Writer, M.D.

by Leah Kaminsky

  I went to his room. He looked scared and said he didn’t think he’d last more than a minute on his back. But he said he understood the situation and was willing to make his best effort. He and I decided that he’d be left sitting propped up in bed until the last possible minute. We’d see how far we got after that.

  I went through my preparations: checking his blood counts from the lab, putting out the kit, placing the towel roll, and so on. I swabbed and draped his chest while he was still sitting up. S., the chief resident, was watching me this time, and when everything was ready I had her tip him back, an oxygen mask on his face. His flesh rolled up his chest like a wave. I couldn’t find his clavicle with my fingertips to line up the right point of entry. And already he was looking short of breath, his face red. I gave S. a “Do you want to take over?” look. Keep going, she signaled. I made a rough guess about where the right spot was, numbed it with lidocaine, and pushed the big needle in. For a second, I thought it wouldn’t be long enough to reach through, but then I felt the tip slip underneath his clavicle. I pushed a little deeper and drew back on the syringe. Unbelievably, it filled with blood. I was in. I concentrated on anchoring the needle firmly in place, not moving it a millimeter as I pulled the syringe off and threaded the guide wire in. The wire fed in smoothly. The patient was struggling hard for air now. We sat him up and let him catch his breath. And then, laying him down one more time, I got the entry dilated and slid the central line in. “Nice job” was all S. said, and then she left.

  I still have no idea what I did differently that day. But from then on my lines went in. That’s the funny thing about practice. For days and days, you make out only the fragments of what to do. And then one day you’ve got the thing whole. Conscious learning becomes unconscious knowledge, and you cannot say precisely how.

  I have now put in more than a hundred central lines. I am by no means infallible. Certainly, I have had my fair share of complications. I punctured a patient’s lung, for example—the right lung of a chief of surgery from another hospital, no less—and, given the odds, I’m sure such things will happen again. I still have the occasional case that should go easily but doesn’t, no matter what I do. (We have a term for this. “How’d it go?” a colleague asks. “It was a total flog,” I reply. I don’t have to say anything more.)

  But other times everything unfolds effortlessly. You take the needle. You stick the chest. You feel the needle travel—a distinct glide through the fat, a slight catch in the dense muscle, then the subtle pop through the vein wall—and you’re in. At such moments, it is more than easy; it is beautiful.

  Surgical training is the recapitulation of this process—floundering followed by fragments followed by knowledge and, occasionally, a moment of elegance—over and over again, for ever harder tasks with ever greater risks. At first, you work on the basics: how to glove and gown, how to drape patients, how to hold the knife, how to tie a square knot in a length of silk suture (not to mention how to dictate, work the computers, order drugs). But then the tasks become more daunting: how to cut through skin, handle the electrocautery, open the breast, tie off a bleeder, excise a tumor, close up a wound. At the end of six months, I had done lines, lumpectomies, appendectomies, skin grafts, hernia repairs, and mastectomies. At the end of a year, I was doing limb amputations, hemorrhoidectomies, and laparoscopic gallbladder operations. At the end of two years, I was beginning to do tracheotomies, small-bowel operations, and leg-artery bypasses.

  I am in my seventh year of training, of which three years have been spent doing research. Only now has a simple slice through skin begun to seem like the mere start of a case. These days, I’m trying to learn how to fix an abdominal aortic aneurysm, remove a pancreatic cancer, open blocked carotid arteries. I am, I have found, neither gifted nor maladroit. With practice and more practice, I get the hang of it.

  Doctors find it hard to talk about this with patients. The moral burden of practicing on people is always with us, but for the most part it is unspoken. Before each operation, I go over to the holding area in my scrubs and introduce myself to the patient. I do it the same way every time. “Hello, I’m Dr. Gawande. I’m one of the surgical residents, and I’ll be assisting your surgeon.” That is pretty much all I say on the subject. I extend my hand and smile. I ask the patient if everything is going OK so far. We chat. I answer questions. Very occasionally, patients are taken aback. “No resident is doing my surgery,” they say. I try to be reassuring. “Not to worry—I just assist,” I say. “The attending surgeon is always in charge.”

  None of this is exactly a lie. The attending is in charge, and a resident knows better than to forget that. Consider the operation I did recently to remove a seventy-five-year-old woman’s colon cancer. The attending stood across from me from the start. And it was he, not I, who decided where to cut, how to position the opened abdomen, how to isolate the cancer, and how much colon to take.

  Yet I’m the one who held the knife. I’m the one who stood on the operator’s side of the table, and it was raised to my six-foot-plus height. I was there to help, yes, but I was there to practice, too. This was clear when it came time to reconnect the colon. There are two ways of putting the ends together—handsewing and stapling. Stapling is swifter and easier, but the attending suggested I handsew the ends—not because it was better for the patient but because I had had much less experience doing it. When it’s performed correctly, the results are similar, but he needed to watch me like a hawk. My stitching was slow and imprecise. At one point, he caught me putting the stitches too far apart and made me go back and put extras in between so the connection would not leak. At another point, he found I wasn’t taking deep enough bites of tissue with the needle to ensure a strong closure. “Turn your wrist more,” he told me. “Like this?” I asked. “Uh, sort of,” he said.

