BY MARK KRAMER
DR. RUSSELL STEARNE STRIDES ACROSS HIS crowded waiting room without looking up, heading for the safety of the offices that lie beyond the receptionist’s desk, his gray-tweed sports jacket flapping around him. This is the way most people first see their doctors. No one present has any trouble recognizing him. Many of the patients seek eye contact, but the surgeon has gone shy, like a waitress who won’t even glance at her charges, for fear of being sent off for a glass of ice water. This smiling, wary, and self-protective man represents desperate hope to some of those assembling. Were he to permit himself to feel their emotions full blast, he might turn and bolt for the exit. He reaches his office. It is bare and large. A print of Rembrandt’s painting The Anatomy Lesson hangs across from a modern desk. He doesn’t even think of fleeing. He does say, “I wish I had a back door.”
Stearne (his name, like those of others in this article, has been changed) is a dark man in his late forties, with striking, deep-set brown eyes. He still has a full crown of black hair, and it seems to have been cut by a barber trained in the early fifties, when sideburns were grounds for suspecting the wearer of Communist sympathies. He’s beyond suspicion. Within moments of our first meeting he had told me that he’s a staunch Reagan man, that nothing’s more important to him than his family, that most surgeons are ill educated outside their fields, that he majored in English at Harvard, that he has gained twenty pounds since then, and that he loves his work.
Stearne practices as a general surgeon, in a small New England city. He estimates that he does some 300 surgical procedures each year, most frequently the common ones— hernias, appendixes, gall bladders. His work is eclectic. He sees “some of everything.” He does cancer work, performs many types of vascular surgery, and handles nonorthopedic aspects of traumatic emergencies. He had a year’s training in London with a famous hepatic surgeon, and occasionally practices this rather uncommon specialty on patients “with operable liver disease.”
Stearne has one active partner, Theodore Culver, another general surgeon his own age, and one semi-retired partner. In the 1930s, the older man was one of the first in the city to be certified by the American Board of Surgery, and because of that the office came to be regarded by patients as “the classy practice” in town, as one old-timer puts it.
In addition to private, fee-for-service work, Stearne does some “prepaid” surgery—it’s called that within the profession, as if “prepaid” referred to another body part upon which he works, rather than to the payment plan used by some patients. During the office’s long history, it has accumulated a variety of contracts for its partners to do emergency work and hold clinics at local factories. And about ten years back, when a health-maintenance organization—an HMO—grew up alongside the local university’s health service, the partners signed on to supply their consulting and operating services for a fee per-head-enrolled. Currently the HMO and the student health service together guarantee the surgical practice payments totaling about $100,000 a year.
Stearne’s varied sorts of business keep him traveling around several cities, from clinic to office to hospital. He writes off the cost of a Mercedes every three years as a business expense. Together his surgical enterprises earn him a substantial yearly income—somewhat above the current average for surgeons nationally, which is about $118,000.
I peer out through the receptionist’s window into Stearne’s waiting room. The patients keep arriving. They sit in black wooden spindle chairs that bear the Harvard motto: “Veritas.” Some read year-old Time magazines. The afternoon holds much in store, Stearne tells me. A few of the people out there have been referred by general practitioners who suspect that their patients may have malignancies: two will be told they do. One has already learned, on his last visit, that he might. The second is about to receive her first news on the subject. Patients will present the minor problems of used bodies, and several will discuss their post-operative troubles.
The patients may feel ambivalent about the doctor who ambles, eyes still averted, back within view of the waitingroom (far behind schedule now, and wearing a white lab coat). Some may anticipate relief from their anxieties about whatever ails them. But the prospect of relief is built upon the dread—well founded in the case of the round-faced, blank-eyed young woman in a white dress, reading in the far corner—that things may be worse than one dared imagine.
“I suppose I like some of the surgery better than some of the difficult office encounters,” Stearne says. Then, chatting about the very good bicycle included in the tag sale he’s staging, he pulls out the first patient’s folder and sets to his work.
He nods to the attendant receptionist. A thin-lipped, seventy-year-old plumber in green work clothes gets the call. He’s got a nice, easy smile. The receptionist herds him into the examining room. Stearne has told me about him. His first wife died a few years back, of cancer. Then he went to plumb a country farm for a retired lawyer and his wife—“from Minnesota, Quaker couple,” Stearne said— and ended up married to the lawyer’s wife and living on the farm. He developed an ulcer. Another surgeon had sewn up the ulcer, and had also sewn the poor plumber’s intestine closed. He’d almost starved before Stearne figured out the trouble and went in after it.
Was this an avoidable error? Was it actionable?
“It just happens. It’s not the kind of thing that’s actionable. But with every patient who comes in here, there’s cause for concern. Every doctor gets suits these days.”
We walk in to see the plumber. He’s in good shape, blueeyed and wiry, lean as a jockey, mild as a vicar. Stearne prods his abdomen for a while, then slaps his butt. The plumber leaves, smiling. Inspected and stamped cured.
In the adjacent examining room, a tiny patient glances away as Stearne enters somber-faced. The patient continues feeding from his mother’s breast. The patient’s aunt watches through rheumy eyes, while the mother flashes an earthy, gap-toothed grin. She’s an Ecuadorian Indian. She looks sturdy, with hearty, unselfconscious expressions. By her forthright tending of the child, she’s redefining Stearne’s quarters as outlandish, high-toned. She presents the baby. He’s fat, drooling, football-headed, smiling, olive-skinned, swaddled in baby blue. Stearne peels away the wrappings and feels a tiny incision on his abdomen, reddened but healing. He had a strangulated hernia. There’s no mortality threatening here. The baby laughs. Stearne laughs. The baby’s aunt laughs. The baby’s mother says, “Sí.” Another cure.
In the hallway, between patients, Stearne says, “You’re going to think this next old man is a religious fanatic.” The old man, tight-skinned and sharp-chinned, steps forward and shakes Stearne’s hand, as if about to sell him a car. While still offering exuberant greetings, the man bends down and pulls both woolen pants cuffs up above his knees. “You praying too much again?” Stearne shouts into the man’s deaf ear. The man lets out a belly laugh. “Tell us again how you got those,” shouts Stearne. Discolored ovals of skin, ringed with large stitches, cover both knees, purple patches on pink pants.
“I’m retired,” says the man, “and I was doing some masonry work—floating a poured floor for my son-in-law. I guess I don’t have much feeling left in my legs anymore. When I got up, my knees were like looking down into hamburger. The doctor here did some skin grafts.”
“He didn’t get it in church after all,” says Stearne, and we laugh.
A fair woman in her late forties, with graying hair, tries to read Stearne’s blank face as he enters the other examining room. She’s had a mammogram; it has shown a slight shadow on the X-ray. “I don’t think it’s a meaningful finding, and neither does the radiologist at the hospital. If this were anything to worry about, there ought to be a palpable mass where the X-ray suggests one. And there isn’t. If there were, I could feel it. Don’t worry. Come back in six months for a re-exam. Come to me.” The woman smiles, and sweetly nods assent, speechless.
Out in the corridor, Stearne says, “These office hours aren’t always as grim as you might think. It’s very rewarding to see some patients.” On to the next.
Stearne welcomes Mrs. Smith, who leaves laughing, and, many patients later, the young Mrs. Jones, who leaves crying. Stearne’s ability to offer reassurances, patient after patient, one dilemma after another, good verdict and dreadful news alike, demonstrates the miracle of insularity that keeps him going year after year. He awaits a final patient, who has phoned to say she’s on her way.
Between patients, in his office, he is like an actor between scenes. The costume remains; the character alters. On stage, he’s measured and gentle, a mere representative of a larger body of knowledge and skill, doing what can be done. He never relaxes with patients. Even when friends come in to be treated, he is surgeon first. He quotes numbers whenever that explains things—usually odds. With the help of science and technology (he gives patients to understand), he reacts to disease as best he can. The numbers help demonstrate to patients that he’s reasonable and deliberate, and give some slim grounds for cheer about something or other, even in the worst of cases.
Off stage, he frolics. His face grows mobile. He laughs, he changes the subject, he utters personal thoughts and evaluations he may not utter in public. The nurses and the receptionist occasionally receive his confidences. But it is his partner Ted Culver who hears the worst Stearne has to say. The two, who rarely socialize off duty, have shared thousands of operations over the past fifteen years.
“She’s here, Doctor,” says the receptionist, standing on one foot, tipped and leaning in past the door to the office. The patient, a janitor in a factory, comes rolling up the hallway with the swagger of a street tough. She’s sixty, stocky and untidy, her dyed-red hair spilling from a babushka, her blue blouse tail unstuck from dirty red stretch pants that sweep outward upon a jouncing belly. She looks about repeatedly as she follows Stearne next door, into an examining room. She smells of stale powder and cigarette smoke. He points, and she sits up on the table, chubby legs dangling. He takes a wooden tongue depressor and a flashlight, and looks in her mouth. He reaches a finger in after the tongue depressor and feels what he has seen, touching disease. What he touches could not be uglier.
Two years ago, Stearne and his partner managed to peel a tongue cancer from this same spot, and radiation further stifled the malignancy there. Stearne has suspected she might be cured. But now she’s having trouble swallowing. It must have been back for some time. She pulls Stearne’s hand away.
“Another look, please, Mrs. O’Leary,” he says, and replaces his hand.
She pouts with her eyes, and issues small glottal grunts of frustration. She’s peevish—she must be afraid. A marble-sized tumor has grown up under the raspy stubble on the back of her tongue. It swells from the padded floor of the mouth like a small boulder in a field with grass grown right over it. It rises up so high that Stearne’s penlight throws its shadow in an arc across the shimmering stalactite of her uvula.
She doesn’t want to realize what has happened. As soon as Stearne takes his hand away, she shouts out, “I don’ wanna have to not work, like last time. How long will I be out, Doc?”
“We can’t tell that yet. Now, you wait here for a moment, will you?”
We go down the corridor, to find Culver in his office. “If you have a minute, Ted, will you see what you think?” Stearne himself thinks the going will be “treacherous, at best.” He thinks the woman will not be cured by surgery, although she may once again be saved for a while. But this time, to get at the tumor, he will have to split her jaw and take away the left side of her jawbone, remove the tumor, and reconstruct a new jaw in the aftermath. This palliative treatment will take many months and several operations.
Stearne re-enters the examining room, and introduces Culver: “This is the doctor who helps me operate.” Culver looks. Then the two men leave again.
“You going to operate?” Culver asks in the hallway.
“Do what I can.”
“What can you do?” Culver turns Stearne’s phrase around. “The lady hasn’t got much time, and the operation would be so extensive, she’d barely heal before ...”
“I think there’s more hope than that,” says Stearne.
“Another opinion? Who’d you use? Mike Bell, down in New Haven?” Culver knows that Bell never wants to operate on cases like this. Stearne goes into the examining room again. And he does send the woman on for a second opinion—to Sam Pincus, in Boston. Pincus is less conservative than Bell. “The other doctor wall help me?” she asks as she leaves.
