I stepped back from clinical surgery the day I turned 75 years of age. I still do some didactic teaching and administrative work for the surgery residency I founded just 6 years ago, but have not touched the scalpel exactly one year ago.
I have had a gratifying run for 51 years in this job, 9 years as a GP in a small town doing the gamut of medicine, along with some surgery and obstetrics, with about 100 deliveries a year. I still see people on the street that come up to me, telling me that I delivered them. Occasionally I see a girl, now a woman, that I delivered with phocomelia of her right arm, a condition where an extremity does not fully develop in utero, and a malformed hand that does not work very well grew from the right shoulder. I see her in the grocery store shopping for her family and she seems to do quite well without one arm. I have to be careful so she does not catch me watching her as she might misinterpret my reasons. I can’t get over how agile she is. My mood is always enhanced when I encounter her, as it is a 100% reversal of my attitude when I delivered her, which was quite brokenhearted.
My last 42 years have been as a surgeon. It has also been an exciting and rewarding experience that I would not trade for anything. I changed from my general practice to surgery by going back into training, as surgery requires the acquisition of skills that a GP does not possess, at least not in the last quarter of a century. My wife and I just had our first (and only) child when I decided to become a surgeon. I asked her permission to go back into training, to which she lightheartedly agreed. In 6 weeks, however, she said to me, “What have you done to our lives?” I was on call every other night in the first few years and every night my last year as chief resident. But we, our child and our marriage survived.
I started the practice of my newly acquired occupation in a small town in Southern California. I had some help initially from the surgeon I replaced until he retired. Later I had some partners. First, a retired two-star Navy admiral who was demoted to a one-star admiral, which mandated his leaving the Navy (but that is another story), and then a woman surgeon shortly out of training. But there was a period when I was the only surgeon around, back to being on call every night. One night, I had gone to bed early as I had some kind of viral illness with fever and dizziness. The emergency room called; they had a patient with appendicitis.
I got up with difficulty and had to crawl on all fours to the closet to get dressed because of the dizziness. My wife was aghast. “You can’t go like this!” she said. But I was the only one around, and I was pretty sure I could do an appendectomy as long as I got propped up against the operating table so I would not lose my balance. I had to have my wife drive me, though. That I could not do, and she reluctantly agreed. My biggest concern was that the operating nurses might think I was drunk, even with an explanation. As long as I focused on a single point and walked straight towards it, I did not stagger. The appendectomy went fine, and my wife drove me home.
My town was along one of Califonia’s most dangerous highways, State Highway 126. It had the euphemistic name of “blood alley” for all the accidents it produced. I had at least one major accident a week, often with multiple injuries. That kept me busy all the time. “Dead Man’s Curve” was the worst. One accident for which I had no bag of tricks was when six men drove under an eighteen-wheeler semi-truck, and all six were decapitated. They brought the heads up to the ER! That was way above my paygrade!
The variety of surgery I saw was overwhelming. I even had to do C-sections at times when no one else was available to do it. A woman in labor had a prolapsed cord, which is when the umbilical cord precedes the baby, When the head engages the pelvic ring, the cord gets trapped and shuts off the blood supply to the baby, a lethal situation. Someone has to push the head up, to allow the cord to be decompressed. I got the call to come quickly! There was no time for the niceties to meet the family, or introduce myself. The patient was on the operating table when I first met her (as it turns out for the second time in my life). The anesthesiologist did what is called a “crash induction.” The anesthetic was administered and the baby had to be out before the anesthetic drugs got to the baby, a couple of minutes, max. I had not done a C-section in some time, but it came back quickly, just like riding a bicycle. The baby was fine and when I went out to meet the family, the patient’s mother exclaimed, “You delivered her!” “Yes, I just did,” I answered. “No, no!” she said. “You delivered her from me 25 years ago!” I did have mixed feelings about that. It definitely implies getting older when you are delivering women whom you delivered as babies.
There are operations I have done that I keep reliving in my mind, often in my dreams. One such operation was on a young woman who was planning on getting married within a week. She liked to do competitive barrel racing on her quarter horse. She was winning when she fell and struck her right upper abdomen on the barrel. She was in deep shock when I first saw her. In the operating room, the injury was a horrendous one. The liver was torn off the vena cava. Every time I tried to see exactly what the damage was I was met with a rush of blood that you could actually hear from above the liver – audible bleeding. I did a maneuver that was called the Schrock Shunt, a plastic tube inserted from the heart down past the injury in the vena cava. They say that there are more papers written about that shunt then there are survivers of that injury. Unfortunately, that was the case in this operation, she did not survive.
