Bernard M. Jaffe, MD Professor of Surgery Department of Surgery Tulane University School of Medicine New Orleans, LA

In David Guterson’s lyrical novel East of the Mountains, Ben Givens, a retired thoracic surgeon with widely metastatic carcinoma of the colon, wanders into the countryside planning to commit suicide. As you might guess, in his final days he learns a great deal about the value of life. During his musings, he recounts the first operation he witnessed. It occurred during his military service in World War II. An injured colleague was brought to the first aid station. The field surgeon performed an emergency thoracotomy, did open cardiac massage, dealt with a subclavian vein injury, and saved the young man’s life. Givens, who had previously planned a life as an apple picker on the family property, was blown away. He was so impressed with the operation that he wanted to do the same thing. It was at that moment that he decided he wanted to be a surgeon.

Guterson romanticizes his protagonist’s decision and does so beautifully. Despite the fact that East of the Mountains is fictional, the plot is not farfetched. I feel certain that a few individuals actually do choose surgical careers based on a single event or after a similar revelation. But this select group likely constitutes only a tiny minority of our colleagues.

Most surgeons don’t know or can’t enunciate why they made their career choice. I must confess that I am one of those. I certainly know what I like about what we do, but these were not the components that excited me when I made the decision to become a surgeon more than 40 years ago. I remember being asked why I wanted to become a surgeon during internship interviews and always felt embarrassed that I never had a compelling reason. We still ask this question of applicants today, although I’m not certain why. The responses are never very revealing. The same is true for personal statements, in which applicants have to explain their reasons in writing. Most graduating students really struggle with this requirement and ultimately author a nonconvincing document that is more fictional than East of the Mountains. The fact is that most of us chose surgery because we liked it.

Despite the intangibles, there are some reasonable correlations among surgeons. The great majority have strong backgrounds or degrees in math, physics, or engineering. I would guess that structure and discipline are important components of a surgeon’s thought processes. As a corollary, relatively few surgeons majored in the social sciences or arts, bypassing the sublime in favor of the ridiculous. Like many of you, I could never get turned on by the touchy-feely approach.

Interestingly, if individuals are torn between surgery and another specialty, that alternative field is most likely to be psychiatry. I know many psychiatrists (personally, not professionally) who started off as surgical residents and switched during their training. I even know two surgeons who were psychiatrists first. This relationship between the two specialties is not widely known but has been carefully documented.

Approximately 30% of residents in surgical programs switch to other specialities. It’s often quite difficult to predict who will do so, but those at greatest risk are those who have wanted to be surgeons since childhood. To many such youngsters, surgery is simply a dream, a fantasy. Unfortunately, when they face the realities of day-to-day surgical life, the bubble bursts and its appeal is lost. In contrast, many of those who remain most loyal to the field expected to hate their student surgical rotations and found, to their surprise, that they loved it. Of course, a huge factor in career choice is the student’s role model. If the teachers I had in pediatrics had been as inspiring as the ones I had during my surgical clerkship, I might have become a pediatrician (Heaven forbid!).

Until about 10 years ago, it was much easier to predict who would become a surgeon. Typically, they were the trainees who worked the hardest and spent the most time in the hospital. Unfortunately, the 80-hour work week regulations have leveled the playing field and this factor is no longer valid.

There are a number of vagaries even within surgical residencies. We ask applicants if they are interested in academic careers and, to impress their evaluators, nine out of ten say they are. But in reality, few of us knew in advance that we wanted to be medical school faculty. If you had asked me during my internship whether I wanted to do research or become a full-time medical school faculty member, I would have categorically denied it. It was only after all the members of my resident class, including me, were forced to do laboratory investigation that I found I loved it and wanted to pursue a career that included research.

Despite objective criteria, including medical school grades, USMLE scores, and performance on the American Board of Surgery In-Training Examination, it’s very difficult”--”if not impossible”--”to predict which residents will excel. Obviously, there’s a lot more to successful training than intellectual acuity and building a database. A number of institutions have compared residents’ ratings at the time they completed their training to their position on the match list. There was no significant correlation in any of the series reported and, if there were trends, many of the best trainees came from the lower echelonsof the match list. Obviously, surgeons are no better judges of talent than NFL general managers.

It will be interesting to see whether performance on simulators and skill in video games can predict technical proficiency. There are not yet enough data to make a definitive assessment. Even if there is a good correlation, it will be relevant only for technical ability, which is but one of many skills residents have to master. Surgeons have to be smart, compassionate, and sociable, as well as facile.

When you are approached by a young person interested in joining our ranks, present the facts, describe the obstacles and possibilities, and ask, “So you want to be a surgeon?”