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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