“A good surgeon also has to have compassion and humanity, and not be someone who is arrogant and difficult to deal with.” – Dr. Thomas J. Russel (former Executive Director of the American College of Surgeons, New York Times interview)
“Like a Surgeon” – Weird Al Yankovic
Operating, like a surgeon.
I hear the comments frequently; in fact, I hear them all the time. At work I hear them from staff, from patients — even from non-surgical colleagues. I hear them away from work, when meeting new people who find out that I am a physician and a surgeon. I think many women surgeons hear the same:
“You’re not like a surgeon. You’re not like other surgeons.”
The comments tend to run along the same lines. You don’t look like a surgeon. You don’t act like a surgeon. You’re too nice, too caring, too compassionate, too thoughtful, too communicative (sometimes, too pretty). Most of the time, the comments are offered as compliments. They are proffered in a context attempting to make me feel welcomed and appreciated.
I understand these comments are meant as compliments, but what do they say about surgeons? And even more specifically, about women who are surgeons?
We all have stereotypes. They are a shortcut we all use to help us understand the people and world around us, especially the unfamiliar. But the unfamiliar becomes familiar, and people and groups evolve and change. Stereotypes are mired in ignorance and misinformation, and they help us to resist that change. At that point they do not serve any purpose, and in fact, harm rather than help.
These comments and compliments speak to the stereotypes of who we think our doctors are, what surgeons are like, speaking volumes about the image of surgeons. It is an image as unfair to men as it is to women. The stereotypes color the way surgeons, male and female, are perceived. So no matter what the behavior or intent, the filter of the stereotype colors the perception. This is not only a disservice to the surgeon, it can substitute dysfunction for function on a team, poisoning communication and interaction.
So, what is the surgical stereotype? Do I even have to ask, do I have to even tell you?
“Stereotype Surgeon” is a (usually) white man with a testoserone-infused swagger, confident and brash, charismatic, commanding. Arrogant. Volatile, even bullying and abusive. Aggressive. Cuts first, asks questions later, because to cut is to cure, and the best cure is cold, hard steel. Sometimes wrong, never in doubt. One of the Good Old Boys club. Good with his hands, but no time to explain; compassion and communication are for sissies. There are some positive characteristics, like from this KevinMD post from a medical student’s point of view: “decisive, well organized, practical, hard working,” but then you get “cantankerous, dominant, arrogant, hostile, impersonal, egocentric, poor communicator.” Oh my.
Then there is the Woman Surgeon. Cold, impersonal, moody. Micromanaging shrew, castrating harpy bitch. Bitch, Bitch, Bitch, that seems to be the most common descriptor. Makes the stereotype of a male surgeon seem all warm and fuzzy by comparison. It is cold comfort to share that title with our OB/GYN sisters, and many women in medicine, and women in any profession. It has taken me a long time to realize that it is the title that accompanies any woman in authority, especially with a powerful or critical role. It says more about the person naming than the woman thus named.
I believed the surgical stereotype, too, when I was in medical school. At the end of my second year, we were picking the order of the clerkship rotations for the third year. Although our upperclassmen and subsequent experience told us that the order of the rotations wasn’t that important, we stressed and obsessed about it anyway. I clearly remember the conversation I had with my Dad that spring, as he was driving me home for the weekend. The gist was: I would be doing my surgical rotation first, but that was fine: It was going to be the hardest rotation, and I would get it out of the way. I would learn the ropes of being on the hospital wards, and be well prepared to shine the rest of the year. I knew I would not be a surgeon anyway, so going first wasn’t a problem. Surgeons were all men, chauvinistic and sexist and overbearing, and I (as an enlightened Women’s College graduate) did not want to fight that battle over and over again. Besides that, all of the men in my medical school class who wanted to be surgeons were <<jerks>> (I used a different word), and I did not want to spend the rest of my career surrounded by <<jerks>>. I have been eating these words ever since. (By the way, most of those <<jerks>> did not end up in surgery, after all.)
I was so wrong. My rotation was great. I learned an important lesson about stereotypes, and especially the surgical stereotype. I was forced to revise my impression of surgeons and surgery. I eventually realized that I wanted to be a surgeon myself, and just like the surgeons I had seen.