A week later, Sam Pincus’s opinion arrives by mail: Operate if you think it will help. I ask Stearne if he’s going ahead with the job, and it becomes clear that now that he has been seconded, he has edged closer to his partner’s caution.
“We’ll see if chemotherapy can knock it back enough so we can have a better shot at it. I’ll do whatever I can to save my patients.”
I find it difficult to imagine Stearne’s experience. His sureness of his skill, and his detachment from the prospects of these patients, are exotic, beyond any experience that can be shared by those of us with more usual burdens. Is he merely an equable witness to life’s odds—observing in flesh and blood the statistics of particular diseases as they work out relentlessly, on schedule?
CUTTERS, BEARERS OF HOPE AND DOOM, DISTANT and avuncular, surgeons cannot be all that we long for them to be. They fail time after time, with the lives of our relatives and friends in their hands. Their successes are painful enough to evoke questioning responses even in those they heal. In the office, their work fosters such feelings of dependency that seriously ill patients may imagine they’re talking to someone other than the surgeon altogether, someone supernaturally protective. “Doc.” Patients call Stearne “Doc” most often when most helpless. Being a surgeon has got to be as wearing as being beautiful, and even more likely to tempt with prospects of power, because there’s more power to be had, and for longer.
A classmate Stearne remembers vaguely from Harvard, Arnold Marglin, wrote in their twenty-fifth-reunion yearbook of his fatigue with the role of doctor: “Flattery, arrogance, uncontested authority, then self-deception, ensconcement in our unearned see.”
The next day is a usual one for Stearne, Surgery. Hospital lunch. Crossing a waiting room full of patients. He is consumed by what he does. Half the days of the year, he goes home for dinner with his on-call beeper clipped to his waist, He doesn’t seem to mind; in fact, he signs up for additional duty at the hospital emergency room. He finds new patients there, and fee-for-service patients at that. But he is not a hungry fledgling, nor so avaricious that he doesn’t savor time off. He simply likes the work and how it makes him feel. He tells very ill patients that they may call him at home. He has a fine phone manner, and seems unrushed, informative, and generous with reassurance. When the beeper reaches him while he is at the dinner table, halfway through the roast or awaiting the souffle, he goes. His children are used to it; they keep talking.
Most of the surgeons I’ve met live this way. From the article “The Effects of Stress on Physicians and Their Medical Practice,” by Jack D. McCue, M.D., in The New England Journal of Medicine, February 25, 1982:
Retreat from family life is probably the most common adaptation to the demands of medical practice. . . . Spontaneous home activities are interrupted by the telephone or pocket pager; late office hours, hospital rounds on days off, and subtle or unconscious encouragements for patients to call after hours erode the time and energy needed for personal development.
Why do intelligent and successful physicians tolerate the failure of an unrewarding family life. . . ? The first reason is peer pressure. . . . The second reason is fear of failure and of success. ... A final factor is self-importance. Insecure physicians can maximize ego gratification at the hospital, where they issue orders, make critical decisions, and receive praise from their patients; at home, the physician is just another suburban husband. . . .
This suburban husband married at twenty-eight. His eldest child, a boy, has headed off to college, and the elder of his two girls is not far behind. His younger boy is in elementary school. The household retains vestiges of formality. To Stearne’s children I am introduced and reintroduced, always as “Mister.”
“I had more freedom than I allow my kids,” Stearne tells me, on a Sunday morning that has progressed free of emergency summons from late breakfast nearly to noon. “From when I was thirteen until sixteen or so, I grew up setting myself up as independent, as outside a group, showing you didn’t need people.”
Stearne is a lavish provider. When I visit, I see children forever heading off to lessons. They retreat in summer and on snowy weekends—sometimes with their father along and sometimes with mother alone—to a condominium on a North Country ski slope. And the house the family has just moved to is very large, a structure Stearne dreamed about for years, and finally helped architects to design.
“The architects showed me the preliminary plans,” he says, pacing and gesturing toward the high, stark ceilings of a huge glass-and-cement-walled living room crossed by an angled catwalk. The room is larger than two squash courts. “They said, ‘Here, it’s got a twenty-by-twenty-foot living room.’ I said, ‘I don’t want a twenty-by-twenty living room. I want one thirty-six by thirty-six.’ I didn’t realize just how big such a room would be.” He looks around it, still chagrined, and shakes his head.
Stearne’s dream house spreads across a half-landscaped hilltop, above a hundred acres of fields and woods. Vshaped, like Noah’s ark beached atop a Yankee Ararat, the house looks down from five miles’ distance upon the city hospital’s red smokestack and the white steeple of the Congregational church. The starboard side of the house contains the big living room, pantries, utility closets, a tiled kitchen leading out to a gravel-floored greenhouse, and above all this, guest rooms and a very ample master bedroom.
The port side of the house Stearne calls “the children’s wing.” Downstairs, a corridor connects the two sections. Upstairs there’s no connection at all. Rooms adjacent but in different wings have solid walls between them. Corridors end. “I designed that into it. From the kids’ rooms, they have to go downstairs, then up the other side. I think it will work out this way. I like to spend time with my kids.
I like kids in general. In fact, I almost became a pediatrician.
“In medical school, you’re impressionable. They have good lecturers, and whichever impresses you on that rotation, that’s what you wanted to be then. I wanted to be a psychiatrist for a while, even. I was good at it—got excellent review reports.
“But I admired the chief of pediatrics a lot. It’s interesting medicine, in young bodies. Not a million things wrong at once. I’d even gone to see about a residency. Then came my surgical rotation. It was the middle of the night. They brought in a policeman by ambulance, who had been stabbed with a broken bottle, right in the temporal artery. It was a mess—looked worse than it was. Blood spurted out of his head like the Fountain of Versailles, up to the ceiling. No one put pressure on it—just screamed and rushed him down to the minor-surgery room. I was on the team. It was exciting.
“As we rushed down the hall, there, at two in the morning, was a little rumpled pediatrician, talking on the phone. I went by, hand on the stretcher, and I caught a few words he was saying into the phone. A few—but they were enough. They made up my mind.
“‘Well, Mother,’ he said, ‘maybe if you boiled the milk a little longer, the baby won’t vomit so often.’ Lights flashed. Boy, did they ever.
“I realized right then I didn’t want to be spending the rest of my life up at two A.M. telling mothers how to cook babies’ formula. At that instant, I had decided on surgery.”
Stearne, on-call beeper still clipped to his belt, takes a green-webbed lawn chair under his arm and sets up among the hanging plants of the gravel-floored greenhouse, past an arch, just beyond the kitchen. The progress of Sunday is measured in spent sections of The New York Times. He’s done with “Sports.” “The Week in Review” lies on top of it, on the gravel floor, and in the next half-hour he tosses the two parts of the first section, beginning with the day’s wars and ending with its marriages, on top of that. He reads, snapping the pages, while family life goes on around him. Children play outside. Stearne watches them through the greenhouse windows, as they tumble on the lawn. His wife washes the breakfast dishes. “This is what I dreamed of doing in here,” he says. Sun streams in upon the surgeon’s smiling face.
STEARNE HAS READ WELL INTO THE BUSINESS section, checking the advances and declines of certain stocks. His black hair gleams. Light reflected from the shiny green plants tints his face. The buzzer on his belt goes off, a thin piping of the local news that downtown a recent disaster is being organized for treatment by him.
Stearne rises slowly out of his chair. He calls the hospital. Then he calls his partner Culver, who is also at home. He does not waste time, but neither does he leave at a sprint. He is not excited by emergencies. They interest him. They are part of his routine, to be handled with decorum, not frenzy. He says good-bye to his wife. Within five minutes of the beeper’s announcement, he is in the Mercedes. Another few minutes of rather fast driving, down the twisting hill to town, and he’s in the hospital’s reserved parking lot.
Sundays, hospitals shut down as much as they can. The few true surgical emergencies that come in are as likely to require an orthopedist to set broken bones as they are a general surgeon. This emergency involves no broken bones but rather a torn circulatory system that is emptying itself. The patient, her life leaving her, is still conscious as Stearne walks into the emergency room. He greets the head nurse. She takes him back to the patient, a woman of about sixty, who lies on a litter, ready to travel, still halfclothed. She herself is a retired nurse, flaccid-faced, waxen, and glassy-eyed. Her medical knowledge has given her a chance to survive. Ten years earlier, according to her chart, she had a nylon artery installed in place of her own ruined aorta. No one uses nylon anymore. It turned out occasionally to erode, slowly. This morning, the wall of her prosthesis, where it came in contact with the intestines, must have worn through—at least that’s what the doctors here were guessing. In her closed body, at the top of the abdomen, just below the fastening of the nylon prosthesis to the stump of the old aorta, seepage must have begun. The symptoms seemed slight to her at first— just a fullness and mild abdominal pain. It could have been indigestion. But the nurse read her own signs and understood something. She drove herself to the hospital. There she grew rapidly worse. She’s in shock now.
The rituals of surgery usually begin a day ahead of time, and proceed with the deliberateness of a countdown for a space launching. Elaborate bathing, and bowel-emptying purgatives, occupy the patient. Operating-room preparations also start far in advance of surgery, also with elaborate, almost ceremonial, cleansings, with the packing of carts with kits of instruments, with the gathering up of special supplies, with the assembling of appropriate paperwork. The anesthesiologist stops by the evening before the morning of the event, to take the measure of the patient and then plan dosages.
This time, aides wheel the sick nurse into the operating room within moments after Stearne’s arrival. They bump a recently scheduled appendectomy; he will go on waiting, drugged and dozing in the corridor, for a few hours.
Stearne scrubs for two minutes instead of ten. The nurses help insert intravenous catheters into the patient’s plump white arms in the same few minutes, accomplishing deftly the fussy chores that sometimes take them half an hour. The anesthesiologist has the patient under in moments, and begins preparing bags of blood for transfusion. Stearne walks in, scrubbed, and the patient is ready. As Stearne makes the first cut through the still-damp skin of the broad, orange-swabbed abdomen—cutting less delicately than he usually does to enter bellies, and in fewer installments—Culver walks in, smiling and pushing his hands into gloves.
Stearne cuts deeper. The clotted seepage from the torn aorta, suddenly freed of the pressure of the gut, tumbles into the abdomen, which Stearne is still opening. In a moment, the clean, deepening incision is a sump of black blood. Ropes of clot swirl in it.
“I hope that blood is available for transfusion already,” Stearne says.
The anesthesiologist nods. Stearne sounds nervous. “She’s had a lot of previous surgery here. She’s been open three, four times before. I hope the last guy left the renal artery out of the way.” He works fast. He seems pure and concentrated, exempt from the burdens of his complex nature. Before planning just how to repair the aorta, he must expose the entire eroded area. He has to look at it. And blood is coming into the wound more quickly than he can pump it out with the one aspirator that’s been set up. The transfusion isn’t going yet. The nurse is in deep shock, and near to dying. Only so much blood can leave the system before pressure drops and the heart, with too little to pump, disorganizes and arrests.
