Unkind Cutter

The Making of a Surgeon

by William A. Nolen M.D.
Random House, 270 pp., $6.95

William A. Nolen’s father was a lawyer. “Billy,” his son quotes him as saying, “if you’re smart, when you grow up you’ll be a doctor. Those bastards have it made.” Billy did grow up, and did become a doctor, and does have it made, at least according to most of the criteria of our society—money, of course, but more importantly status and power. Now Dr. Nolen, practicing general surgery at the Litchfield Clinic in Minnesota, Chief of Surgery at the Meeker County Hospital, and a part-time clinical instructor at a university-affiliated medical center, has attempted to describe the “tedious, painstaking, laborious and time-consuming process” by which he became what his father hoped so earnestly he would become. He has produced (“written” seems almost too generous a term) a dismal book, which, nevertheless, if closely read, reveals much about contemporary medical education and practice.

The Making of a Surgeon is an account, episodic and roughly chronological, of the author’s five years of training in Cornell’s surgical division at Bellevue Hospital in New York City. Those years of internship and residency are, as Dr. Nolen correctly notes in his Introduction, the critical apprenticeship period in which a young doctor is transformed “from a helpless, frightened medical school graduate into, hopefully, a capable confident surgeon.” The transition is indeed fascinating, almost magical; in the operating room it can be measured by subtle details that may, under stressful circumstances, mean the success or failure of one phase of an operation: the speed with which a knot is tied (tight enough to hold the tissue, not so tight as to destroy it); the ease with which an elusive “bleeder” is located and clamped; the dexterity with which a vessel is “stripped” or a segment of small bowel sutured.

Dr. Nolen has, disappointingly, passed over most of these details. How are such skills gained? What is the relation between acquiring them and learning how to “manage” a surgical patient? What is the relation between the science of surgery and its art (for the distinction here is real, however misused)? These questions he has been unwilling, or unable, to answer. Instead the reader is given such homilies as “The man that suffers through it will never forget it. I never have.” Or: “But when it’s all over and the new surgeon is turned loose to practice his art, somehow he’s ready. He has to be.”

Dr. Nolen’s failure to describe the evolution of surgical skills (his own or anyone else’s) is paralleled by his failure to describe another critical aspect of the discipline, though a much neglected one—its aesthetics. After even a week “on” a surgical service one understands how much a craft surgery can be—intricate and immensely satisfying, at times beautiful, even sensuous. Yet for this the author expresses no feeling, which suggests a larger and much more serious deficiency of the book and of its author. Dr. Nolen, at least as he …

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Getting Out of Bed at Night August 12, 1971