  In medicine, there has long been a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think that patients actually benefit from teaching. Studies commonly find that teaching hospitals have better outcomes than non-teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seems to help. But there is still no avoiding those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of colon. No matter how many protections are in place, on average these cases go less well with the novice than with someone experienced.

  Doctors have no illusions about this. When an attending physician brings a sick family member in for surgery, people at the hospital think twice about letting trainees participate. Even when the attending insists that they participate as usual, the residents scrubbing in know that it will be far from a teaching case. And if a central line must be put in, a first-timer is certainly not going to do it. Conversely, the ward services and clinics where residents have the most responsibility are populated by the poor, the uninsured, the drunk, and the demented. Residents have few opportunities nowadays to operate independently, without the attending docs scrubbed in, but when we do—as we must before graduating and going out to operate on our own—it is generally with these, the humblest of patients.

  And this is the uncomfortable truth about teaching. By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden, behind drapes and anesthesia and the elisions of language. And the dilemma doesn’t apply just to residents, physicians in training. The process of learning goes on longer than most people know.

  I grew up in the small Appalachian town of Athens, Ohio, where my parents are both doctors. My mother is a pediatrician and my father is a urologist. Long ago, my mother c
hose to practice part time, which she could afford to do because my father’s practice became so busy and successful. He has now been at it for more than twenty-five years, and his office is cluttered with the evidence of this. There is an overflowing wall of medical files, gifts from patients displayed everywhere (books, paintings, ceramics with biblical sayings, hand-painted paperweights, blown glass, carved boxes, a figurine of a boy who, when you pull down his pants, pees on you), and, in an acrylic case behind his oak desk, a few dozen of the thousands of kidney stones he has removed.

  Only now, as I get glimpses of the end of my training, have I begun to think hard about my father’s success. For most of my residency, I thought of surgery as a more or less fixed body of knowledge and skill which is acquired in training and perfected in practice. There was, I thought, a smooth, upward-sloping arc of proficiency at some rarefied set of tasks (for me, taking out gallbladders, colon cancers, bullets, and appendixes; for him, taking out kidney stones, testicular cancers, and swollen prostates). The arc would peak at, say, ten or fifteen years, plateau for a long time, and perhaps tail off a little in the final five years before retirement. The reality, however, turns out to be far messier. You do get good at certain things, my father tells me, but no sooner do you master something than you find that what you know is outmoded. New technologies and operations emerge to supplant the old, and the learning curve starts all over again. “Three-quarters of what I do today I never learned in residency,” he says. On his own, fifty miles from his nearest colleague—let alone a doctor who could tell him anything like “You need to turn your wrist more”—he has had to learn to put in penile prostheses, to perform microsurgery, to reverse vasectomies, to do nerve-sparing prostatectomies, to implant artificial urinary sphincters. He’s had to learn to use shock-wave lithotripters, electrohydraulic lithotripters, and laser lithotripters (all instruments for breaking up kidney stones); to deploy Double J ureteral stents and Silicone Figure Four Coil stents and Retro-Inject Multi-Length stents (don’t even ask); and to maneuver fiber-optic ureteroscopes. All these technologies and techniques were introduced after he finished training. Some of the procedures built on skills he already had. Many did not.

  This is the experience that all surgeons have. The pace of medical innovation has been unceasing, and surgeons have no choice but to give the new thing a try. To fail to adopt new techniques would mean denying patients meaningful medical advances. Yet the perils of the learning curve are inescapable—no less in practice than in residency.

  For the established surgeon, inevitably, the opportunities for learning are far less structured than for a resident. When an important new device or procedure comes along, as happens every year, surgeons start by taking a course about it—typically a day or two of lectures by some surgical grandees with a few film clips and step-by-step handouts. You take home a video to watch. Perhaps you pay a visit to observe a colleague perform the operation—my father often goes up to the Cleveland Clinic for this. But there’s not much by way of hands-on training. Unlike a resident, a visitor cannot scrub in on cases, and opportunities to practice on animals or cadavers are few and far between. (Britain, being Britain, actually bans surgeons from practicing on animals.) When the pulse-dye laser came out, the manufacturer set up a lab in Columbus where urologists from the area could gain experience. But when my father went there the main experience provided was destroying kidney stones in test tubes filled with a urinelike liquid and trying to penetrate the shell of an egg without hitting the membrane underneath. My surgery department recently bought a robotic surgery device—a staggeringly sophisticated nine-hundred-and-eighty-thousand-dollar robot, with three arms, two wrists, and a camera, all millimeters in diameter, which, controlled from a console, allows a surgeon to do almost any operation with no hand tremor and with only tiny incisions. A team of two surgeons and two nurses flew out to the manufacturer’s headquarters, in Mountain View, California, for a full day of training on the machine. And they did get to practice on a pig and on a human cadaver. (The company apparently buys the cadavers from the city of San Francisco.) But even this was hardly thorough training. They learned enough to grasp the principles of using the robot, to start getting a feel for using it, and to understand how to plan an operation. That was about it. Sooner or later, you just have to go home and give the thing a try on someone.