Surgery is seldom like this. Most of the millions of procedures done by surgeons each year are elective, deliberate, and come and go with no moments of crisis at all. With the institutionalization of anesthesia, more than a century ago, surgery became rather unhurried. There’s still a tradition that speed counts—it goes back to the days when surgical patients were held down, screaming, as the work progressed. Hours do still count; general anesthesia is hard on the body. And busy surgeons may work quickly so that they can perform more operations in a day. But surgeons nowadays take care, rather than save minutes, whenever there’s a choice between the one and the other. There’s no choice now.
Things get worse, Stearne is feeling through the anatomy of the upper abdomen with his hands submerged. He lodges retractors behind the intestines and has nurses pull the gut back out of the way. The blown prosthesis fragments further. It excretes a clot the size of a baby’s fist, which floats up into view. Blood floods the widened incision. “It’s just ruptured,” Stearne says. His hands are under blood to the wrists. He can’t see. Too much time is passing. At least the transfusion has started flowing. Stearne says something now so tame, so unpreening and frank, that it seems endearing: “My experience with this kind of complication is pretty limited.”
It would be a rare surgeon whose experience with this kind of complication was not pretty limited, for patients whose aortic prostheses let go nearly always bleed out in moments, and do so wherever they happen to be, which is seldom on the operating table, where help may save them. It’s not a bad way to die.
Stearne has trouble finding surgical landmarks in the murk. He’s having trouble even finding the mouth of the flow so that he can clamp it off. He sorts blindly through the chaos of adhesions and clot. Someone dumps saline solution into the wound. The blood marbles, then reddens again. Culver reaches into this wash, feels, then finally nods and says, “Yup.” He has located the aorta’s upper stump. He folds his hand down onto it. Stearne picks up a large arterial clamp—called a “Cooley,” after Denton Cooley, one of the pioneers of cardiac surgery. It must be a height of manly success to have the only tool that can do the trick in crisis moments named after you. Cooley enters, from 1,500 miles away, when nothing less will do.
Stearne follows the line of Culver’s wrist and thumb with his own hand and forces the clamp under the sunken stub of artery. A nurse gets a second aspirator organized and, finally, blood begins draining from the wound. The play of hands and the prodding clamp come into view. The flow is under control.
“If I can just get around completely, I can get the clamp secure on this,” says Stearne. Under ordinary conditions, “getting around” the aorta with the clamp would have been accomplished deliberately, set up even before blood flow in the artery was interrupted. Only Culver’s folded hand, thrust into the abdomen, keeps the unconscious woman’s remaining blood in her now. The patient’s blood pressure rises on the red digital meter by her head: 57, 59, 58, 70, 80, it flashes.
“Things are so mixed up here,” Stearne says, “I can’t tell for sure if I’m feeling plastic or artery.” He thrusts with the Cooley clamp in his right hand and cuts, tentatively at first, with scissors in his left.
“I’ve got this okay,” says Culver. “It looks like you’re up far enough so it ought to be the real thing, not scraps of the old prosthesis.”
“There, I’ve got it clamped.” Everyone sighs, almost in unison.
“Syringe,” Stearne says. A heavy-set nurse hands him a giant syringe with a rubber bulb on the end. He draws up a cylinderful of blood and hands it back to the nurse, who squirts it into a bowl and throws in the new graft she is preparing. Things are looking up. They’re thinking of finishing this operation.
“This is still spraying—I’ve got it clamped, but we’re still losing blood,” Stearne says to Culver. He sounds freshly alarmed. “If this clamp is on the shreds of the old graft after all, and not back on the real aorta, and it blows above it along the old suture line, we’re in real trouble, because I can’t get more room to reclamp any higher.”
Stearne probes more. The aspirator finally drains to the floor of the wound. He can see into its whole depth.
“It’s okay. It’s high enough,” Culver says. Stearne has his sense of location now. He slides another arterial clamp in and fastens it quickly, just below the first. The spraying stops. He and Culver clean up. They lift from the wound strands of blood clot and cracker-sized sheets of the “neointima” that must have formed inside the blown-out prosthesis. “Yuck,” says Culver. They cut away at the top of the old prosthesis.
“There,” says Stearne. “There’s the ring of the proximal aorta, clear of junk.” It’s a red, fleshy cross section of tube, craggy and rough-edged. “It’s like cement inside, and lousy tissue outside.”
“Maybe you can clip away at it and clean it out?”
“May I have a right angle?” Stearne asks a nurse. He reaches into the aorta and fishes out more clot. He probes farther. “The back wall of it is pretty much eroded”—more prodding—“but we may have enough to work with.”
Inches below the patient’s pumping heart, he tidies the ring of the aorta, shearing it back to tissue stable enough to hold the stitches that will tie in the new prosthesis.
Culver opens the incision into the belly still further, neatens it up, and then inspects the lower section of the torn graft. He clamps off its two iliac legs. Stearne decides he will preserve them. He cuts the loosened old graft away just above the iliac clamps. The new graft will join to good aortic tissue at the top, but onto these nylon cuffs at the bottom. They’re still sound. This will allow a smaller incision and a briefer operation. The patient has been through a lot.
Slowly, Stearne builds order. He resets the retractors to open the territory. He displays—framed and suspended by clamps—the stubs of aorta and of both graft legs. The impeccable organization he imposes crowds away the bloody mess in this belly and promises more life. Stearne again seems calm. It seems to occur to him that he has appeared—however appropriately—timid for a time, and has accepted encouragement, and even valuable help, from Culver. He works on, lighthearted and bold now, and his talk seems to flow from such a realization.
“Charlene, would you keep your boobs out of the way?” he says to the white-haired nurse next to him. She doesn’t answer, she doesn’t move, and she doesn’t smile. “I don’t mind,” Stearne says, “they’re so soft and nice.” Then he asks the anesthesiologist, “How you doing, Sid?”
“Why don’t you ask me how I’m doing?” Stearne asks everyone present. He seems to reflect as he cuts and sews. “The hero is the assistant, who has to stand around for three hours, watching,” he says.
“I urge him on,” Culver says. Combat’s behind them now.
“The urine output has increased,” the anesthesiologist reports, doing his job.
“The patient’s or Stearne’s?” Culver asks.
Stearne smiles behind his mask.
STEARNE’S ALLIANCE WITH CULVER IS NO ODDITY. Joined by the strain of dangerous service together, surgeons in partnership become as tight as cops in the same patrol car. Their loyalty to one another, as each other’s most expert aide and witness, may at times exceed their feelings of obligation to any passing patient. One should not get second opinions about impending surgery from partners, or even acquaintances, of one’s surgeon. In rough moments, partners help and empathize with each other; afterward, they may explain away each other’s misadventures.
In Stearne’s city, most of the surgeons who operate regularly have assisted each other at least a few times over the years, during operations that regular partners could not attend. Such alliances are imperfect—factions and grudges abound. Surgeons have long memories and ample pride. Few surgeons take the ability of their colleagues on faith. Denton Cooley has been quoted as saying, “A successful surgeon should be a man who, when asked to name the three best surgeons in the world, would have difficulty deciding on the other two.” But if the rivalry between surgeons is extreme, perhaps the most obvious cause is commercial; one surgeon’s patient is another surgeon’s lost business. There’s not quite enough to go around. All surgeons can prosper; few work as hard as they might. Surgeons say vicious things about other surgeons, but only after choosing their audiences with care. One never bad-mouths a surgeon to his patient. But surgeons know each other’s worst moments. And most surgeons have in common a scorn for bad craftsmanship.
This paradoxical familiarity turns out to make surgeons mutually vulnerable, and, finally, makes them all allies. They’re in it together. Locally, they can implicate each other for not being perfect. Everyone’s committed a few errors in his years of practice. On a national scale, surgeons have joined together in a professional and political alliance that has almost crowded non-surgeons out of the operating room (although some rural GPs still do tonsils and appendixes). Their organizations lobby to control both the licensing of foreign-trained surgeons and the numbers of surgeons trained each year in America.
But beyond the shared vulnerability, and the commercial advantages of a national alliance, surgeons share a world. They share a proprietary feeling of competence, of responsibility, of unlimited aspiration, yet of frustratingly limited capability tested daily in crucial episode after crucial episode. “There is no minor surgery” almost any surgeon will get around to saying. Only other surgeons share the assumptions and memories of this odd life, whose functional moments take place inside other, sleeping, trusting people.
The alliance seems most obvious in the surgeons’ dressing room at Stearne’s hospital, at the far end of the sixoperating-room surgical corridor. The younger surgeons, in scrub suits, crowd around each other for a few moments now and then like boys at a pajama party, while down the hall nurses prepare patients, or wheel them in or out of surgery. Stearne can’t share his everyday world so fully with any other group. Its premises are too odd, and the only others who belong have endured the same ordeals of danger-by-proxy and the touching of the sick places where life is hidden, held, and lost. Like the students staring at the corpse in the print of Rembrandt’s Anatomy Lesson that hangs in Stearne’s office, surgeons stand together, in the thick of things.
HAVING SEEN THE RETIRED NURSE SETTLED IN the recovery room next door, Stearne joins Culver in the dressing room. It could be a dressing room for a private gym—white-tiled, full of blue lockers. They make small talk about Culver’s ten-speed bike. Culver likes to go on hundred-mile rides. A burly gynecologist comes in. His operating suit is drenched from the waist down with pale-pink ooze. Stearne shouts out, in greeting, “Heinrich, you’ve been swimming!” It seems cavalier at first thought, and consoling at second. The dressing room is their senate cloakroom, officers’ mess, men’s-club library. It’s where, while changing clothes, surgeons consult on fine points, share combat stories of surprises recently found in patients; where they trade righteous accounts of frustrating dealings with nurses and hospital administrators; where, summers, they tell each other tales of an endless, jointly played round of golf.
Samurai meeting here between battles, surgeons sustain each other in ways they’d be reluctant to acknowledge. They seem to tolerate, even to admire, in each other the very proudness and self-absorption that others in the hospital refer to when they complain about “surgeon’s personality” If such self-absorption condemns most surgeons to lifetimes of hard work, bonhomie, stiff bravado, and clubbishness but little intimacy, it also may make the daily onslaught of carnage endurable. It must be very gratifying indeed to be on the team that can rescue persons.
In street clothes, Stearne stops once more in the recovery room to see his patient. Then he drives back up the hill home, and resumes his place in the lawn chair in the greenhouse. He reads the Times Book Review for a while. I ask about the operation he’s just finished. My technical questions he answers with aplomb. Questions about his moments of seeming timidity and bewilderment he waves aside. And when I ask if he feels proud of himself, and if his alliance with Culver comforted him this afternoon, he stops me.
“I’m not much for introspection,” he says. “It’s like peeling the petals from a rose.”
He reflects, then looks sheepish, a boyish smile playing on the small features of his chubby, angelic face. “Maybe not like a rose. lake an onion, maybe,” he says. “Anyway I don’t do much introspection. In fact, I avoid it. I wouldn’t step out the door in the middle of winter without dressing up warmly. It’s cold out there, and I’d quickly be uncomfortable.” He holds out a hand, palm up, being reasonable. “It’s the same way with all this stirring things up. I function very well as i am. I wouldn’t want to disturb things. Sometimes when I’m up in the middle of the night, scenes do play back, but I don’t take note of them so I remember them afterwards, and I don’t know how to get into that state.
