Sunday, March 16, 2008

Light and Dark: Surgeons, Radiologists, and Why They Need Mutual Understanding to Succeed

Douglas P Monroe MD, LRCP&SI, Beth S Edeiken-Monroe, MD, FACR, and Nancy D Perrier MD, FACS

In many ways, surgery and radiology embody opposites. The surgeon usually practices at the top of the hospital in daylight amplified by bright OR lights and glaring headlights. Radiology reading rooms are often dark caverns lit solely by unnatural fluorescence filtered through dim transparencies. Imagers conduct business at sub conversational volumes, quietly whispering specialty secrets to their students and dictating machines. In contrast to the quiet of the reading room, operating rooms are filled with the sounds of buzzes, beeps, whines, and whirs. Notoriously, surgeons do not “whisper the secrets” of their profession; more often, they loudly proclaim them at their students and then wonder why no one knew them in the first place.

These differences are not limited to traditional stereotypes. Surgery is an ancient art, and appears to have been around since prehistory in the form of trepanation.(1) In contrast, Roentgen won the first Nobel Prize in Physics for discovering the x-ray just over 100 years ago. Surgeons serve patients via direct referral, while radiologists provide service to another physician. In the majority of cases, radiologists never actually meet the patients they are serving. The surgeon, on the other hand, not only meets the patient, but becomes intimately familiar with their exterior and interior. The goal of radiology is most often diagnostic; the goal of surgery is most often therapeutic.

There is no doubt that in a minority of cases these two specialties have begun to overlap. There are now surgeons who interpret images and radiologists who perform intervention. For example, intraoperative CT and US equipment is increasingly available to the surgeon for interpretation, and mini operating rooms with anesthesiology support are provided for radiologists with interventional skills. The resulting friction can cause rifts between medical professionals who see themselves in competition for resources and patients. While we do not propose a solution to these dilemmas, we do seek to define the important nature of the relationship between surgeon and radiologist in a majority of cases.

Despite their differences surgery and radiology share a fundamental commonality that inextricably links them; both require detailed knowledge of anatomy to be successful. This bond is accentuated because procedures with minimal exposure rely less on intraoperative gross inspection and more on preoperative planning based on imaging interpretation. Thus, the advent of minimally invasive procedures necessitates a professionally intimate relationship between surgeon and radiologist.

Surgical grand rounds and multidisciplinary conferences have long provided an educational opportunity that transcends the science of medicine. For the inexperienced medical student, these meetings may seem to be little more than a battle of egos. A more astute student may recognize that the often-contentious tone of these meetings has less to do with ego and more to do with the nature of the questions and answers originating from each side. The radiologist seeks accurate interpretation of the images, whether definitive or equivocal. The surgeon seeks definitive answers to whether, where, and how to perform surgical intervention. Both approaches are correct when we consider the nature of the two disciplines: diagnosis and therapy. Mutual recognition of these different approaches can lead to successful interdisciplinary communication, integration, and most importantly, appropriate treatment of the patient.

Effective communication is increasingly cited as the key to successful practice and the avoidance of legal action.(2) Medical professionals who are skilled communicators are more likely to have compliant and satisfied patients.(3) Therefore, it is not difficult to extrapolate that good communication is effective not only between physician and patient, but also physician and physician. When the surgeon questions or criticizes the interpretation of the radiologist, or vice versa, the criticism must not be construed as a personal attack. Good medicine requires that ego and competition be superseded in the best interest of healing the patient.

In the current era of minimally invasive surgical intervention, level 1 trauma centers, percutaneous cryoablation, and radiofrequency ablation, the success of both radiologist and surgeon are linked. One discipline cannot fully succeed in benefiting the patient without the other. Success relies upon integration of the two disciplines through clear and open communication and the exclusion of personal or professional self-interest.

Western philosophy is rooted in the study of dichotomy: the tension that exists between opposites. As it often is with the brilliant Greek philosophers we find ourselves, in spite of our advanced technology, defined by their ancient tenets that preceded our bovies and MRI machines by millennia. As it was in the past, so it is with surgery and radiology today. One cannot exist without the other. In short, light is defined by dark, and dark is defined by light.