I would not be here if the surgical stereotype were true. My surgical mentors, male and female, have been among the most compassionate and sensitive of the doctors I have worked with. Thoughtful, communicative, empathetic, respectful to patients and each other. Smart, passionate, enthusiastic. They have been my role models in surgery and in life, good people in and outside of medicine. All of the best characteristics I carry through my career, that I get complimented about, the things that do not seem so “surgical,” have been reinforced by, if not modeled on, those surgeons around me. My teachers, professors, attendings, mentors, colleagues and peers. I am a surgeon because of them showing me how, not just the surgery and operating, not just the patient care, but by the example of their lives and careers. They are being themselves, empowering me to be my self.
So you see, I am exactly like a surgeon, exactly like those surgeons.
That stereotype of surgeons, and women surgeons, is not me at all. It is hardly anybody.
This stereotypical behavior no longer has a place in modern medicine or surgery. Organized surgery has been working hard to dispel and defuse the old surgical stereotype. There is a very real and tangible effort to identify and eliminate the behaviors that reinforce the stereotype. The stereotypical behaviors are classified as disruptive, and the surgeons who display them are marked as impaired and interventions recommended.
Dr. Wen Shen asserts in her thoughtful piece that the “kinder, gentler surgeon” may be less effective. I disagree.
From burnout and substance abuse to patient care and risk management, the data support the collegial, compassionate surgeon over the bully. Surgeons love their sports analogies, and it is the same when we talk about the surgical team. Surgeons may be the captain of the team, and even occasionally the coach, but must always keep in mind that it is indeed a team, and we depend on the efforts and enthusiasm of that entire team.The importance of team-building and leadership is central to surgery, and always has been. It is even more important as we move into the future form and practice of medicine, and both these behaviors and the perceptions/expectations of these behaviors will not serve. It is the role of the leader to motivate, inspire, lead, educate, guide; not cajole, bully, dictate, humiliate. Data supports the functional, cooperative team model. “Nice” may not be the same as “good”, as the author asserts; but nice and good can and do coexist, and can live comfortably with “confident” and “self-assured”.
Celebrate the surgeons who are compassionate and caring, thoughtful and communicative, meticulous and skilled. Yes, and bright and enthusiastic, hard-working. Detail-oriented. Commanding, assertive, leaders, teachers. We must be all of these, for we must make decisions when there may not be enough time or information before we must act in critical situations, navigating high risk and high pressure. We have to choreograph and then lead the dance that is an operation. We have a strong sense of responsibility for those in our care, to make sure our hard work and the patient’s recovery turn out for the best. Motivating the team, even as we lead them. There is room in the House of Surgery for men and women, and for diversity. This is the new stereotype.
It is also the old stereotype; I am heartened by words that reach out from the 13th century:
It is necessary that a surgeon should have a temperate and moderate disposition. That he should have well-formed hands, long slender fingers, a strong body, not inclined to tremble and with all his members trained to the capable fulfilment of the wishes of his mind. He should be of deep intelligence and of a simple, humble, brave, but not audacious disposition. He should be well grounded in natural science, and should know not only medicine but every part of philosophy; should know logic well, so as to be able to understand what is written, to talk properly, and to support what he has to say by good reasons. – (Chirurgia Magna, 1296, Guido Lanfranchi; Italian-French physician and surgeon who was one of the first to promote learned medicine in medieval Europe, and is regarded as the founder of surgery in France)
So, I will graciously accept the comments as intended, as compliments, but also answer humbly that indeed, I am exactly like a Surgeon.