The onion’s hard to peel. The sun slants in from the far side of the greenhouse now. The kids play in the kids’ wing and not on the lawn. Cats prowl about. A new puppy howls from its cage, alone in the big living room. Stearne remembers his boyhood.
“I know what my kids are doing. I was allowed to come and go from the age of six—I was the eldest and I used to take my mother’s ration book to the store and do the shopping. That was a lot of responsibility for a little kid. I don’t ever recall my parents telling me not to do something. My parents didn’t provide much of a family structure. My dad worked all the time. We kids provided our own, more or less. A home with that many kids—there were five more after me—all the authority absorbs into itself. I got quite alienated from the household for a while. My conflicts at home absorbed a great deal of my energy in those teen years. The rest was taken up by school—and cold showers.
“What kept me in line was Catholic school; I am the child of a parochial-school education. The priests wanted the top kids to join their order. Four of the top six in high school did. They work on you. They take you aside. I was on the rifle team—how’s that for channeled aggression? Rifles? Get it? But the priest who was coach gave me constant doses of Thomist philosophy—the Good, the Beautiful, the True, which, according to them, are the aspirations of the human soul. I wonder if they are. The other top kids were placed in leadership positions. I wasn’t, because I was never religious enough. I was feature editor of the yearbook, but they kept me from being editor. It still annoys me.
“Then, in my senior year, I told the priests I wanted to apply to Harvard. They said I couldn’t. They said they wouldn’t forward my records or give me recommendations. They only wanted me to go to a Catholic school, like Boston College. I went up to Boston on my own, and explained it to the admissions people at Harvard. No one else in my school had ever gone there. No one else in my family had completed high school, much less college, much less Harvard. After me, my next-younger brother went to Yale. They wouldn’t forward his records, either.
“Just a few years ago, I saw a newspaper from that high school, boasting that one of their students had just gotten into Harvard. They called him the first. Times have changed there, but that boy wasn’t the first.
“The second year at Harvard, my roommate started psychoanalysis. Now he’s a psychiatrist. He became so terribly moody and upset that year. I never want to do that. I saw right then what too much introspection can do to you. It’s a time-consuming practice. Everyone needs their armor. All I can say is this; I had a sense that doing well was showing them. It made me independent. You don’t have to rely on people.” I think of today’s emergency surgery, of his reliance on Culver, and guess that he’s found an ally in spite of himself.
Having once decided to be a surgeon, Stearne plunged into his training with a vengeance. After graduating from Harvard College and Medical School, he studied with surgeons in New York City, and, later, in New Hampshire and in London. He had known even before he went up to Harvard that he wished to be a doctor. He is not forthcoming about his memories of medical school—a trait that turns out to be common to the profession. The experience is a long tunnel of drudgery, marked chiefly by the first bout with a cadaver, and by one’s eventual emergence, transformed and professionalized—and a stranger to the innocent who started the journey four years before.
LIKE MOST GENERAL SURGEONS, STEARNE SEES cancer all the time. He’s used to it, and he’s even proud of his ability to defy the terror of it. “I think my partner and I must have more cured cancer patients running around town than any other surgical practice around here does,” he says one day in early winter. I feel trapped by the boast. I will have to see what he sees if I stick around. I’ve seen enough already: uncles, aunts, grandmothers, friends.
I stick around. Every week a few cancer patients, some cured, visit Stearne’s office. Then one week he announces, “I have an interesting series of appointments. There’s a professor from the law school—came in through the HMO. He’s had a five-year battle with cancer. They took out a perforated colon cancer to begin with, then more and more surgery, including some heroic surgery. He was working in spite of his disease for most of that time. Now he has a resurgence all over. Nothing to do for him anymore.
“Also, I have down a plastics engineer. A rare bile-duct cancer. May be job-related. It’s hard to tell in these cases. He won’t make it, either.
“And then there’s a schoolteacher—she has cancer too. Stomach cancer. Knows what’s going on. Her internist doesn’t usually send me patients. But he’s one of those people who does send me patients he cares for especially.” “Did the internist diagnose her?”
“She came in to me thinking she had a stomach ulcer. ” “Does she have a chance?”
“About zero. That’s what the long-term studies show. But some recent studies show that chemotherapy may possibly do some good. I’m going to discuss it with her.” “Will it really help?”
“Some, perhaps—for a while. But who knows? She may be a first. There’s also a boy with Hodgkin’s disease. He’s number one on the list for this afternoon.”
“You must look at these difficult visits with some dread.” “I’m not to blame,” he exclaims, quite intently. “I’m not the one who gave them cancer. I’ve done them good, in fact. Kept them alive. I feel good to see them, knowing there’s a chance that I can help.”
A giant of a teenager walks into the office, as big around as the trunk of an old maple. He’s wearing gray sweat pants and sweat shirt, as if he’s just come from doing roadwork.
“How’s the truck-driving business?” Stearne asks as the boy opens the office door.
“Good, I guess,” he answers slowly. His face, broad and red, stays expressionless. He’s beyond reach of Stearne’s professional manner.
“He has a couple of rocks in his neck,” Stearne explains. The boy sits down. Stearne wheels his office chair forward a yard and feels the right side of the boy’s neck, confirming his memory of the condition. “Remember,” he asks, addressing the boy, “the last time, I told you there was a possibility that you had Hodgkin’s disease? Hodgkin’s has changed”—it doesn’t appear to me that the boy understands, or that the doctor is speaking to be understood— “and I think the probability is that you do have Hodgkin’s disease. Now, 85 percent of the people who we see who get it get over it completely, through X-rays, and medicine.”
A ringing phone interrupts the presentation. I wonder how Stearne, with a hundred or so cancer patients in various stages of learning their fates, fighting, raging, accepting, keeps track of the delicate progress of these hundred relentless narratives. Stearne remains on the phone for a full five minutes, arguing with some bureaucratically powerful nurse. The boy stares out the window and doesn’t twitch a muscle. It seems that Stearne has dictated yesterday’s incoming-patient reports after the closing time stipulated by hospital regulation for new admissions. The nurse wishes to remove the name of a patient from the next day’s surgery roster. Stearne is polite, claiming that he was on hold, awaiting his turn to dictate the admitting information, at three minutes before deadline, and that he appreciates the nurse’s help in keeping things just as they are. He finally hangs up, assured that, just this once, she will make an exception for him.
“And a bit of tissue from your neck, I think, and that haul gland under your arm there, would make it diagnostic. Also, the farther you get from the source, into the armpit, the more your symptoms tend to be diagnostic.”
The patient still looks uncomprehending, unshaken, inert. Stearne notices. “You have a treatable cancer,” he says. “Cancer of the lymph glands, I suspect. We need to get you in for a biopsy. The nurse can schedule it out there for you.” He points out into the hallway.
“Okay,” says the boy, getting up. He grips the office door, then, holding on to it, asks, “You want this door shut or leave it open?”
Why can’t he slam it, trap the bad news inside? I admire his defenses. This is the moment he hears that fate has turned on him. I ask Stearne about his own feelings: Does it bother him, telling the boy that kind of news?
“I tell maybe fifty patients a year that they have cancer—usually breast or colon. I didn’t give it to him. It doesn’t have emotional impact on me. I probably cure more than I don’t. The patients get more of a charge out of it than I do.”
“What if you were in the patient’s shoes, and another doctor were giving you the news that you had cancer?”
“I don’t know how I’d feel. Probably about the same as I feel telling them they have it.”
Can it be that to be professionalized is to lose touch with all fear, all sense of the desperate sweetness of life? Can one become so mechanistic in comprehending one’s own somaticism that one might actually have cancer dispassionately? And how long might the dispassion endure? Past the first ten pounds of weight loss? Twenty? Fifty? It’s as if you might live on and on if only you could keep from noticing. For a few years, a late senior partner of Stearne’s assisted in operations upon cancer patients, all the while keeping his own prostate cancer in check with hormonal treatments. The partner’s insularity, like Stearne’s, was awesome.
The law professor is in next, quickly seated in the armchair by the window. He and the truckdriver must have passed each other in the corridor, both lost in their own concerns. Did either notice the other? The professor is stooped, gray-haired and gray-skinned, curled in on himself in the bright-green chair—a garden snail on a leaf. He looks up at Stearne through groggy eyes, only half engaged by this late chapter of an old oideal. There’s nothing more to do. The questions that come from Stearne are kindly ones, about how he’s doing, and if he’s comfortable, and does he need or wish anything. “You can call me anytime,” Stearne says. The professor just nods, and then he’s gone, out through the open door, dying on his own now.
The receptionist says the plastics engineer has rescheduled for tomorrow. I’m glad. One fewer.
Later, the teacher with stomach cancer comes in. Rather, she slips in sideways, as if entering a lecture late, hoping not to be noticed while things go on normally, as they must have before her illness. She is powerful, imploding with the force of new terror. She returns nothing to the outer world as she moves in slowly, wide-eyed and stoopnecked. Stearne studies her appearance, and who knows what he thinks? My thoughts fly out toward her and fragment, gone. She’s very thin. She says, quietly, “Can’t keep food down.” She makes an apologetic shrug. It’s the only thing she says. She folds into the easy chair.
Her husband has walked in behind her, a big, sandyhaired man, a fireman. He doesn’t touch her or look at her. He stands across the room and squints. “I traded time with someone so I could make it after all,” he says. They have two kids. “Kluzko,” he says, introducing himself, wrapping a hand like a rolled roast around the doctor’s.
On Stearne’s desk is a letter from a surgeon in Boston:
I saw your nice young patient, Bea Kluzko, in consultation on Wednesday. She and her husband are certainly most delightful and pleasant people, and it is sad to see such a terrible problem thrust upon them. . . . The diagnosis is poorly differentiated adenocarcinoma of the stomach.
The cancer is gone now, along with the rest of the stomach. Stearne has told me that after removing the mass, he searched and found no visible metastases—“no macroscopic spread,” is how he put it—but that he had taken little reassurance from that fact, because of the sort of tumor he’d found. “The numbers aren’t good,” he said to me. “They give us little reason to hope.”
What he tells her now, however, is that a twenty-year study of adjuvant chemotherapy in gastrointestinal cancer has “given good evidence that we benefit people by giving this chemotherapy.” He tells her she’s fortunate, because an oncologist—a tumor expert—who helped in that very study lives in a city just half an hour away.
She doesn’t ask him about the therapy; she doesn’t even ask what he means by “benefit people.” She’s doing battle with the real issue. She nods a nod of assent so slight it might have been just an isolated tremor. Stearne says, “I’ll have the oncologist’s office call tomorrow to schedule a first visit,” and she slips back out of the office, followed by her husband.
