There is a reason surgeons are generally disliked by other physicians.  And a lot of other people, too.  A fair percentage of us are assholes.  While disagreeable surgeons may be easily found in every field of surgery, it is universally agreed that the biggest assholes are thoracic surgeons.  There are many reasons for this, generally relating to the type of person attracted to a program that requires every-other night call for upwards of seven years.  There are other reasons, too.

As a senior medical student, I considered myself hot shit.  I was smart and extremely hard working–in other words, I had no girlfriend.  As a hotshit senior medical student at an institution that considered itself to be the world’s best medical school, and destined in my mind to be a famous surgeon, I felt compelled to do an elective rotation on the thoracic surgery service at the University Medical Center.  The audacity of such a move cannot be overstated.  This was undoubtedly the most demanding rotation a student could elect.  Actually, the term most often used by my predecessors was “abusive.”  My two housemates, at the time, were both performing elective radiology rotations in Hawaii.  They came back tan and able to surf.  Also, with a condition that required antibiotics and, for one of them, eventually required clandestine child support.  I never left the hospital.

The thoracic surgery service was run by a young, brilliant, academically-trained surgeon.  For many, many reasons, too many to go into here, I regard him, to this day, to be the greatest asshole the surgical world has ever known.  I spent two months on his service, rarely leaving the hospital except to change clothes.  He never learned my name.  The tone of the service was evident almost immediately.  On my first day, I was told to scrub in on a complex operation being performed by Dr. Asshole.  This didn’t faze me, as I had already completed two lengthy surgical rotations and felt at home in the OR.  In addition, I had spent the vacation time prior to this rotation reading everything I could about thoracic surgery and Dr. Ahole’s publications–all of them.  I told you, I was hot shit–and had no girlfriend.  Anyway, I scrubbed in and introduced myself to silent nods all around.  Dr. Ahole seemed at ease, bantering with the Chief Thoracic Surgical Fellow as the operation proceeded smoothly.  I was familiar with the procedure from my readings and quite knowledgeable regarding the controversies surrounding it, as well as Dr. Ahole’s writings on the subject.  As the majority of the operation was accomplished and the chest was being closed, I gently but professionally asked Dr. Ahole a question; an insightful, sincere, and well-meaning question.  The question was greeted by complete, cold silence.  During this silence, Dr. Ahole stopped working, carefully put down his instruments, and looked me straight in the eyes.  “Who are you?” he finally asked.  I reintroduced myself, it having been a full forty minutes since I last told him who I was.  At this, he gently shook his head, picked up his instruments, and went back to helping close the chest.  During the subsequent eight weeks of working with him, he never said another word to me.  Great guy.

During this rotation I became good friends with the Chief Thoracic Surgical Fellow (CTSF), a very decent individual, married with two kids, who spent every single moment for two years in the hospital.  Every few days his wife brought his kids over so that they could all have dinner together and the children reminded that their mom really wasn’t a single parent, meeting lovingly in the hospital cafeteria.  She also brought him clean clothes for office hours and conferences–every other moment he was dressed in scrubs.  He was a great teacher and mentor.  About three or four weeks into the rotation, I was scrubbing with the CTSF, getting ready for a very interesting procedure.  It was one of Dr. Ahole’s specialties and he did a lot of them, patients coming from literally all over the world to have him perform the operation.  Usually, Dr. Ahole would appear about thirty or forty minutes into the operation, allowing time for the CTSF to get the patient positioned and the chest opened with the Senior Surgical Resident currently rotating on the service.  On this day, however, Dr. Ahole suddenly appeared and started scrubbing with us.  He was in an exceptionally good mood, joking with the residents (and, of course, completely ignoring me).  Just before we’re all ready to quit the sink and head for the OR, Dr. Ahole turns to the CTSF and asks, “So, Paul, how long?”

“I’m not betting,” Paul, the CTSF, replies.

“You have to bet, Paul,” Dr. Ahole responds.

“I don’t think it’s right, Dr. Asshole.  I can’t bet you.”

“If you don’t bet, Paul, you might as well scrub out because I’m gonna do the whole goddammed case with whoever this asshole is (nodding at me), then.  You won’t touch the knife.  So, how long?”

The CTSF shrugs, “Fine.  Thirty minutes.”

“Great, thirty minutes, twenty bucks.”  And Dr. Ahole sweeps into the Operating Room.

“What was that?” I ask the CTSF

“Shut up.”  He followed Dr. Ahole into the OR, and I followed him.