1. Verano JW. Trepanation in Prehistoric South America: Geographic and Temporal Trends over 2,000 Years. In: Arnott R, Finger S, Smith CUM, eds. Trepanation: history, discovery, theory. Lisse, The Netherlands: Swets & Zeitlinger; 2003:223-236.
2. Colon VF. 10 ways to reduce medical malpractice exposure. Physician Exec. 2002;28(2):16-18.
3. Kotegawa T. Communication skills for pharmaceutical care. Yakugaku Zasshi. 2007;127(2):237-244.

Print Publication:
J Am Coll Surg. 2007 Dec;205(6):805-6. Epub 2007 Sep 17.
PMID: 18035265 [PubMed - indexed for MEDLINE]

Thursday, March 13, 2008

Grandfather. Hustler.

My grandfather was 65 when he began to take poker seriously, although he was always a sharp hustler. He hustled on the basketball court for Villanova prior to the invention of the jump shot. He paid his own way through medical school hustling pool in the forties, and then hustled over to Germany for the end of the war. Throughout his life, he hustled himself into seven marriages, and out of six, all the while hustling around town in a Porsche.

Silk shirted, chain smoking, hard drinking, gold chain wearing, womanizing, joke cracking, rat-pack era hustler with a brilliant mind. Growing up he was my absolute hero. Still is.

Age began to remove his need for sleep, but limited his physical activity. He fell in with a crowd of like-minded retirees. Like him, they had all been hustlers. Among them were two doctors, a university president, a general, the owner of a ski resort, the founder of an airline, and a guy named Happy Jack whose background remains unclear. So they started a no-limit, cash poker game.

The set up ran like this: Park your car in the lot of a nearby grocery store in a leafy, upper class suburb. The dealer and his wife shuttle you from the lot to their house. The games typically ran 24-48 hours, so the wife made food while the husband dealt. There were guest rooms to crash in, and plenty of booze.

Always was a friendly game. I think it added ten years to my grandfather's life. I can't say the same for Happy Jack.

One night my grandfather was betting a straight against a possible flush when he went all-in against Happy Jack. He was waiting for Jack to call, sure he was bluffing. It was a big pot.

Seconds later, the plate glass window bursts, the door flies in, and the entire first line of the varsity SWAT team appears, automatic weapons trained on the players.

Like true hustlers, nobody bats an eyelash. Slowly, Happy Jack pushes his chips to the center of the table, looks my grandfather dead in the eye, and says, "I call."


The next thing my grandfather knew he was on the floor. After he was cuffed and read his rights, he was hustled out the door. He looked back to the room one more time. Happy Jack was still sitting at the table like he just called, still looking at where my grandfather had been sitting.

The next time my grandfather saw Happy Jack was at his funeral. The only people that showed were the very same ones that had been sitting around the poker table the night he died; left sitting in that very same position until the ambulance took him away. No one ever found out if he had the flush.

I like to think Happy died the way he wanted. Not winning the hand, but just on the cusp of it.

That's where the true hustler is happiest.

From Scrub Skirts to Pants: The Evolving Role of Women Physicians

I have the good fortune to be related to three generations of women physicians: my great-grandmother, mother, and wife. Although each of their stories is different, they also bear the hallmarks of the times in which they lived; this is the connection among them.

Nettie Solomon, my great-grandmother, was born in 1896. She was a talented opera singer, rode a motorcycle, smoked a pipe, and graduated from Women’s Medical School in Philadelphia. Grace Goldman, a younger relative who shared some of her childhood, remembers my great-grandmother in her memoirs:

Nettie was irrepressible. She was the warmest, most outgoing, most self-sufficient person I ever knew…Her laughter was a pure cascade of silver. Whenever Nettie visited it was a holiday; she brought sunshine and radiated a feeling of joy and vitality. She was famous for her escapades. She had a motorcycle and would go tearing about Passaic, N.J., when this was hardly considered seemly for a young lady. But because it was Nettie, it was a lark. She matured early, and love affairs were legion. In her parents’ eyes, no one was good enough, or aristocratic enough, but Nettie had her own way. She chose her friends as independently as she chose her clothes. No one could dictate to her, and yet she was the warmest and most unspoiled person. Everyone adored her.

