What You Know and What You Don’t

I am studying for my recertification exam in surgery, which comes around every ten years. The more I review everything (and I mean everything), the less I know. My knowledge base falls off pretty quickly once I get out of my window of expertise. But general surgery is called general for a reason. It’s a broad waterfront. I liked surgery because the doing of it is pretty knowable: create exposure for the target tissue to be worked on (least sexy, most important of the mechanical skills in surgery–ask any surgeon), cut, hold tissue (without damaging it) and sew. That’s it! The tricky part about surgery is not the doing of it, it is the judgment, the responding to problems and complications and the knowing when to operate and when not to operate.

This latter issue of when to operate is more important than knowing what the diagnosis is. Example: If you get shot in the abdomen I don’t know the diagnosis (hole in stomach? spleen? bowel?) but I know that you need an operation. That is an easy one, but the decisions get more complex as the acuity (the imminent danger) is further away. That process of thinking, consulting with colleagues and medical literature is also what makes surgery fun, believe it or not. I know, it can sound dry as toast, but there’s no accounting for taste. Some people want to be rock stars, some want to operate on infected gallbladders.

Also I am wondering not only about what I don’t know, but what surgeons and “Medicine” in general does not know. We (“we” as in “we in medicine, Western, Eastern or otherwise–the same principle applies) think we know something and then we study it and it is way more complex than we ever imagined. For instance, steroids help decrease inflammation so “we” assumed that steroids for spinal cord injuries would decrease inflammation and “help”. Turns out that it depends on how far out from the injury the steroids are given and for how long. Very early after the injury, less than three hours and they help a little, but only if given for 24 hours. After eight hours, they hurt. Between three and eight, they might help but they must administered for 48 hours. What? When I read complex solutions like this to serious problems I think that it is not the problem’s fault, but rather the questions “we” are asking to solve the problem. We don’t even know where to begin much of the time, and I think we are missing an important piece of the puzzle. Who knows, though, maybe it is that hard.

I know this waffling may not inspire confidence, especially when you are reading a blog post from a surgeon who should be studying. In the end though, it is the art of medicine (in all its forms) that aids in healing. The science is the tool in service of that art. Applying the science without the art is like painting technically perfect strokes without a vision for the picture. Applying the art with the science creates a healing environment that is bigger than the sum of its parts. So, take heart, I am working on the art part of things for a few minutes. I am understanding me here, which I think I better do if I hope to understand you well enough to know when to make that first incision.

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5 Responses to What You Know and What You Don’t

  1. Barbara says:

    Thanks for sharing your process in this post. I actually found it did inspire confidence.
    The photo does not look like a photo, but an ink drawing……..very cool

  2. Bob D says:

    Steven,
    Sometimes the why is more important than the what. Following your blog has helped me understand you as a friend, and physicians in general as people. Thanks!

  3. Kathleen says:

    The human body seems to be endlessly fascinating. I always enjoy reading the medical stuff you post. I read four blogs regularly and two of them are written by doctors, although the other is not a surgeon, but he is a friend of mine that works with children in developing countries (and he seems to have a lot of patients that need surgery, although mostly cardiac, and can’t get it in Haiti).
    I love the photo and I agree with Barbara’s description of it!

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