  Patients do eventually benefit—often enormously—but the first few patients may not, and may even be harmed. Consider the experience reported by the pediatric cardiac-surgery unit of the renowned Great Ormond Street Hospital, in London, as detailed in the British Medical Journal last April. The doctors described their results from 325 consecutive operations between 1978 and 1998 on babies with a severe heart defect known as transposition of the great arteries. Such children are born with their heart’s outflow vessels transposed: the aorta emerges from the right side of the heart instead of the left and the artery to the lungs emerges from the left instead of the right. As a result, blood coming in is pumped right back out to the body instead of first to the lungs, where it can be oxygenated. The babies died blue, fatigued, never knowing what it was to get enough breath. For years, it wasn’t technically feasible to switch the vessels to their proper positions. Instead, surgeons did something known as the Senning procedure: they created a passage inside the heart to let blood from the lungs cross backward to the right heart. The Senning procedure allowed children to live into adulthood. The weaker right heart, however, cannot sustain the body’s entire blood flow as long as the left. Eventually, these patients’ hearts failed, and although most survived to adulthood, few lived to old age.

  By the 1980s, a series of technological advances made it possible to do a switch operation safely, and this became the favored procedure. In 1986, the Great Ormond Street surgeons made the changeover themselves, and their report shows that it was unquestionably an improvement. The annual death rate after a successful switch procedure was less than a quarter that of the Senning, resulting in a life expectancy of sixty-three years instead of forty-seven. But the price of learning to do it was appalling. In their first seventy switch operations, the doctors had a 25 percent surgical death rate, compared with just 6 percent with the Senning procedure. Eighteen babies died, more than twice the number during the entire Senning era. Only with time did they master it: in their next hundred switch operations, five babies died.

  As patients, we want both expertise and progress; we don’t want to acknowledge that these are contradictory desires. In the words of one British public report, “There should be no learning curve as far as patient safety is concerned.” But this is entirely wishful thinking.

  Recently, a group of Harvard Business School researchers who have made a specialty of studying learning curves in industry decided to examine learning curves among surgeons instead of in semiconductor manufacture or airplane construction, or any of the usual fields their colleagues examine. They followed eighteen cardiac surgeons and their teams as they took on the new technique of minimally invasive cardiac surgery. This study, I was surprised to discover, is the first of its kind. Learning is ubiquitous in medicine, and yet no one had ever compared how well different teams actually do it.

  The new heart operation—in which new technologies allow a surgeon to operate through a small incision between ribs instead of splitting the chest open down the middle—proved substantially more difficult than the conventional one. Because the incision is too small to admit the usual tubes and clamps for rerouting blood to the heart-bypass machine, surgeons had to learn a trickier method, which involved balloons and catheters placed through groin vessels. And the nurses, anesthesiologists, and perfusionists all had new roles to master. As you’d expect, everyone experienced a substantial learning curve. Whereas a fully proficient team takes three to six hours for such an operation, these teams took on average three times as long for their early cases. The researchers could not track complication rates in detail, but it would be foolish to imagine that they were not affected.r />
  What’s more, the researchers found striking disparities in the speed with which different teams learned. All teams came from highly respected institutions with experience in adopting innovations and received the same three-day training session. Yet, in the course of fifty cases, some teams managed to halve their operating time while others improved hardly at all. Practice, it turned out, did not necessarily make perfect. The crucial variable was how the surgeons and their teams practiced.

  Richard Bohmer, the only physician among the Harvard researchers, made several visits to observe one of the quickest-learning teams and one of the slowest, and he was startled by the contrast. The surgeon on the fast-learning team was actually quite inexperienced compared with the one on the slow-learning team. But he made sure to pick team members with whom he had worked well before and to keep them together through the first fifteen cases before allowing any new members. He had the team go through a dry run before the first case, then deliberately scheduled six operations in the first week, so little would be forgotten in between. He convened the team before each case to discuss it in detail and afterward to debrief. He made sure results were tracked carefully. And Bohmer noticed that the surgeon was not the stereotypical Napoleon with a knife. Unbidden, he told Bohmer, “The surgeon needs to be willing to allow himself to become a partner [with the rest of the team] so he can accept input.” At the other hospital, by contrast, the surgeon chose his operating team almost randomly and did not keep it together. In the first seven cases, the team had different members every time, which is to say that it was no team at all. And the surgeon had no prebriefings, no debriefings, no tracking of ongoing results.

  The Harvard Business School study offered some hopeful news. We can do things that have a dramatic effect on our rate of improvement—like being more deliberate about how we train, and about tracking progress, whether with students and residents or with senior surgeons and nurses. But the study’s other implications are less reassuring. No matter how accomplished, surgeons trying something new got worse before they got better, and the learning curve proved longer, and was affected by a far more complicated range of factors, than anyone had realized.