Surgical Reflections

A view from engineering: Part 1

Surgery’s a vividly visible part of medicine — every medical television show has an arrogant surgeon somewhere in the mix. It makes for compelling television, and it definitely makes an impression, but what’s surgery really like?

Here are a few things I came away with from my third/fourth year surgery rotations as a medical student. Uniquely, I’m still an engineer at heart (my medical school grades prove that) so I’ll try to take a systems-approach to my perspective.

Surgery is engineering

Surgery is not like engineering, it is engineering. The central drive is to achieve a goal, whether the science is there or not, in the messy real-world. Each patient is very similar (physiology) and very different (pathology, socioeconomics, etc.). The job is to use, or make, whatever tools you need to fix the problem.

This is pretty different from careful experimentation designed to reduce variability and isolate your interest. Physician-scientist programs are challenging in part because medicine and science cultures are diametrically opposed to each other. This is more vivid in surgery.

I never felt that tension. But I’ve also never felt like a scientist.

Where subsystems meet

Surgery, like engineering, involves complex subsystems interacting at all times. These subsystems are dynamic, variable, and potentially inaccessible. Anytime you have a surgery, there’s a lot of ancillary work that goes into accounting for all these subsystems, their variability, and their stability.

Ignoring a subsystem for convenience or rigor is a recipe for disaster — your patient’s blood pressure may not be interesting to you as you take the tumor out, but you don’t have much choice.

Neurosurgery has great examples of this — the perfect domain for biomedical engineers — because it always involve pressures, blood flow, electrical function, metabolic demand, and the systems that regulate all of those.

It can be very overwhelming.

Jump? How high?

Because even simple surgery involves complex interactions, and no two patients are alike, there’s a reasonable culture of “just do as you’re told.” This likely came out of necessity: asking ‘why?’ is (a) not fruitful when the science is so far behind and (b) a potentially dangerous waste of time when seconds matter.

This is very frustrating for a scientist but, unsurprisingly, aligned with a lot of engineers. Part of the reason for this is that it sets up the perfect environment to learn about complex pathophysiology using reverse-engineering — Sherlock Holmes style inference. Tracing back the reasons is, paradoxically, easier when you’re working with a complex system because you know the pieces move together in very un-random ways.

Rubber, meet road

That ‘unrandomness’ is important because of one important subsystem I haven’t talked about yet: the healthcare system this all lives in. And it’s a doozy.

Half the battle of a surgeon is with healthcare, not patient (patho)physiology. Which can be frustrating, but part of it makes sense when you realize two pieces: surgery is all about volume, and volume is unpredictable.

What is patient volume

Volume is how many surgeries you do, including how many specific types of surgeries you do. Institutions like Emory, in Atlanta, GA, have huge volume because we’re one of the few big players in town (there are issues with this I’ll tell you about later). That means we see a lot of patients, and a lot of different pathology.

Unpredictable volume

But volume isn’t easy to schedule — a lot of training happens in emergencies, and emergencies are random variables. Surgeons just don’t know when the perfect storm will hit, but they know it’ll hit a few times every week. That’s the job, and it’s unpredictable.

You have to be ready at any time for any thing, which can make dedicated time to focus impossible.

Your time is swiss cheese

Every day on surgery is a microcosm of medicine. While the whole day may be 4:30am–7pm, at the least, there are a reliable number of gaps in the day.

5:00am to 6:00am: checking on medical records from patients overnight, between yesterday evening and this morning. Writing down blood test values (what are we, in the 20th century?), checking on X-ray/CT scans, etc. This gives us an idea of where we’re starting the day with patients.

6:00am to 7:30am: is usually dedicated to checking in on groggy patients, making sure they’re stable. This is called rounding and is the closest surgeons get to the standard ‘medicine’ workflow. Except it’s a lot faster. Sometimes too much faster.

7:30am to 4:00pm: is spent in the surgeon’s workshop — the operating room. This isn’t a solid block — cases can take ~2–8hrs and in between cases there is a ~30min cleaning session. So this part is very variable without any fixed schedule at all. One thing that surprised me is that the OR has a social “mechanic’s garage” vibe, with so many people in and out trying to help get the job done.

4:00 to 7:00pm: Depends on whether cases are scheduled or if an emergency/addon showed up. You may be in the OR, you may be taking care of all the needed tasks on the patients that just got surgery, or the ones that are stable in hospital rooms.

7:00pm to sleep: for a medical student really depends on what they’re looking for in the rotation. You can fit in studying, research, or life before you’re exhausted. For a resident this is when they help the “night folks” get set up to do their job by finalizing outstanding tasks and medical notes from the day.

Overall, there’s a lot of work and a always something to do, but there is “downtime” in the form of 5 minutes here, 10 minutes there.

The problem? You have no idea when those gaps will be. Surgeries can take shorter or longer (always longer) than scheduled. Patients are rarely straightforward and surprises are expected.

Final thoughts

Surgery is an incredible, intense experience in medical school. A lot of it resonates with the engineer’s approach to iterative problem solving in complex systems, while deluged in noise. There’s a thrill that comes from being so right when the cards are stacked against you, while also actively saving lives in no uncertain terms.

In subsequent posts I’ll talk a bit more about specifics from surgery rotations, including how neurosurgery blends all aspects of biomedical engineering, how mathematical thinking is making its way into surgery’s intuition, and the way healthcare is imposing on surgeon’s autonomy enough to reshape the profession.

Neuroengineer, Control Theorist, Medical Student at Emory/GeorgiaTech

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