Although I never met Nettie, I am told she loved babies and small children. After graduating from medical school, it was her intention to become an obstetric surgeon. However, she was promptly informed that women did not perform surgery, and so she entered family practice instead. Nettie married Louis Edeiken, a kind and affectionate radiologist beloved by the Philadelphia medical community. Antique sepia photographs, surprisingly candid for the time, document the obvious affection and happiness between these two remarkable physicians. I can only assume that Louis’ love for Nettie had something to do with her accomplishments and independence. However, he was also, like her, subject to the conventions of the time. Upon the birth of their first child Nettie abandoned medicine forever. Like most of us who enter medical school, she had once devoted her life to the art, science, and challenge of healing. She now faced an even greater challenge: abandoning her life’s passion. I often wonder if that sacrifice was advocated by Nettie, Louis, both, or neither. Regardless, there is a discrepancy between the Nettie in the photographs and how her granddaughter, my mother Beth, remembers her.

My mother Beth recalls her grandmother Nettie as a stern and mean-spirited woman. A kind word was rare, and a smile rarer still. Later in her memoirs, Goldman describes the elderly Nettie in stark contrast to the photographs and recollections of her youth.

In the last years of her life…Nettie knew the pain of loneliness and sorrow. Her eyes were often shadowed with sadness. Through physical and mental torments, her strength did not falter.

When my mother was a small child Nettie asked her what she would like to be. “A doctor” replied the child thinking only of her father, a physician whom she adored. Because Nettie had abandoned medicine before my mother was born, Beth was unaware that her grandmother was a physician. “Oh Beth: keep very quiet, study very hard, don’t make a spectacle, and they may let you do just that until the day you die” was the old woman’s advice. My mother considers this a solitary kindness offered by her grandmother, although the true intimacy of it was lost on her youth. It tells me a little about how Nettie viewed her life in retrospect. Could she have been both a successful physician and mother? My own childhood experience tells me yes, but I grew up in the seventies after so much had changed.


Beth Edeiken, my mother, was born in 1948. An all-American field hockey goalie, she struggled with dyslexia before it was a well-accepted diagnosis. Thus, she was unable to earn her undergraduate degree due to the foreign language requirement. Based on her science and math scores she was admitted to Jefferson Medical College, and graduated in 1973. In those days, female medical students wore white hose, white nursing shoes, and scrub skirts. The women of her class circulated a petition protesting this inequity. When asked to sign, Beth remembered the advice her grandmother Nettie had given her so long ago. She declined to participate, and avoided risking her career through “spectacle”. Soon after, several of the petitioners were expelled. In spite of her grandmother’s advice, my mother had finally had enough.

As she sat in the Dean’s office, Beth explained the intricacies of performing compressions on a patient in cardiac arrest. She told the Dean that because of their height, most of the women could not perform compressions of gurneyed patients from the floor. Instead, they straddled the patient to gain adequate leverage. She made a point of illustrating how, in a skirt, the straddling women were forced to expose themselves, flashing those present, while trying to save the patient’s life. The Dean flushed, and shortly thereafter scrub skirts disappeared from the hospital and were replaced by pants. The expelled students were reinstated. Eventually, like her grandmother, Beth chose the road less traveled. She married a foreign-born physician, my father, whose origins were not considered “seemly” in her generation. Against her mother’s advice, but with her husband’s support, she continued to work as a resident, and thereafter a radiologist, through two pregnancies and thirty-five years (and counting) of marriage.

In contrast to her medical school exploits, my mother did not spend her career as an activist. She wanted to be an orthopedic surgeon, but was told it was not a “woman’s specialty”. Remembering the words and life of her grandmother, she kept quiet and maintained a low profile while being paid half the salary of her male peers. On night-call she dutifully taped the requisite sign to the call room door that read, “Girl Sleeping in Here.” At conferences the men normally referred to each other as “doctor,” or by their last name. My mother was commonly referred to as “The Girl,” or Beth. None of that has ever mattered to her; she tells the stories out of interest, not complaint. She is satisfied, and even feels lucky, that it is better for her than it was for Nettie. Beth fondly recollects the men of the previous generation, including her father, who generously shared with her the secrets of medicine. She is happy to have been allowed to follow her professional passions while raising a family. She has achieved some recognition, and if you are a radiologist you may be familiar with her work. From my perspective as her child I had a female hero who was out saving lives. I grew up happy, and more than a little proud. From my perspective as an adult Beth is not only my mother. Along with my father, she is my personal and professional mentor. Since my marriage to a medical school classmate, my wife finds Beth a valuable source of insight and advice. I often wonder what it would have meant for my grandfather if his mother, Nettie, had been able to fulfill that role for him.