A happier case was a 10-year-old boy who was riding “the grasshopper.” That is what they called it. An oil well that is in production looks like a giant grasshopper moving its head up and down as it sucks that black stuff out of the ground. He climbed up to the “head” and when that moved down he fell off, and his knee was crushed by the “head.” I had just had an anterior cruciate ligament repair done on my own knee by my orthopedic surgeon friend Tom. It was an old ski injury that finally got too bothersome with the knee giving out at the most inopportune times. I had worked all day in the office and did not eat or drink anything, walked down to the hospital at 4:30 PM, hopped up onto the operating table and had my ACL replaced with a graft fashioned from a portion of my kneecap and patellar tendon. Tom gave me lots of Norco (this was before the opioid crisis) and sent me home with a knee immobilizer with strict instructions to elevate the extremity, keep an ice bag on it, and not bear any weight on that leg by using crutches. Being on the sharp side of the knife was a new experience for me, but I tried to be a good patient, until 2 AM. Tom called. I was initially a bit disoriented because of the time and the Norco, and thought he called to check on me. I was pleased that he cared, but he could have waited until the morning. As it turned out, he was not checking on me! He wanted me to come back to the hospital to help him, as he was operating on the boy with the crushed knee. Unfortunately, the “grasshopper” had destroyed his popliteal artery which courses behind the knee joint and is the sole blood source for the leg and foot. I told Tom that I was full of Norco and could not walk without crutches, and was trying to do precisely what my surgeon had instructed me to do, ice and elevate the leg. Again I was the only one available, even though I was impaired for several reasons. Again I had to impose on my wife to drive me, which she reluctantly did, continually reminding me that if things didn’t go well, I would get crucified for operating under the influence of drugs, as well as being disabled with my leg. My malpractice carrier would likely disclaim responsibility for such wanton disregard of common sense and unconcern for the standard of care. The problem was that I was the only surgeon in the area that had the technical ability to fix this. I recognized the risk, but as Tom emphasized to me if I don’t do it, this boy will lose his leg. I did what is called a reverse saphenous vein graft bypass, using his veins from the opposite leg of the injured leg. This was actually not in my field of surgery and the last time I had done it was under supervision in my residency and at that on an adult, not a 10 year old. All went as it should, and his leg was nourished by blood that was now coursing through the new conduit that I installed. I risked my own operation’s success by ignoring my surgeon’s instruction of not walking on the leg. My malpractice carrier who would rightfully refuse to cover me and my reputation which would suffer if my judgment proved that I was not successful in saving the boy’s leg. But seeing this boy walk on two normal legs was worth it! Speaking of worth, a 10-year-old boy playing on an oil rig after midnight might give you a clue that he had no health insurance, no support and parents that didn’t either. So I didn’t get paid, although several months later he did qualify for Medi-Cal, the state-sponsored welfare health program, and I did get $74.93 for the surgery and all the risks I took.
Interestingly, the family sued the oil company 5 years later because the fence surrounding the oil well was not high enough, allowing their son to climb over it. The final settlement was $4,000,000 despite the fact that he had no evident disability except for the surgical scar. I had already been paid by Medi-Cal so none of that came my way. But the lawyer got 40%. I knew I should have studied law instead.
As you get older, you do get wiser, but you also start to forget stuff. Professional and life experiences have taken off the rough edges, having a woman surgeon as a partner, a daughter, two granddaughters, and many female surgery residents have made me lose my last shreds of white male privilege and bias. As an old German proverb says, “You get too soon old, and too late schmart.” I had decided that I would stop working at age 70. I had many reasons. The practice was getting more complicated with rules, paperwork, governmental oversight, malpractice risks, and malpractice insurance costs, $60,000 a year for me. That is a lot of gallbladders at $600 a bag. More of my friends were no longer working, and I had a harder time running up and down the stairs. It was also not as much fun anymore. I clearly had an element of “burnout.”
Then an opportunity came up that I had not considered, teaching! I was offered a job as the founding program director of a newly minted general surgery residency. Much of the practice bureaucracy was lifted from my shoulders, but new ones with the regulating organization of residency programs, the ACGME (Accreditation Council for Graduate Medical Education) was substituted, a new challenge. But at least my malpractice was paid for. Dealing with young doctors who want to learn the art and science of surgery was the crowning experience and achievement of my career, challenging, fun, rewarding, and unforgettable. But all good things must come to an end. I went for advice to one of my mentors, who taught me to operate, and asked him the right time when to retire is? His sage advice was, “You will know!” At the time, it didn’t sound like wisdom, but it was. There are subtle hints to which you must pay attention. Getting up at 6 AM to make a 7:30 OR time gets more and more difficult. Likewise, that post-midnight call from your chief resident that the patient we did in the afternoon is not looking so good gives you heartburn or is it chest pain? Challenging cases become a heavy burden to carry. Simple cases become much more desirable. Watching the sunset with a glass of Cabernet Sauvignon is more appealing than picking up the Journal of the American College of Surgeons. And finally, when your residents question you more and more often, and their percentages of being right are going up, it is a mandate to watch more sunsets.