Stearne calls the oncologist. He carefully describes the patient and her disease, then stresses her youth, her children, her career, her happy marriage, and he tells the oncologist he plans to suggest chemotherapy to her. The oncologist may be resisting the idea that he can help, because Stearne says, “What else can we do?” The oncologist must finally be persuaded. “Then you’ll call her tomorrow? Good.”
Stearne dictates his record of her visit at once. It ends with the curious sentence “Prognosis is, of course, guarded.” The prognosis is, of course, death. And what is actually guarded is Stearne.
Still later, I follow Stearne into an examining room. He sees a man who got kicked by a horse. He sees a newlywed, examines her breasts, and tells her that the lumps she has felt there do not alarm him.
“IT’S BLOODY’ G0ING INT0 CHESTS,” STEARNE explains. “On the way in there’s well-vascularized tissue.” The patient lies on her side, knocked out, with a table of tools swung out right over her head. She’s sunk in anesthesia, buried in green cotton. A teardrop section of rib cage shows through the draping, swabbed the familiar Betadine orange. Stearne has begun below the woman’s breast, cutting a sweeping curve along the contour of a rib, ending halfway down the left side of her back.
He cuts not with a knife but with an electric scalpel, which cauterizes as it cuts. The room, to my regret, soon smells of steak. “This makes things neater until we get through the area here filled with all these small blood vessels—they tend to be a little messy,” Stearne says over the sparking of the device. “There, now we’re going through the latissimus dorsi, the wide muscles of the back . . .” He puts two rubber-clad fingers under the wide muscles of the back, draws the muscles up away from the underlying surface, and cuts through them. As blood oozes, he clamps and stitches the cut vessels. He looks around. His gaze settles on the tamest, oldest nurse.
“Charlene, how long does pulmonary surgery usually take?” He asks the question with a baby-faced grin.
Charlene shrugs. Other nurses, caught in his gaze in turn, shrug. His partner Culver shrugs satirically. Even the anesthesiologist, staying out of trouble up at the end of the table, shrugs. A shrugfest. Stearne is meeting with resistance.
“Three hours, frequently, doesn’t it?” he asks the nurse.
“I suppose. It depends on the kind of pulmonary surgery, Doctor.” Her answer will have to do.
“Well, this is going to take an hour and a half.” He dissects inward, buzzing, stitching, deepening the smile he’s drawn.
“This is the rhomboid muscle, attached to the scapula,’ Stearne mutters. After a while he moves to the other end of the incision. “ . . . and this is the serratus muscle.” He again forces his gloved left hand under muscle, then halves the separated fascia with the cautery. “My partners and I have a lot of patients walking around town cured of cancer,” he says.
“Yesterday was her birthday,” says the anesthesiologist, looking up from his charts. I imagine the wistful comments that must have been exchanged in her hospital room last night.
“We usually take a rib out to do this. In this case”— Stearne pauses and counts ribs—“it’s the fifth rib.” With a sculptor’s tool, a long-handled blunt chisel, he strips flesh from the candidate rib. Three firm slides of the tool and it’s clean white bone. He works the chisel through the cartilage at the rib’s chest end. He holds the rib up.
“Spare rib,” he says, laying it on the specimen cart.
“There isn’t much meat on it,” the anesthesiologist says, cheerily. I think of studies showing that anesthetized patients register what is said in the operating room.
With the rib out, her lung shows, pale purple, like the skin of a boiled tongue, and as shiny as if it had been waxed and buffed.
Stearne lays down the chisel and the cautery, and reaches his hand, knuckles up, through the slot into the chest. He slides his fingers far up along the inside of the chest wall, toward whatever has made the shadow on the X-ray that hangs on the wall across the room.
Then, in a fiat voice, a tone laden with disappointment and guardedness, he says, “Ooh, boy. This tumor has gone up into the chest wall.”
It’s a verdict. The prisoner shows no emotion. She is fitted with a rib spreader. It resembles a large woodworker’s clamp, F-shaped and a foot long. A crank and gearing are built into the middle intersection, and prongs come out from the extremities of each crosspiece, like the legs of a trivet. Stearne fits the prongs of one crosspiece against the fourth rib, and the prongs of the other against the sixth rib. He cranks. The jaws spread, and the opening in her body, mail-slot sized, doubles in width. An elegant tool. It’s easy to see more lung now, and easier to take stock. He reaches back up to feel the tumor again.
“This may not be operable at all,” he says. “You got blood?” he asks the anesthesiologist. “If I take it out, it might be bloody. It comes right over to the aorta.” He’s feeling, reporting, working his hand in, feeling farther in. He shakes his head, draws his hand out, and sighs.
On the face of the upper lobe of the exposed lung, I see hundreds of black dots, as if someone had dabbed a fountain pen again and again against purple blotting paper. I ask about them.
“That’s not the cancer?”
“No, anyone who smokes has lungs like this. Also anyone who lives near a factory, or beside a busy road. Anyone who works in smoky areas, or where there’s carbon dust. Anyone who lives in a city. Environmental pollution looks like this.”
I look closely at the black spots. I wonder if the goals of environmental preservation would be more easily accomplished were we all transparent, like tropical fish—if our purple lungs showed their every foul soot spot right through glassy skin.
Culver reaches in and feels the tumor. Stearne feels the tumor some more, and describes what he finds for Culver’s verification: “The tumor surrounds the upper lobe and impinges on the artery there. Also on the aorta. Also on the chest wall. The inter-lobar fissure is complete.” Culver nods. Stearne thinks, and says decisively, “I am going to take the bulk of it out. If the arteries and veins are encased in tumor, you can’t. At least in her case the artery isn’t.”
“I’m starting a unit of blood,” the anesthesiologist says, “and, let’s see, pressure reading, one-ten.”
Stearne cuts, deep in the wound. He begins the resection in earnest. He’s focused, civil, at his tamest when in action. He talks constantly to Culver as he works. “I can get a tie around here . . . Yes . . . This will be a palliative operation. She’ll have radiation, too . . . Let’s see if I can get a little more, distally... a clip for there ... I think there’s a big patch under there . . . yes . . . Maybe it’ll be better using this . . . artery’s good around here . . . I’ve got to find the other branch now. . . Theoretically, without this lobe she’ll stand X-ray therapy better because there’ll be less broken-down flesh for the body to cart away. . . I can get to the end of that ...”
Culver, who has been assisting inside the wound, snipping sutures, probing and shoving tissue in order to display work better for Stearne, interrupts the monologue. “It’s a total loss,” he says. “Too much tumor.” It’s the first time he’s spoken.
Stearne backs up and pauses. He looks over at the nurse who wouldn’t tell him how long pulmonary surgery takes, and asks her a new question: “How are you, Charlene?”
“That’s good, because if you weren’t, it would ruin my day.”
He has the lung freed of most of its attachments. He folds it up out of the wound and invites me to inspect, gesturing into the cleared opening like a host leading a guest into the parlor, graciously. The incision is now a foot and a half long, half a foot wide, and a foot deep. In past the frame of the F-clamp, the gauze-cloaked sidewalls slope toward a pink, pulsing floor.
“That’s the pericardium at the bottom, with the heart just inside it, making it bounce.”
The pericardium shakes with sharp, healthy pulses. It is veined, like a leaf. Its rhythm matches the peeps of the anesthesiologist’s heart monitor. The abstracted sound I’ve heard on every hospital visit for a year signals this throbbing flesh. I back away, listening.
“It’s a very normal beat,” the anesthesiologist says, and sings along, “Ta-deet, ta-deet, ta-deet.” According to the clock on the wall, we are an hour into the operation. According to Stearne, we have half an hour to go.
He takes up his monologue again: “Now, then, this is one large branch going down there ... Do you have a fine stitch to put into the pulmonary artery? . . . There, you’re okay, yes . . . We control all arteries to the lower lobes, then the veins . . . Over here the lobes aren’t connected together by tumor . . . yes, they’re not . . . That’s easier than when they’re stuck together by lung cancer. In a case like that, though, a surgical stapler can quickly develop a fissure between the lobes. That’s one good use for it , .
Okay, let’s flip the lobe over. . The tumorous lobe, dangling from a tongs, comes up out of the incision farther.
I see the cancer.
It’s smog-yellow, and it lurks just under the surface of the lung, smeared around in patches, like skin-covered cottage cheese. Stearne clips in around the strands of tissue that still tie the lobe into the lung, right down at the edge of the pericardium. In a moment, the lobe is attached by only one thin strip of membrane. He draws it well clear of the wound. I can see across the arch of the chest interior to the far wall of the rib cage. The surgical lamps glow down through the skin. The view across the interior is like looking up at the arches and spokes of a pink beach umbrella.
Stearne points to the strand of lung running into the wound from the nearly severed lobe. “Is this anything important, Charlene?” he asks. “Is it okay if I tie and cut this thing here when I don’t know what it is?” He clamps and cuts. “Have you any 3-0, Charlene?”
Charlene passes along 3-0. Stearne stitches. Charlene gingerly lifts the detached lobe of lung with a tongs and drops it into a stainless-steel pan. She carries the pan away from the operating table, to the small cart by the door. I walk over to look. The lobe sits next to the rib. As I watch, it hisses, like a cut tire, sagging, losing life.
The same noise seeps from the severed bronchus, inside the patient, where the lobe joined the next lobe down. Stearne closes the breach with more 3-0, and says to the anesthesiologist, “Okay, hyperventilate the patient.” He spills a gallon jug of warmed saline solution into the patched chest cavity and stands watching the pooled water, alert for bubbles that would indicate leakage of air. When he’s sure she’s airtight, he drains the chest with an aspirator, then closes.
Stearne relaxes. His shoulders unhunch. “Many people don’t have too much pain from this operation,” he says, “but it’s variable.”
“Official name of operation for the form?” a nurse asks. Behind her, two other nurses count sponges, then needles.
“Left upper lobectomy.” The incision, stitched up, looks like two enormous pursed lips, beaming at the surgeon. He says, to no one in particular, “Taking out the tumor won’t affect the length of survival. It may make her more comfortable. It will stop her from being short of breath; tumor infiltrated the lobe we removed, so that blood pumped in there didn’t oxygenate. Now all the lung she has will oxygenate blood for a while. Lung cancer is very bad.”
Charlene is crawling around the floor at Stearne’s feet. “I dropped a needle,” she says. She finds it by a leg of the table. She groans getting back on her feet, and sighs. “I’m getting old.”
Unburied from the draping, the patient is eased from table to cart. Her rib and lung leave the room on their own cart, now draped as if the cargo were a tiny cadaver. We follow in a line as the patient is wheeled down the hall to the recovery room. The nurses there—among those in the hospital with the greatest opportunity to exercise their skill freely—flurry around the bed as it rolls into the recovery room. Stearne hands over the intravenous jars he’s held aloft during the short journey. The patient awakens quickly, and must, somewhere in her filling mind, hear a nurse, a big, sweating, red-haired nurse, talking quietly into her ear: “We’re going to be all around you, honey. You want your blanket pulled up? Is your hand hurting? There’s tubes in it is all.”