My wife, Maria Gule (pronounced goo-lah), was born in 1980. She is the daughter of a dairy farmer from a tiny, rural village on the northern coast of Norway. The village, also named Gule, sits next to Gule River, and is overshadowed by Gule Mountain. Growing up she attended the Gule Skule (pronounced skoo-lah), and a recent visit to the local cemetery revealed that most of its inhabitants share her surname. Never satisfied with the opportunities available in her isolated hometown, she traveled to Ireland for medical school. At The Royal College of Surgeons she was among the top five in our class. Although I represented the other end of academic achievement, she allowed herself to be wooed. At our wedding ceremony far from Norway, performed at a Houston steakhouse by the Enron judge, we made an odd-looking pair. She is 5’3” in heels, strikingly beautiful, and a buck-fifteen after a large meal. I am 6’4”, less than beautiful, and double her weight after a month’s strict diet. I love my wife for her brilliance, independence, and moxie. It was no surprise to me when she declared her intention to apply for a general surgery residency. I warned her of the rumors of brutality, but she was not dissuaded. Why, she asked, come so very far to abandon your dream because of fear or adversity? I had to agree. I was keenly aware that her decision was a luxury not available to my great-grandmother and mother.

During medical school, while on her first stateside elective in general surgery, Maria shared her goals with the administrative assistant of the Chairman. “You have no business being married and becoming a surgeon. Your husband will want you to give him children, and a surgeon cannot afford to take time off to be pregnant. Why don’t you do something like pediatrics, or family practice instead” said the woman. Maria is no complainer. She described this exchange to me in a matter-of-fact way, added a laugh, and promptly went on studying. I, however, was enraged. Five minutes later, I called my mother for advice. Surely she would understand my anger. Surely she would want to fight back. Beth’s first question was, “Douglas, does Maria still want to be a surgeon?” I looked through the glass door to my wife’s home office. She was blissfully content, using the skin of an unpeeled orange to practice surgical suture knots. I gave my mother the truth. Beth replied, “Oh Doug: tell her to ‘keep very quiet, study very hard, not make a spectacle, and they may let her do just that.’”

During the past few years I have heard numerous stories about contemporary women physicians who are treated badly for being ‘in the family way’, or for simply being women. These are not unique, or indeed new, stories. There are times when I wonder why someone as gifted as my wife should expose herself to that kind of ignorance. There may be times when she wonders the same thing. Luckily, those times never seem to be the same for both of us. I know she will become a gifted surgeon. She would never say so, but I know that she knows the same thing. I often remind myself how much better it is for her than it was for my mother Beth, or great-grandmother Nettie. Maria, on the other hand, needs little encouragement. She has the singular, awe-inspiring focus of most surgeons. Like most surgeons, and indeed most physicians, she simply plods on, ignoring adversity, one step at a time towards her goal. I know she will achieve it no matter how many curve balls come her way. And that is the rub.


On a recent tour of a surgical residency program at a level one trauma center, one of my fellow applicants asked the question, “do the residents in this program really adhere to the legally-mandated 80 hour work week and, if not, do they document when they exceed it?” His question was met with a blank stare from the obviously sharp, young, black, female chief resident wearing scrub pants, and not a skirt and hose. Before she answered, I had to smile at how far we really have come. She replied flatly,

Of course we adhere to the 80-hour work week, which is the law. But let me add one thing, hypothetically of course: if I, or any of the other residents here documented a breach of the law, it would put my residency program, and thus my chances of becoming a surgeon, at risk. Would that be smart?

Indeed, I thought, it would not be smart at all. I understood her angle completely.

In the future, should I have daughters who choose medicine, I know that it will be a little better for them because this woman, and others like her, chose to keep very quiet, study very hard, and not make a ‘spectacle’… at least in one sense. In another sense, of course, each of these women is a remarkable spectacle.