The Thinking Man's Surgeon

Harvey Taterka matriculated and graduated first from Bronx High School of Science and the University of Michigan (B.S., 1952) before he began his lifetime love affair with New York University Medical Center. Following the successful completion first as a medical student, then as a Resident in Ophthalmology, he joined the full time faculty, rising to professor of Clinical Ophthalmology and section Chief at the New York Veterans Hospital , positions he held until his death in 1990.

Most of all, Harvey Taterka was a caring man—he cared about his residents, cared about the staff, and especially cared about his patients. Like all great leaders he led by example. He was a moral compass, an ethicist-in-residence, a mediator for issues personal or personnel.

Nowhere were his attributes appreciated more than in the operating room where he taught and thought surgery. It is not an oxymoron to describe him as thinking man's surgeon. He wrote essays on various aspects of being a surgeon and one of them is excerpted below.

A house officer and I recently had this exchange, after an operation. To his surprise I said that one of his problems was that as a surgeon he lacked the killer instinct. Pleased with his look that said, “Oh, oh, here we go again, “I persisted, comparing him to an athlete who, having his opponent at a disadvantage, loses his concentration and permits the opponent to recover and defeat him. Others have described this as a talent for snatching defeat from the jaws of victory.

An understandable reaction would be, “what has surgery to do with battling an opponent?” It seems to me that in surgery, the opponent is a complication which we have been trying to avoid. In most operations there occurs a brief “window” when a step is best performed. A description of a window suggests that there are temporal boundaries for a certain set of circumstances, outside of which, the generation of our opponent, the complication, is more likely to occur. The analogy of the launch window for sending a rocket to a target is tempting.

The point is that the appearance of the window should establish the pace of the operation. The surgeon's internal clock, or psychomotor derangement, must not be allowed to prevail. Here is a scenario well know to teachers of cataract surgery. The window for insertion of the IOL is open. The eye is soft, the pupil dilated, the cornea clear, AC deep. In other words, the eye is receptive.

Surgeon #1 inserts the lens and closed the eye. Surgeon #2 at the moment of lens insertion is distracted by a few specks of cortex. He hands back the lens, gets the IA probe in preparation for aspirating the cortex. In the meantime the chamber shallows and there ensues a difficult lens insertion attended by corneal trauma, capsule rupture, vitreous loss, etc.

The man with the killer instinct, the moment the insertion window opens, exploits it and shuts out the complication. The man without it looks the wrong way. The complication, just about shut out, is allowed in by leaving the eye open and causing miosis.

Surgeon #1 realized that the complication in question rarely happens after the surgery is over, so he pounces the instant the opportunity to end the operation materializes. Besides a terrible style, surgeon #2 has a concentration problem. This can always beat good hands and intelligence. Any professional baseball pitcher would verify that. Listening to the rationalizations of ophthalmic surgeons is a treat.

1. “The patient was uncooperative, and moved just at the wrong time.” This means if she weren't kept on the OR table for 45 minutes before the surgery listening to the surgeon complain about nursery school tuition, she would have been back in her room long before she moved.
   
   
2. “There was vitreous pressure, and vitreous came out.” This means that there was vitreous pressure because I was leaning on the eye with a muscle hook trying to squeeze a lens out through a 50° incision and I pushed the vitreous out, and as a matter of fact almost got the retina.
   
   
3. “The capsule broke.” This means that I broke it when I forced out the vitreous. Usually, if I don't break it then, I get it with the IA cannula.
   
   
4. ”The pupil constricted because of excessive iris manipulation from iris prolapse.” This means that the incision was so posterior that when I injected three times the volume of Healon necessary, nothing would have kept the iris of anything else in the eye.
   
   
5. “I don't know why there is so much corneal edema, because I hardly touched the eye.” This means that even though I didn't touch it, I used four litters of irrigating solution and the eye was open for 90 minutes.

The thinking disorder which assigns volition and animation to the inanimate objects begins in the summer of the senior year and never goes away. Examples: (1) the vitreous came out. (2) The lens nucleus went into the vitreous. (3) The lens capsule broke. (4) The sutures kept breaking. (5) The cryoprobe froze to the cornea. I once saw a cornea chase a probe across the room before freezing itself to it. I would have found this hard to believe had I not been holding the 12:00 cornea traction suture myself. On thinking about this case, I remembered perhaps by coincidence that a nurse with an interesting profile kept getting into my line of vision while I held the cornea.

I have seen many surgeons victimized by a conspiracy of operating instruments. For instance, one forceps after another will keep dropping the same tissue and grasping it in the wrong place; one knife after another will make an incision at the wrong location at the wrong depth. A cryoprobe will persist in freezing the iris during a cataract operation. Unkind individuals have characterized some of the above phenomena as examples of ineptitude.

The resident surgeon does not hesitate to call the above examples poor supervision by the attending physician. I will acknowledge however, that local discipline does impose considerable restraint on the attending's choice of language. I myself find this most irritating, and the occasional relief permitted by general anesthesia is always welcome.

While some of the above comments may impress as self-indulgent or sophomoric, it is my intention to stress that describing surgery only in terms of “put tab A into slot B” type of language is inadequate. Intellect is almost never an issue. Motor consideration in terms of, say, kinesthesia is rarely a limiting factor because what we do is not as demanding as our marketing propaganda suggests. Personality is very important. For instance, I have noticed that many ophthalmic surgeons boast that they are obsessive-compulsive. The rigidity imposed by this, if true, would be a surgical calamity. Of course, they are usually confusing thoroughness with compulsion. Most important is the self confidence acquired by practice and discipline. From the experience gained by supervising from 3000 to 4000 resident surgical procedures, I can confidently relate most technique-oriented poor results to loss of concentration.