Atul Gawande

Atul Gawande

A weeklong electronic journal.
June 4 1997 3:30 AM

Atul Gawande

VIEW ALL ENTRIES

       The first hour or so before sunup is a pell-mell scramble to see all the patients. This is "pre-rounds." I check lab results, vital signs, how everyone's feeling (they hardly ever know, since I have to wake them up to ask), and then wangle them around to check their lungs, bellies, hearts, wounds (now they're awake). Then I join the other juniors to round with a senior resident. We whiz by everyone again, the senior double-checking that we didn't miss anything and giving us our orders for the day. Some patients are to go home. They need prescriptions, instructions, visiting nursing, follow-up appointments. My young splenectomy patient has a fever. I'm told to get a chest X-ray, blood and urine cultures, and to get him out of bed more. I'll keep a close eye on him today.
       I continue in a controlled frenzy to do everything by 7:30, when operating begins. I am assigned to four breast cancer operations. The senior keeps the more difficult cases for herself. I make it downstairs just in time to catch my first patient before she goes into the OR. She's having a breast biopsy.
       "I'm Dr. Gawande. I'll be assisting your surgeon. Is everything going all right so far?" I extend a confident hand, give my best you're-in-good-hands smile, make sure to pose my empathetic question. But she gives me a withering glare.
       "No residents are doing my surgery," she says. I try to explain that I just assist, that her attending surgeon is always in charge.
       The whole edifice of medical training is based on subterfuge. I know I'm not just an extra set of hands. Otherwise, I'd never learn to be a surgeon. Two years out of med. school, I hold the knife in most of today's cases. I have the table raised to my six-foot-plus-height. I struggle to get a breast cancer out through a tiny incision without violating the mass or burning the skin with the electrocautery. I remove the lymph nodes from an armpit and avoid damaging critical nerves or puncturing delicate nearby arteries. The attending surgeon leaves to talk to the family while I sew the skin closed.
       Yet it's not as simple as that, either. There's a distinction between pilot and navigator. A pilot needs a modicum of skill, but beyond that, the navigator is in charge. The attending draws the dotted line where I am to cut. She warns me if I'm too close to the cancer or too far. She tells me how she wants the skin sutured. Many cases are too complex to do without both of us playing our roles. And if she loses confidence in me, she utters the dreaded words--"Switch sides"--and I slouch shame-faced and silent away from the operator's side of the table. In the end, for a given attending, the quality of surgery varies little despite the variety of residents who help him or her.
       To this first patient of the day, however, her surgery is more like the NBA Finals than steering a submarine. She wants Jordan shooting the ball. She is unrelenting. The surgeon caves in, dismissing me since she can handle a biopsy without extra help.

Atul Gawande is a surgical resident in Boston who will be starting a regular column for SLATEcalled "Medical Examiner" in July.