A Doctor’s Penetrating Fear

Question: Does emotion ever come into play in the operating room?

Atul Gawande: You know, I think they -- I think emotions were from the very beginning. Your biggest emotion is fear. I remember that first time I got handed a knife, and you know, the surgeon opposite me had drawn the dotted line where I was to use the knife. And I pressed down on the skin, and half of my thinking was, oh my God, what if I cut too deep? And instead I found that skin is springy, it's tough, it's rubbery, and drawing the knife through that very first time, I didn't go nearly deep enough. I had to cut a couple of times in order just to get through. So fear and learning not to be paralyzed was fundamental to what it was to get good at surgery, grappling with it in ways that you weren't ignoring the fear. I think the worst surgeons are the ones who have no fear, and therefore can become almost cavalier and not learn from inevitable errors. But I've also seen folks who can become paralyzed by the fear and the choices and the proliferating complexities as a case goes on. And all of that fascinated me, and I was trying to get a handle on how do you temper yourself in ways that you can be effective individually? And then later on, as I grasped that there are whole teams involved, it got more and more complicated.

Question: What was your greatest difficulty in becoming a surgeon?

Atul Gawande: You know, I don't know that they were issues that were unique to me personally, but my experience going through surgical training was tempered by an unusual set of experiences. My fifth day of surgical training, the fifth day of July in that first internship year, my son was born. And then 10 days later at home, he went into congestive heart failure. And I was in the operating room, doing -- assisting in my first gall bladder operation, when I got called to -- that my son was in the emergency room at Children's Hospital and I needed to go over. When that happened, I left the operation, walked over still in my scrubs, and walking over the bridge between the Brigham and Women's Hospital, which is an adult hospital, and the Children's Hospital, which was right next door, I felt myself transforming from doctor to father, and arrived in time to see my son failing to breathe, everybody scrambling, and the nurse saying they weren't sure he'd make it. He did pull through. They got him intubated, they got him into an intensive care unit, they slowly figured out what was going on. It was a -- part of the arch of his aorta was missing and needed to be reconstructed. He was in the hospital for two weeks. He left still quite ill. It was two months before he really was on the mend, and during that whole time I got two days off, and then needed to be seeing my patients, and then walking back and forth between the hospital where I was a surgical trainee and the hospital where I was a dad.

And that sense of being in the middle of my training, trying to talk to people about, well, I'll be assisting you in your case today, and then walking over to the other side, seeing one of my own fellow interns come to me and say, I'll be assisting the surgeon in your son's case today -- it was revealing; it gave me a kind of double sense of what it meant to be on both sides of the scalpel. And I think that has pervaded the way in which I've tried to think. What does it mean for us to be good at what we do in medicine? It's also been personal because, growing up in a small town where my parents were local doctors, where everybody knew them, where people would call on the phone and have medical emergencies or minor problems, and trying to sort through it all as a kid picking up the phone, my parents saying, ah, tell them to go to the emergency room -- that sense of seeing it from afar and from up close, the micro and the macro, has been a way that fed into my training and my writing.

Question: What did this experience with your son teach you about medicine?

Atul Gawande: Well, I think that there -- one of the things that surprised me was that there was an art to being not just a doctor that I had to learn, but an art to being a patient. We are in a realm where there is constant awareness of the ways in which we're no longer assumed to be gods. We are fallible in medicine, and I understood that extremely well. My son had his fair share of complications, bleeding that forced them to rush him back into the operating room within an hour after his operation. And yet his heart problem was one that they couldn't repair 15 years before. They used a new procedure on him that still hadn't -- they didn't have all the data on. And as a patient, as a family member of a patient being on the other side, I was trying to grapple with when do you ask for second opinions? When do you push the team? And when do you just back off and say, okay, I understand they're fallible human beings, but the best thing for me now is to trust in them as a team?

And so what I came away with was two things: a sense that our relationship with medicine has changed enormously since the days when we could just believe that everybody was infallible in medicine; and second, that none of this was in our textbooks, none of this was in any of what I was being taught about, that there was a kind of second education going on in the course of my training. And I wanted to identify it and describe it and show what was good about it and show what was not so good, what needed to change.

Imagine the shock of being told for the first time to grab a knife and cut along a dotted line on a patient’s body. Does the fear from this initial incision ever go away? A surgeon and Harvard professor explains why patients should hope not.

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