Hi Dr. Hughs and Dr. Cochran. This drmuchogusto from twitter. I read a lot of your posts on twitter and your blogs as well, you both are amazing. I’m speaking as a rookie in this field. During my initial yrs of med school, I never had intentions of going into surgery. In fact, my mentor as a MS would explain to me the future problems in surgery and the stereotypes involved. Then people love discussing reimbursement, etc. It’s amazing how the stereotypes live on because people in our own field have not moved on. I had my GS rotation late and maybe it was a blessing. All the stereotypes presented to me were all wrong. The GS attending I followed majority of the time was the most amazing doc and person. I grew into a young man/doc observing him and listening to him teach me. His repertoire with patients went above and beyond and his interaction with staff was exemplary. I absolutely loved being in the OR, being part of the surgical team, and saw what a positive impact my attending was having at the bedside. I feel very lucky. I have seen unprofessional behavior in other univ hospitals by surgeons. I feel the stereotypes that are defined for a surgeon, very much overlap in other fields of medicine because of the rigorous hours and stress. There was one univ I did a visiting rotation at that did have 1 GS res who was female in the program. She looked beat up, tired, bitter, etc. I decided I wanted nothing to do with that program in the future because it had many of the aspects/stereotypes discussed above. The reason I bring up this ex is because I strongly believe that we as doctors or surgeons do not support each other enough. I remember this same program where this young lady was a resident, she was among men who were not respectful. In fact, many of the men were competitive with each other to the point I do not think residents were learning form each other. I found it to be a malignant program and it started with the leadership of the program and it was a “well known” program. I feel that we need to listen to each other better and this was not happening in this program. The young lady was labeled many of the stereotypes that are common for female surgeons. I just feel if someone with the faculty sat with her and really listened to her, she might have been more warm with others. She would be happier to be a part of that program. I do think when we go 100 percent all academics, all about absite, all about performing surgery, all about pt care, then a lot of problems occur and these stereotypes are brought out. We need to be about life and taking care of each other too. How many programs out there have residents and attendings that don’t know much about each other. It really happens more often than we think. So while my experience has been amazing and I have focused on the people who have impacted me to become not just an excellent surgeon, but an all around excellent doctor/person. We cannot focus on the one or two people who ruin things, but we do need to get these people help to find out why. Is it burnout, is it family, is it the leadership etc? Its amazing when I share a part of my life that might not be going so well, then a colleague might share something similar. Thank you so much for your contributions and wonderful blog. Sorry, I typed this so fast. Have to go work!!
Dr. Hughes – I really enjoy the perspective of your writing. Over the past year I have had the privilege of being the patient to two exemplary surgeons. From a patient’s perspective, there is nothing more comforting when you are valued as a team player in your care. My sense is you make your patients feel very much a part of your team in regards to their health. Cheers!
Thanks for your comment and kind words, Terri! I’m glad you had a good experience with your surgical team. I certainly try to provide that good experience too!
There has been a continued shift in medical and surgical care that has been evolving in the years (decades!!?) since I was in medical school. The current term is “patient-centered care”, with the combination of patient education and patient empowerment in the decision-making process and treatment plan. The older more paternalistic model is giving way, though vestiges and hints of it may remain (primarily because of the expertise and knowledge imbalance between physician and patient).
Communication is key in this, protecting the time needed for good communication is a challenge. It will take the teamwork of patients together with physicians to push back on the systems that are eroding the time and space for physician-patient communication. This is one of the important issues where the patient voice may be stronger, a more important part of the team. So you see the team style approach works for all the players!
Thank you. I needed that 🙂
Kris, sorry that I can’t reply above for some reason-
The unmodifiable, or less modifiable, factor, is someone with a personality disorder and who is predisposed to bad behavior.
And yes, assault is beyond the pale ALWAYS. Even when we have “grey zone” discussions about the particulars of what constitutes disruptive behavior, that’s never in question.
Thank you for the reply. I appreciate your input and perspective, as it is very interesting.
Being a huge research nerd, I couldn’t help myself from reading your paper, “A model of disruptive surgeon behavior in the perioperative environment.”
It is very interesting, and I like that there is an open dialogue about it.
I can say from a med student perspective that those who are drawn to surgery sometimes have those personality flaws. I see it in my classmates. They buy into the surgeon stereotype and are a pain to work with, because they are so “poorly behaved” and are struggling with larger issues outside of medicine.
I often wonder if GS programs can see through their facade. And if they do, do they even care?
I feel so identified with your words.
When I was a medical student, I used to think that surgeons only operated. After my first General Surgery rotation, I realised that surgeons are doctors, that besides, can operate.
Now I am a general surgeon as well. A woman surgeon. A surgeon who tries to become a better surgeon everyday. And I don’t think that a surgeon can’t be nice, communicative… We are human beings taking care of another human beings, not only an “operating machine”.
I really appreciate your blog (just discovered today). Thank you for writing.
