"You are born a surgeon or a physician, even if you don't know it, even if you never set foot inside a medical school."
The first thing you decide after medical school is whether you want to be a surgeon, a physician or a something else. Actually, it is less a decision than a fact, like your star sign. You are born a surgeon or a physician, even if you don't know it, even if you never set foot inside a medical school.
If you are brave and decisive and like cutting things, you are a surgeon. My dad was a surgeon; he quit school in year 9 and became a cabinetmaker. He liked to hunt, in the bush, in extreme weather conditions. People like my dad are always surgeons. If you like mulling things over, slowly accumulating data, without the need to draw a conclusion just yet, then you are a physician.
The taxi driver who took me home from work through Melbourne on a recent Saturday night was a physician. "Look," he said and rolled his hand towards the window. "What are all these people doing out on the streets in not enough clothes?" We paused at the intersection of Flinders and Swanston; we were two tired workers watching groups of revellers scream and gesticulate on mute. The driver muttered, "What brings them all out at the same time? How do they know to come to the same place?"
Surgeons spend a lot of time standing up; sometimes they stand up for days at a time. It became evident that I was a physician around the age of five: I liked reading, hated adventure sports and threw like a girl. I was at my happiest inside the house, supine for preference. But no matter how obvious it is that you are and always have been a physician, as a junior doctor you have to do at least one term of surgery.
I only remember a few things from my surgical term: very fast ward rounds; being sent out of theatre to re-scrub - again - because I'd forgotten not to touch my goddamn face; and one night shift when a nurse from ward G1 paged me with the message, "You'd better get down here; we've got sausages [meaning suddenly exposed intestines]." I didn't mind; I knew I wouldn't have to scrub in on a night shift. All I had to do was calm the patient, call the surgical registrar, describe the extent of the sausages and then continue dealing with all the smaller things that go wrong overnight on a surgical ward: vomiting, delirium, dislodged cannulas, catheters and nasogastric tubes. And the surg reg didn't mind me waking him up: instantly upright, like a flick knife, an urgent operation was his dream come true.
To become a physician, you work for five years in the hospital, then you sit some horrendous exams, choose your specialty, work in that specialty for three or four years, and after that, you can finally see a patient all by yourself. Surgical trainees follow pretty much the same route but end up with more arrogance and frighteningly dexterous fingers.
Take this as an example of the difference: there's a rapidly deteriorating patient in intensive care who has septic shock and a lactate of five. Some part of the patient is infected in a big way, but which one? The physician systematically searches for clues in the patient's history, presentation and physical examination. They order test after test until they've ruled out the lungs, the bones, the brain, the skin. The lactate level is rising; maybe the infection is hidden in the abdomen?
The patient is too sick for the scanner, so the physician calls the surgeon and the surgeon listens to the physician's five-sentence summary of the situation, pokes the abdomen, flicks through the available imaging and rings someone to prepare the emergency theatre. The surgeon explores the problem their way: they make a large mid-line incision through the patient's abdominal wall, stretch the hole open with stainless-steel clamps so the contents bloom up like a soufflé, and they sift through the organs and guts to find the burst viscus or infarcted intestine or whatever it is that's rotting away in there, trying to kill the body that supports it. Then they cut it out.
There's an old joke physicians sometimes tell: what's the difference between a butcher and an orthopaedic surgeon? The butcher knows more than one antibiotic. The joke mocks a surgeon's lack of medical - as opposed to operative - knowledge. The subtext is that you'd better not get sick when you have an operation, as the surgeon won't know which medicine to give. But here's a version no one tells: what's the difference between a butcher and a physician? The butcher knows how to fix a joint.
What happens when a patient needs a new hip joint and also medicine to fix an infection, high blood pressure or a speeding heart? I can't give a patient a new hip, but I can treat diabetes and optimise heart medications before the patient has their operation to help minimise the chances of them dying on the table. The surgeon sees the patient after the operation to check the wound is healing, the tubes are draining and that they haven't accidentally left something inside, while I work out why the creatinine has doubled, their ankles have swollen or they are suddenly short of breath.
The surgeon cuts out, saws off, sews in or reconfigures stuff; I fiddle with the pills. And it's becoming standard practice for us to do this work in concert. So, to my great surprise, I find myself back on the surgical wards. Who knew that staying home reading novels would lead to this? And I do feel at home: there's no need for me to stand up and scrub in.
