warmth among colleagues even though we're not talking very much for fear of spreading infection through our masks.

There's a sense that I'm sure every mature baseball team must have - although we reorganize ourselves for every operation. I think that - how can I call it - locker room mentality that involves not just men but women also.

CONAN: Dr. Nuland and Dr. Gawande, thank you both very much for your time and for telling us a little bit about your jobs.

GAWANDE: My pleasure.

NULAND: Thank you.

CONAN: Dr. Atul Gawande joined us from a studio at Brigham And Women's Hospital in Boston. Dr. Sherwin Nuland joined us from Yale University in New Haven. Stay with us. It's the TALK OF THE NATION from NPR News.

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