PS. Excuse my English… I guess I made lots of mistakes 🙁
Sofia, thank you for your comments, beautifully stated.
(I must disagree with your assessment of your English skills
Dr. Hughes,
Kudos!!! Have you read “The Woman in a Surgeon’s Body?” Your work reminded me of it, & you might enjoy reading it. I’m so on board with everything you’ve said. I’ve finally (!!!!!) finished with training, and am in my first job as a vascular surgeon. It is true that the good ole boy surgeon is a dying breed (hooray!), but there’s still quite a few lingering (especially in the south where I trained). But I’ve noticed that patients don’t respond to that type of physician approach anymore. They want someone that is kind & that actually listens to what they’re saying…in addition to being technically skilled. Just wanted to say thanks for writing this. It’s nice to know that there are others who feel the same way I do.
To Dr. Hughs,
In response to this wonderfully written and beautifully crafted piece, I will make my argument with a simple question. How many thrown scalpels/scissors have you seen or been documented at hospitals that you have worked at?
Btw, you have a very unique voice that I enjoy reading.
Thanks for your comment, Kris. I have certainly seen behavior as you describe, maybe even worse. However, even many years ago when I was a baby surgeon, the shift away from tolerating and accepting this behavior started, and today it is viewed as completely unacceptable. Regional variation, differences between large urban academic centers and small community settings? Sure, but the view of this as inappropriate or even impaired behavior is nearly ubiquitous.
I wanted to point out by writing this piece that even “back in the day,” the stereotypic surgeon was a minority. By virtue of the outlandish behavior, charismatic personality, and power/position, those surgeons were highly visible, and made a huge impression. The “one bad apple” principle certainly holds here,and certainly colored/colors the way all surgeons are viewed. I’m certain there are a few hold-outs, even today. But they are, thankfully, a dying breed, and not representative of the majority of surgeons.
Take care, thanks for following/reading!
What do you think is the best way to handle these holdouts?
Often times, these doctors are reprimanded but their malignant behavior manifests and persists in different (and sometimes worst) ways.
How else do you suggest we change this stereotype other than punishing the bad ones and celebrating the good ones?
Kris, really good question. First, and importantly, there has been a shift in the culture of medicine and surgery labelling this as inappropriate and unacceptable. To some degree, peer pressure both from surgeons and non-surgeons (yes, referring physicians) can work to a degree. It takes time for a shift like this to impact established behavior, but I have to believe that it discourages future surgeons from adopting this style.
At the level of the American College of Surgeons, and many other medical organizations and societies, these are identified as behavior issues, and as as such are treated under the umbrella of physician impairment. Rather than simply reprimand and punsishment, which still may be used as a consequence of the behavior but which could backfire, there is training, coaching, and even counseling. This approach may have a more durable result.
Hi, Kris- I wanted to weigh in because this is an area I research and have a strong interest in.
The modifiable piece of the “bad behavior” puzzle is culture- a culture in which it is not tolerated, and a culture in which people who cannot behave in a civilized manner (which can include persistent “insidious” behaviors) are “excused.” More chairs in academic departments are making the hard choices to get rid of surgeons, some of whom make the hospital a lot of money, because they are more of a liability than benefit.
This behavior deters students from entering surgery when they do witness it because they don’t want to become one of “those people.” And honestly, when we have such a great profession, that’s both a shame and a loss.
May I ask what are the “unmodifiable” pieces of the puzzle? This too is a very interesting (or rather concerning) topic for me.
IMO, I should never be assaulted with sharp objects in the OR.
Hi Kris, Thanks again for keeping the conversation going. I don’t want to speak for Dr.Cochran, as she is expert in this, but I imagine her to mean that we are empowered with others to change the culture; the person has to change him/herself and behavior, we can’t do that for them. I will be interested in what she may add, if she is following the thread.
I’d ike to explore more, and will reach out off-line.
I’m one of your “Ob/Gyn sisters”…I also like to think I don’t fit the unfair stereotype.
Great post…I think the characteristics you describe are those of great leaders in any field. We should all aspire to be like “surgeons”. 🙂
Thanks for the comment. It is a work in progress, aspiring to be like those exemplary surgeons, but they inspired me to keep trying!