SURGEONS’ WORK NEARLY ALWAYS MAKES PATIENTS feel far sicker the hour after their operations than they were beforehand. Their treatment may well buy time, put the ill on the road to recovery, eventually ease pain. But all that comes later. The first task of the sick body is to recover from whatever the surgeon has done to it. A hundred thousand surgeons do things to sick bodies at the rate of about 25 million procedures a year, and get well paid for the work. While healing us, they prosper from occasions of our suffering.
Once taken into the profession, surgeons ally with one another to protect their privileges and wealth. They limit the quality and number of us who may become like them. They speak to each other in a private language. They have organized themselves as experts, insiders, declared us a public. They control an enormous and largely self-regulated cash flow—more than $10 billion a year just in compensation and many times that amount in money spent on surgeons’ authority or at their behest. And as they work, they discuss forbidden topics with each other—death, sex, and their own accomplishment—with the abandon of a huddle of twelve-year-olds. Daily, they have opportunities of a sort most people long to have—to be useful, instrumental, to do things well, to be paid well, and to work within a strong alliance of highly regarded peers.
“Surgeons are a bunch of bastards,” Stearne says, by way of explaining his trade. “Boorish bastards taught by boors—no, no—although that’s an old line, and it’s pretty close to how I’d characterize them.
“Here. Try this. They’re sensitive, caring guys who are completely capable of taking care of people. They are able, doing types, full of vitality and energy, and they like to take action.
“You’ve heard the story about the GP. the internist, and the surgeon? They go duck hunting. They make a bet. The guy who shoots the first duck gets his dinner bought by the other two. But if anyone shoots a bird that isn’t a duck, he pays the other two a hundred bucks. A flock of birds comes over, and the hunting starts. The GP says, ‘There’s a bin]—it looks like a duck . . .’ and finally he gets off a shot at it. The internist says, ‘There’s a bird—it looks like a duck . . . gee, maybe not . . . well, maybe yes, I’m not sure . . .’ and by then it’s too late to pull the trigger. Meanwhile, the surgeon says, ‘There’s a bird,’ and bang goes his gun. As the biid is falling, he says, ‘I hope it was a duck.’ ”
A few sociologists and physicians have undertaken studies that correlate personal characteristics with choice of medical specialty. A persistent social scientist named Henry Wechsler sorted through these studies and put their findings about surgeons together in two pages of his Handbook of Medical Specialties, which I paraphrase here, omitting the many footnotes but sharing some of the handbook’s language:
Surgeons are mostly males, and most come from families with many brothers. A high proportion went to public colleges, and had fathers and brothers who were doctors too. Only some have done remarkably well in college: three studies on the subject contradict one another. One reported that surgeons had low grades as medical students, another that surgeons’ grades were evenly distributed throughout their classes, and a third that surgeons were the best students.
Of all doctors, surgeons have been found to be most firmly set about their career choice. Studies of surgeons’ emotional lives reveal a group with things well in hand: surgeons tend to be low in neuroticism, low in anxiety about death, low in depression and nervous tension. The studies show men able to handle taxing emotional situations without distress, with thick skins, with self-confidence.
Surgeons are described by researchers as extroverted, easygoing, “oriented toward people,” emotionally expressive, and easily pleased (the last ought to worry any prospective patient). “They are not very reflective and have little tolerance for ambiguity,” are authoritarian, are stubborn, believe in the need for controlling dealings with patients. They are practical, realistic, not very “concerned with establishing warm and friendly relationships with patients,” because such psychological skills seem to them less crucial to healing than do the technical ones. They don’t place a high value on rapport with patients or on “the psychosocial aspects of medicine,” and feel “less bound by traditional roles of conduct” than other doctors do.
Surgeons score high on tests measuring aggression, dominance, endurance, perseverance, cynicism, compulsiveness, and memory for facts and details. They score low on need for introspection, emotional support, humanitarianism. They trust logic above feelings, aren’t very immersed in aesthetic and cultural concerns, and are good at and interested in handling tools, materials, and machinery.
“Finally, a high percentage of surgeons-in-training expected to earn a high income and tended to give great weight to the recognition and opinions of colleagues.”
This sometimes contradictory dose of social scientists’ wisdom, representing dozens of studies, stops at the office door. There’s nothing personal about the findings, of course; they reflect an actuality of aggregates, not of humans in particular—not Stearne, not anyone. But surgeons seem so often to embody the aggregate type to other hospital workers that the term “surgeon’s personality” commonly communicates something akin to the findings— an egotistical, emotionally cold, and skillful technician. Nurses at Steame’s hospital confided in me that he has “a real surgeon’s personality.”
Wounding in order to do good seems a particular and remarkable sort of occupation to wander into, and surgical rotation either repels or beguiles medical students considering the prospect of a lifetime of repeatedly re-enacting this formulation of saintly aggression. But finally, “surgeon’s personality” simply goes with the territory The circumstances of the job would seem to invite practitioners to develop whatever such traits they lacked when they first chose the work.
STEARNE OFFERS MORE CANCER SURGERY. I’M EAGER to go, and when I do, the room seems less exotic, and more humdrum, than it ever has before. I feel the logic of the full-time healer’s armor. It makes sense. To remain raw to the chanciness of life is to remain in mourning. A salute to the doers. Today this is a workshop with good tools, with craft going on. Wheel in the job, check the work order that comes along with it, fix things as well as they can be fixed, and on to the next. The jokes seem mild, a handy way to relieve the pressures of a long workday Old guy who’s rich asks young girl to marry him. What about sex? she says. In-frequently, he says. That one word or two? she says. On the table, another incision develops, getting down to more business.
The patient is a mild, gray-haired man not yet sixty. He appeared trim and pleasant when I met him the previous evening. His X-ray hangs in a light box behind the table. The shadow of the real thing, on film, leaves the malice of the disease unannounced. Only the gross trouble shows, and the patient’s fate depends on details, on millimeters’ difference of location, on the timing of the accident of discovery
Stearne returned to the hospital after office hours yesterday to study this film. He visited with the radiologist, then went upstairs to see the patient. The man’s head and hands shook as Stearne talked about what the films show. “As we mentioned in the office, it is a tumor, it is in the lower bowel, and it is about a foot above the anus. From this new X-ray, it does look small and easy to remove. We’ll take six inches of intestine on either side of it, and join the remaining bowel together—you’ll still have a colon, just it’ll be a little shorter. If things are as they appear to be, no colostomy You’ll never miss that section. Looks good.”
“I can’t understand it,” Stearne said, once we were out in the corridor. “I don’t know why he shook like that after I told him it looked okay. I still don’t think I’d react like that.” This time, I believe him. He’s got it all stored away, maybe for keeps. The patient and I are sentient apples; Stearne’s a sentient orange. Takes all types. Judge not. He gets the job done.
In the operating room, Stearne has dissected down to the site of the shadow. He grabs hold of the loop of gut harboring the offending tumor and feels it.
“It’s contained,” he announces. “This feels favorable.” He works it with his fingers. “It’s easy to mobilize. There are no attachments. It isn’t through the wall of the intestine. I can’t see it now, and that’s a very good sign.” He reaches up, then, under the intestines, and feels the lobes of the liver, where bowel cancer usually migrates, where bad news might still announce itself. He searches the liver with his fingers, and as he searches, he glances up over his shoulder, catching the eye of one of the younger nurses, one he knows cares especially about the fate of patients, and he says, “There appear to be no metastases present, left lobe, and . . . none present, right lobe. It’s clean.” No sighs of relief, but everyone smiles. The eyes of masked faces look nice.
A life is being saved. A newcomer could not see the rejoicing, but the procedure becomes downright festive. Nobody kicks up heels. It looks like yesterday and last week, except that the laughter sounds less strained. The staff and the surgeon have reason to feel useful and not helpless. To be on the job now justifies much other labor amid hopelessness. The cleaned end of the severed gut, clamped off half an inch back by duck-billed hemostats, is fat, roseate, like a baby’s pout after feeding. Stearne praises a prompt surgical technician straightforwardly, saying, “She’s good. She’s very good,” and even when he repeats the line every now and then until its meaning changes, he draws a chuckle or two.
As he jokes, he works, more gymnastically than he must during most operations. The surgical field is deep in the patient, diagonally in from the navel, below and between the iliac arch, and on down into the funnel of space inside the pelvic cradle. He sews with curved needles held in long-handled clamps. He is bent over, and under his gown, his hips rotate as he stitches, tests stitches, and stitches again. “She’s very good.” His voice echoes out of the damp abdomen. His surgical fields always end up looking splendid. A lattice of clamps suspends the site of his stitching in Fulleresque tension. “She’s very good.” He hands the severed foot of gut over to a nurse, for transportation to the pathology lab. He inserts a machine that looks like a caulking gun, and is in fact a colon stapler, into the patient’s anus, from the outside, slides it up the stub of gut still extending inward, slides the free end of the man’s colon down onto the machine’s tip from the inside, trims and tucks until all tissue is nicely placed, and then fires off a ring of stainless staples. Sealed, clean, cancer-free, the patient is again topologically identical to healthy persons, a torus, a doughnut, a solid with a hole through it, blood brother once more to every living thing further evolved than a paramecium. Into this patient, too, Stearne dumps a gallon of warm saline, as matter-of-factly as he might fill up a washbasin. No bubbles. Job done. He closes quickly. He sutures the scar with monofilament. He helps the very good technician undrape the patient. When he comes to the penis, he pauses and regards it. It’s pointed chinward, taped, a catheter emerging from its tip.
“You want to see an example of passive aggression?” he asks.
He yanks the adhesive off the penis, perhaps more forcefully than is necessary.
“There,” he says. “Now I don’t have to go home and kick the dog.”
SURGEONS DO BUSINESS EVERY TIME THEY OPERATE, and their business comes to them largely from other doctors who think well of them. Surgeons are, in that sense, doctors’ doctors, and their clients are not just the patients they repair but also the doctors who send the patients. Being successful as a surgeon has as much to do with diplomacy within the medical community as it does with surgical skill.
At the end of one long workday, following upon a string of similar days, with Culver on holiday, Stearne tiredly reflects.
“In medical school they told us you’ve got to know about how bodies work. They taught us that. All they ever said about the business side of things is that you have to know the three A’s, and that, they said, can’t be taught. Affability, Availability, and Ability—and in that order.”
“How do you rate yourself on them?”
“Ability—I’m very good. Availability—I’m a worker. I do pretty well there. Affability? I’m like most surgeons. I’m not too damned affable.”
In a recent typical month, one internist, following a steady habit, sent Stearne several patients, three of whom required hospitalization. Stearne and the internist, John Smith, have a cordial professional friendship.
I sought out Dr. Smith and asked him about his methods of making surgical referrals. He speaks in a low, confiding voice. “Stearne is one of two surgeons in the area I’d let operate on me for something serious,” he says. “Two others I’d trust for bread-and-butter things—gall bladder, appendix. Why do I refer to Stearne? First of all, an internist never refers to someone he doesn’t like and trust. I like and trust him. The next thing is, you first tell your patient, ‘You need an operation, so do you have someone you want me to refer you to?’ That’s standard. Just about every patient who has had surgery before will then name the doctor who worked on them. Occasionally that will be someone I wouldn’t send people to. So far, it’s been for minor things, and the surgeons they named were adequate, so I didn’t have to say anything.