Dr. Ahole, as Chief of the Division of Thoracic Surgery and a very busy surgeon, had his own operating room with a dedicated team of nurses and technicians.  He had been at The World’s Best Medical Center for quite a while and his team was exceptional.  As a testament to their experience and competence, whole procedures would often be accomplished without the surgeon ever asking for an instrument.  He would put out his hand and Stella, the scrub nurse, invariably slapped the exact right instrument into his palm without the great man’s eyes ever leaving the operating field.  In two months, I never saw her give him anything except the exact right instrument without so much as a fraction of a second’s hesitation.  Stella was a middle aged African-American woman, tall and soft spoken, who scrubbed on all of Dr. Asshole’s procedures.  The two circulating nurses on the team were just as dedicated and competent.  Every operation was like a beautifully choreographed ballet.  And there was never any doubt in the room about who was the principal dancer, maestro, and sovereign authority.

On this day, however, it was immediately apparent that something was up.  As Dr. Ahole dried his hands, he asked Stella how she was doing, and made small talk about her family.  “Just fine, Dr. Asshole, thanks for asking,” Stella replied, smiling.  I’d never seen him so personable.  Maybe my impression of him as the world’s biggest prick wasn’t completely accurate, I remember thinking.  “Everybody all set?” Dr. Asshole asked jauntily.  Everybody enthused their affirmatives, and the CTSF made the incision.

The operation was going great,  Dr. Asshole was letting the CTSF do most of the work and Paul was an extraordinarily skilled operator. Dr. Asshole was actually complimenting him on his technique.  About twenty minutes into the operation, Dr. Asshole, in a completely nonchalant tone and without looking up, asks Stella for a curved Satinsky clamp.  Immediately, Stella shot a glance at the circulating nurse.  The circulating nurse bolted for the door.  Dr. Asshole still had his hand out.

“Dr. Asshole, that clamp is not on my field.  I’ll have it for you in sixty seconds,” Stella stated calmly, though I could tell she had blanched above her mask.  “Is there another clamp that will suffice?”

Dr. Asshole stood up straight and looked aghast.  “You don’t have the Satinsky?” he asked, incredulous.

“Dr. Asshole, we’ve done this operation together over one hundred times.  You have never asked for the Satinsky before.  That clamp is not on the tray.  I’ll have it for you in  thirty seconds,” she responded smoothly.  She was right, of course.  I had, myself, scrubbed with him twice earlier in the week on the exact same procedure and he hadn’t asked for the clamp in question. I had no idea what was going on.

“My God, woman!” Dr. Asshole suddenly shouted.  “How the Hell am I supposed to do this operation without a goddammed clamp? Huh?”

“Is there another clamp I can give you, Dr. Asshole?”

Dr. Asshole reached over onto her tray of instruments, something that I’d never seen any surgeon do before.  The scrub nurse’s Mayo stand was her territory and sacrosanct.  It was almost as if Stella had reached over into the wound to pinch the heart.

“Just give me a fucking clamp,” he growled.  As he grabbed a clamp off of the tray in front of Stella, he knocked about twenty carefully arranged instruments crashing to the floor.  Stella’s eyes were wide above her mask, but she said nothing.  Dr. Asshole began to roughly dissect in the patient’s chest cavity with a long right angle clamp he had grabbed from her tray.  At  this moment, the OR door burst open and the circulating nurse skittered in, breathless.  She smoothly delivered the Satinsky clamp onto Stella’s back table with the practiced motion of a professional baseball pitcher.  Stella smoothly proffered the clamp.  “I have the Satinsky, Dr. Asshole,” she said flatly.

But at this point Dr. Asshole was loudly cursing into the wound as he roughly dissected in the chest.  Dark blood began to well out of the chest cavity.  Paul had become a statue.  He looked like he was in pain.

“Look at this, Stella,” Dr. Asshole nearly screamed.  “Now he’s bleeding, he’s goddammed bleeding because you don’t have the tools I need to do this operation.  This guy’s gonna bleed out because you didn’t think to have the tools I need.”

“I have the clamp now, Dr. Asshole,” Stella repeated.

“Too late, goddammit,” Dr. A snarled.  He grabbed the clamp from her and hurled it across the room, just missing the circulating nurse.  It clanged off the wall behind her.

Stella looked stricken.  There was a brief moment of silence as we all looked at the merlot colored blood welling up from the chest cavity.  Suddenly, Stella burst into tears.  She muttered something apologetic about having to step out for a moment.  She ran from the room, pulling off her gown and gloves.

The operating room was stone silent.  Dr. Asshole looked at the clock, then at Paul standing on the other side of the OR table.

“Twenty-four minutes.  You owe me twenty bucks, buddy.”