“That leaves about 70 percent of my patients in need of surgery where, essentially, I’m the consumer. I’m the one choosing which surgeon to send the patient to. What do I do? I rotate, more or less, on the list of the four I’ve decided 1 especially trust. I make an effort to take personalities of patients and doctors into account, and also technical strengths of surgeons with regal’d to particular diseases. If I’ve sent a lot to one surgeon, I’ll send some to another. My guess is that I send Dr. Stearne about twenty patients a year. I don’t keep track; I could be off by a hundred percent.
“Stearne has his peculiarities. Not everyone likes him. I happen to. Very much. And he’s extremely technically competent. A little conservative about jumping in, say, on a patient he might think is too old, or too far gone, and he’ll say, ‘Well, it isn’t worth doing this procedure.’
“Something else you have to bear in mind about surgeons—some are lucky. Just lucky. Two surgeons do everything right, and one gets better results. The other one’s suture lines will separate, and he’ll get infections or postop complications. You can’t put your finger on it, and say it’s skill or judgment or care. Dr. Stearne is lucky. Some other surgeons around here are not. Dr. Goode is lucky. Dr. St. James is not. You see your patients over the years coming back to you. You hang out and you hear the nurses talking all over the hospital. You see other patients in the hospital, not just your own, and you hear talk about other cases, too. Those are your sources. After a while, you get to know who is lucky.”
This insistence by a man of science on the mysterious operation of luck seems inspired more by diplomacy than by the inscrutability of life. Having seen the same procedures repeated often, and by different surgeons, I have come to suspect that “surgeon’s luck” results from factors not closely associated with chance. Some surgeons are keener and better trained than others. They conceive sounder strategies. Beyond that are two traits that are virtually matters of character. One is mechanical finesse. Some surgeons—it takes only a few minutes of watching for even a layman to guess who they are—quite obviously are sound craftspeople, who do all manual chores nicely. Stearne appears to be in this “lucky” club. The valentine cards its members made in fourth grade to bring home to Mother no doubt arrived unwrinkled, and lacked any trace of white paste oozing between doily and backing.
The other telling aspect of “surgeon’s luck” is consistency—day upon day and moment after moment, relentless, mood-proof consistency. Surgery frequently gets tedious. Details take hours to do right. They’re the same details that took hours yesterday on someone else. Fixable mistakes get made, or step-by-step plans to do things routinely dissipate as unforeseeable interior conditions reveal themselves. Shoddy tissue turns up where sound mooring was expected, and an afternoon’s work lengthens into evening. The “lucky” surgeons are the ones with the patience and the self-abnegation to go on composedly, still taking all the care they can. Such luck calls for a passionate interest in each job, and a detachment from such private concerns as having dinner. Some surgeons I’ve watched have seemed in a constant contest to contain their own disorder. They scare the nurses.
1 ask Dr. Smith if he has seen Stearne at work, if he in fact had any occasion to judge his operating-room technique before putting him on the list of four trusted surgeons.
“No,” he answers. “I’ve never seen him operate. And I wouldn’t know what I was looking at if I did go in there, really. I haven’t spent much time in an OR since medical school.”
Then how, I ask him, can he form the judgment that Stearne is both lucky and extremely technically competent?
“I hear it—from operating-room technicians, from nurses in the recovery room, from the staff in intensive care. Between us internists there’s even a little hallway chat about surgeons—but in this city the internists don’t get together much to chat about anything. You don’t get much from the hospital committees that know what’s going on—the tissue-review committee, the surgical-mortality committee, the tumor board. Their procedures are confidential. It’s true, some extreme situations do leak out, and there’s a little information there.
“But now that I stop to think about it, I do actually feel fairly confident that I have had enough information to choose surgeons wisely for my patients. I have some of that information not from any official channels but because of—well, I might as well come out and say it—gossip, confidences of various sorts. I couldn’t refer well without confidences I shouldn’t officially have from nurses and from other physicians. It’s easy to cut yourself out of that sort of thing, too. Many doctors don’t talk to nurses. If you’ve got any sense, you keep your ear to the ground.”
I go on the gossip trail, ear low. I eat lunch with some of Dr. Smith’s secret sources. They don’t see themselves that way. The first lunch is with a cheery anesthesiologist, who turns out to be unabashedly discreet. He has overseen anesthesia in thousands of operations—many of them performed by Stearne upon patients referred to him by Smith. Anesthesiologists frequently come to reganl the surgeon as a client. They see their jobs as requiring constant diplomacy, and they are obviously right— their work can make surgeons look good or careless, and they observe every minor mis-cut, every sloppiness before it gets corrected, every rash maneuver that works out, every display of fear and temper on the part of every surgeon. Every mistake. They know everyone’s secrets, and they acquire protective discretion.
“I may think to myself that some surgery is better than other surgery,” the anesthesiologist tells me. “But there are many gray areas in medicine—almost everything is gray. If the medical community doesn’t have allegiances to each other, what will happen? If surgeons teel too vulnerable, they can’t work well. And the public has to have faith in something. The staff down in surgery are like blood brothers.
“Now, if a GP or an internist comes right up to me—and it’s happened all of three times in thirty years, even though I am, frankly, in a better position to know the best surgeons than most other doctors in the hospital—and asks me right out to rank the surgeons, I’ll refuse. Then, if he’s smart, he’ll ask me next, ‘Well, who’s your surgeon?’ That I will answer, and it’s Dr. Stearne.”
I switch from lunch to breakfasts, and eat shortly after dawn with nurses and with surgical technicians. While they do not work under the discipline of a partnership of colleagues, the sole employer of their skills is the hospital in town. They all have seen Stearne perform hundreds of operations—including those he’s done on Dr. Smith’s patients, aided by the discreet anesthesiologist’s anesthesia—and feel a need to be loyal to their friends and employers. They are aware of their replaceability in the hospital’s scheme of things. Still, they have seen a lot, and they seem also to wish to be frank about what they know.
An operating-room regular, a sturdy and very tall nurse who has scrubbed in daily for half-a-dozen years, speaks with similar bewilderment and frustration about her judgments of surgeons. “I may think,” she says, “that the operation is not going as well as it should, and I may think the problem is the surgeon is not as skilled as some others. But who am I to say? Alone, off by ourselves, we’ll call them names. We’ll make gross jokes about them afterwards. But actually we’re so busy—there’s always a next operation to set up for. You work with the same people—surgeons, techs, nurses—for years, and it’s tense sometimes, but we wisecrack. Still, you know, if I’m mad enough, I’ll talk some about what has happened. I know I shouldn’t. I’ve been scolded. But, hell, sometimes you have to say, even if it gets around.”
I admire the nurse’s loyalty. I also admire what I take to be her courageous indiscretions, confidences—perhaps made out in intensive care, to Dr. Smith, perhaps whispered to other nurses, in fury, in the recovery room, right after some bumbling procedure. She also feels loyal to patients.
Records of procedures are of little use in judging surgical quality. They aren’t routinely available to referring physicians for scrutiny. And, in any case, they record results that defy quantification—some surgeons who operate skillfully on the sickest patients have poor complication and survival rates. Others, who stumble through unnecessary procedures on nearly well patients, have fine-looking statistics. Sometimes the best shortstops in baseball make the most errors: they come close to making plays others wouldn’t even try.
Members of the hospital tissue-review committee, who check on most surgery that results in the removal of normal tissue and tissue indicating unanticipated problems, do become aware if a surgeon performs flagrant numbers of unnecessary procedures. They may eventually scold the offender, and inform the chief of surgery. And chart reviews of individual surgeons’ work are undertaken by hospitals, but only when long-recalcitrant practitioners resist more tactful pressure to reform.
Surgeons’ rights to entrepreneurial independence, and to the autonomous control of patients’ treatment, are well protected by custom and by law. The professional societies representing most of the surgical specialties have frequently resisted even such mild controls on the art of their members as issuing protocols suggesting which sets of symptoms ought to lead to which procedures.
The key issue of referrals goes beyond supplying knowledgeable recommendations to sick patients in search of surgery. It leads right to the adequacy of quality control in surgery. If no one is free to examine or to speak of the quality of surgeons, even within the profession, who is minding the gates? Who guards patients’ well-being against whatever misfits slip through and start careers as poor surgeons? And what happens at the other end? Who guards patients from the occasional surgeons whose quality of performance suddenly slides because of illness, alcohol, emotional problems, or—most commonly—advancing age?
The profession calls them “impaired physicians,” and state medical societies have standing committees to study the subject. Impaired physicians, once noticed, are leaned on, their practices curtailed and overseen—tactfully if possible, and strenuously only as a last resort. The long process of containing them starts with discreet gossip by dismayed colleagues. In one hospital, a senior man is said to be taking hours to do half-hour procedures, and seems to be getting lost in the middle of elementary anatomical excursions, and just the other day he was bailed out by soand-so, a passing colleague, and didn’t even seem to know it. Experienced nurses, mid-operation, utter reminders tactfully. Elsewhere, another unnamed man is rumored to have worked despite occasional petit-mal seizures during operations. And still another is remembered for a final year of operating under the influence of Scotch whisky.
Such stories are important, not as a warning off for prospective patients but because they demonstrate something about surgeons’ basic collective priorities. In the cases I have heard about—perhaps half-a-dozen described, and a few more mentioned—matters were handled tactfully, even though with each passing day a few patients faced unusual risks. Meanwhile, failing colleagues were “spoken to” over golf or beer, and urged firmly to retire.
The basic fact seems extraordinary on the face of it: there’s no dependable way that referring physicians can accurately judge the ability of surgeons. Those who are in the knowfeel they can’t tell all. Perhaps their indiscretions keep the system honest enough so that it usually works in spite of itself. Certainly nothing more formal helps out.
“THE SAME DIFFICULTIES THAT PREVENT YOU from continuing to practice effectively also prevent you from knowing that it’s time to quit,” Russell Stearne says. We are discussing impaired physicians. He is on his way to work. He is well rested, relaxed, unimpaired. “How incompetent do you have to be before the rest of the medical community calls you on it? That’s a tough one, a gray area. Should any surgeon not as competent as me quit operating? Should I quit because I’m not Denton Cooley?”
“Is he better than you?”
“Oh, he’s pretty good. Surgical competence isn’t really just about technique. An intelligent ape could be trained to cut and sew. The most important thing about competence is actually judgment, and to tell the truth, the one thing you can’t judge for yourself is your judgment. That’s where the problem of impaired physicians who won’t quit comes from. When your judgment goes, how can you know? I wouldn’t do any better than anyone else in telling that. I say I’ll retire by sixty. I hope I do. Then again, maybe I’ll go out and sell my soul to the devil so I never grow old.”
Stearne is ambling through the hospital’s long corridors, eyeing the competition, returning quips and curt nods from other physicians, He’s on his way to surgery, to perform an operation that is moderately elective—anytime in the next week will probably do. It will help the patient for a while, but not for long. The patient’s prognosis, Stearne says, is moderately poor. His foot has gone blotchy from occluded circulation. His attitude is moderately resigned—in Stearne’s office yesterday he didn’t seem to care much about what happened next. This will be his fourth, and most likely his last, bout of limb-saving vascular surgery. We encounter the patient now, parked on a cart by the elevators in the blind end of a hallway, accompanied by an orderly.
“Herbert,” Stearne shouts at the half-dozing man on the cart, “I’m going to have a look at some pictures of you— the ones we took before in X-ray. Then I’ll see you in the operating room. Don’t worry.” The patient nods agreement without opening his eyes. The elevator door slides open and the orderly trundles Herbert aboard.
Stearne continues up the corridor into the X-ray department, to collect shots of the occluded artery. “A walkingdisaster case,” he mutters.
The radiologist sits in her small chamber all day, lanky and black-haired, attending to ghostly pictures relentlessly and methodically. She recites a checklist to herself as she inspects each photograph. She says this wards off the carelessness of long habit. Radiologists’ rooms are always like inside cabins of a ship, cavelike and yet set in the midst of hospitals’ traffic flow. She peers into lungs and limbs, reconstructing three-dimensional trouble from anatomical shadows in two dimensions. All day, she whispers about what’s wrong, leaning into a small microphone cupped in her palm. Visitors interrupt constantly. She glances at Stearne now, nods recognition, and presses a black button built into her worktable. X-rays on a rack flip in sequence past the viewing screen above her. Ten patients’ troubles flash by.
She stops at the hip, the femur, the knee, of the walking disaster case and offers Stearne some vigorous medical metaphors. “He has a real pruned tree.” Her hand waves over an area of shadow where there should be a florid branching of vessels; only a few thin ones wander, branchless. “His arborization is crappy,” she says. To the radiologist, either vascular repair or amputation seems clearly necessary. She adds rodent insult to vegetable injury: with her finger she traces the popliteal artery; it thickens and thins with plaque on its trail down the thigh to a final clog. “It’s a very ratty vessel,” she says. Stearne picks up the Xrays and steps out into daylight for just a moment, then down, down into surgery.
In the dressing room, Stearne acts unusually cordial. He throws me a blouse and pants from the shelves of clean green operating-room clothing. I dress. We walk down the hall toward the operating room, and meet Culver. “Look at this man,” says Stearne, pointing at me. “I deliberately gave him an outfit that was far too large for him, so he’d look funny.”
Unlike radiologists’ caves, where hidden territory is revealed only to knowing eyes, operating rooms have windows. They look on to corridors full of passing surgical staff. There are no secrets within this secret place. The stainless-steel scrub sinks in the hall overlook a choice of two operations in adjacent rooms. Surgeons putting in their ten minutes of ablution keep entertained and up-todate on colleagues’ performances, joking with each other and studying hovering figures at work beyond the glass.
Stearne turns on hot water, stares into the operating room through the window, and scrubs hard. Herbert lies in there stoned out on Pentothal. Stearne watches as the staff works and chats inside. The discreet anesthesiologist stabs Herbert’s spine with a thick needle, paralyzing and numbing the legs. Two nurses lay green tables of silver tongs, pliers, tweezers, knives, small hoes, and scissors, and thread and tubing, both transparent and opaque. Things go on here, in spite of the windows. As I wander in, the nurses’ and technicians’ discussion smacks of sacrilege. Secrets are being discussed. A doctor working across the corridor, says a nurse, is taking three hours to do a twenty-minute job he’s never done before. Next topic.
“The girl that arrested here last week—the kid?”
“She died. Thursday”
“Probably best thing could happen—brain damage is what I heard.”
“Let’s not discuss it. There shouldn’t be a discussion here, understand?” The nurses all look at me.
Through the window I see that Culver has joined Stearne at the scrub sink. Culver winks as the nurses glance past me toward the window.
Stearne comes in, receives gloves, checks preparations, and shouts Herbert alert. He’s a stone-faced old man, with cauliflower ears, nose, brows, chin. In aquamarine paper beret, he resembles an old pope, eyes closed in prayer, lips pursed in concentration. He’s gathering strength. Never opening his eyes, he says, “I didn’t get to sleep until two A.M.”
“We didn’t want you to sleep all night. You’re going to sleep all day,” Stearne says to him cheerfully He finishes the orange paint job the nurses have begun on Herbert’s numb legs. The anesthesiologist sets up a cloth screen a foot high across Herbert’s neck, making two worlds. Herbert above. Herbert’s body below.
I look across the room, through the windows and down the length of the surgical corridor. No one in view. When I look back, Stearne has already made four diagonal slashes, each a few red inches long, deep, nearly bloodless, at intervals along the inside of the right thigh. Stearne sets about freeing what he calls “God’s gift to us—the saphenous vein.” It makes a straight run up from heel to the joining of leg and belly.
That homely, vigorous language of the radiologist shows again, returned to vegetable themes now. Stearne says he is “harvesting” the saphenous vein. He labors at the reaping. The vein begins to peel out intact, made of strong tissue, and wide enough to be useful in this operation. Stearne disconnects it from its roots, tying each tributary off in turn with black sutures, and, inch by inch, threads the freed vessel back from slit to slit. At knee level, with nearly two feet of saphenous vein dangling free, he’s got enough.
He opens and deepens a cleft directly under the arched meeting of upper and lower leg bones, in the depths of flesh below the knee joint. He ties off the saphenous vein, leaving its unneeded lower end behind. The freed section of the vein wanders out from this cave like a thin snake. He severs it from the body, carries it across the room to a green-topped workbench. He cleans the outside of clinging scraps, pumps it full of saline with a hypodermic, watches for leaks, closes up the few he finds with tiny stitches, then brings the vein back to the patient.
It’s to be installed upside down, so the vein’s valve flaps—which have prevented the column of returning blood within the leg from falling back down between heartheats—won’t block the flow of blood on the vessel’s new arterial mission. Stearne decides, for some reason, to chat up the patient again. Herbert dozes on, up at the top end of the table, keeping company with the anesthesiologist.
“Herbert, what’s wrong with your leg that brought you here?” Stearne shouts. Herbert opens his eyes now. They’re luminous, ocean blue.
“Pain,” he mumbles, and closes his eyes again.
Stearne re-enters under the knee, and dissects still further inward until he finds the popliteal artery. It’s pale, as thick as a fountain pen, and seems to deserve Stearne’s praise.
“This is soft and rubbery to here. Seems very good—I’m going up a little more.” He slices upward toward the hip a few inches farther. “Here’s the occlusion. Very well defined. Just like that X-ray.” He points. “We’ll come in just past it.”
To come in just past it, he will control blood flow to and from the chosen point, clamping off a section of popliteal artery He will puncture the isolated section of artery. He will spread the puncture into an oblate slit. He will shape the slit so it will kiss, mouth to mouth, the end of the freed saphenous vein, for the rest of the patient’s life. This kiss is the reason for the surgery It’s the opening of a new blood route, a way, for a while, around the pain.
Stearne’s stitches are tiny. Stearne calls for a new instrument: “That pair of Dr. Boswell’s glasses. I need ‘em.”
The circulating nurse, a willowy and fast-moving person about whom Stearne has said, “Lifts weights—she’s a body-builder,” slips onto the surgeon’s nose a pair of scholar’s black-framed spectacles. Upon their lenses are glued small, dice-shaped magnifying blocks. Stearne’s face moves lowly downward, like an anti-aircraft gun shortening range, raking the length of her body In a thin, robotic voice, Stearne says, “I can see right through your clothing now. ”
The nurse laughs a laugh that says Stearne’s acting up again, and she goes about her business. Stearne turns back to the cave, looking through Dr. Boswell’s glasses. He sews, and eventually says, “Through these glasses, this vein looks like a garden hose, and these big fat fingers get in the way”
Then he moves up to the soft tarpaulin of skin that spans the triangle of navel, pubic mound, and hip. He makes a new incision, and again dissects inward, again stitches closed bleeding vessels. He’s heading for the profunda femoris, to be the site of the upper anastomosis, a second kiss, and the source of new leg blood. In the midst of his search, he glances up and smiles at the aging nurse to his left, who is pinned in place by her obligation to hold on to retractors that stretch this new incision.
“You all right, Charlene?”
“Charlene thinks she’s all right.” No one laughs.
Stearne finds the artery, clears around it, chases it up through a hardened patch. “He’s got a very tight profunda block,” he announces, “and I’m going to do an endarterectomy.” An operation within an operation. He does what is required. He clamps the profunda femoris, fore and aft, ties tributaries, hauls Teflon ties closed to seal the area, and unzips the sidewall, revealing a two-inch run of plaque. He flays the vessel open, spreads it like the belly of a dissected frog. The plaque is white as soapstone, and the shape of an arrowhead. He slips the point of a tongs underneath, and works the plaque’s edge free of the intima, the artery’s inner wall. It comes away, for the most part, in one teaspoon-sized section. “That’ll make a tremendous difference in flow,” he says.
As he works, deepening, positioning, sewing, taking away, he accumulates scrap. Charlene collects it in containers, for the lab, where the pathologists will examine the tissue under microscopes. As Stearne pulls used sops from the wounds, the circulating nurse lays them out, each one a yard long and a hand’s width wide, blotched with blood, side by side on a green towel on the floor. She lines up a dozen, and suddenly they resemble bacon on a green griddle. The aspirator sucks blood and saline rinse through transparent tubing to a jug by the far wall; the suction sounds like bacon frying. Stearne calls for mosquito clamps and bulldog clamps. Time speeds.
The geography of the jungle cleft grows familiar, cliff of fat above red corrugated muscle floor. It becomes the only world, where all events take place, more real to us than the life out through the windows, where people laugh and, once, someone calls something out, just beyond intelligibility.
As he stitches, Stearne begins speaking of his new puppy “She jumps in bed at three A.M., loves snuggling. She discovers the cat asleep at the end of the bed, and flies off the bed, chasing it downstairs. The other cat, who sleeps down there, hears this. The downstairs cat hates the upstairs cat and runs out to meet it. Lots of hissing results.”
He calls for the weightlifter: “Remove Dr. Boswell’s glasses.” He halts her as she reaches for them. “One last look,” he says. He rakes her with them again. Then they get taken.
He is disturbed. He asks slowly, in a voice that sounds full of wonder, “Why does the surgical lamp keep moving?”
“It’s like the sun, moves slowly across the sky” Culver says.
Stearne begins sewing together the subfascia of fat.
Nurses commence sponge count in canon. “One, two (One), three (two), four (three) . . .”
The patient stirs. Culver dances past the table, heading for the outside world. “Another cure! O happy feet!” he cries, then exits, and waves back in through the window.
Stearne fires off long rows of stainless staples along the incision lines—zippers where mayhem just showed. Off drip, the patient whispers a question that comes right to the point:
“Is this going to take the pain away?”
“I’ve done the best I can,” Stearne says.