The Forgotten Art of Surgery

What each of us can learn from "the Dextrous Surgeon"

Shortly before I went to medical school I came across a forgotten Chinese spiritual classic that provided numerous metaphors for meditation. A few months later, a passage from it about a dextrous butcher popped into my mind as I began working with cadavers in the anatomy lab and it dawned on me that its metaphors for entering the deepest aspects of our being also applied to the art of surgery.

Since then, I’ve come to appreciate how well it ties into not only surgery, but also the art of giving therapeutic injections and arguably the entire art of medicine. The verse (I’ve nicknamed The Dextrous Surgeon) goes as follows:

Cook Ting was cutting up an ox for Lord Wen-hui. As every touch of his hand, every heave of his shoulder, every move of his feet, every thrust of his knee — zip! zoop! He slithered the knife along with a zing, and all was in perfect rhythm, as though he were performing the dance of the Mulberry Grove or keeping time to the Ching-shou music.

“Ah, this is marvelous!” said Lord Wen-hui. “Imagine skill reaching such heights!”

Cook Ting laid down his knife and replied, “What I care about is the Way, which goes beyond skill. When I first began cutting up oxen, all I could see was the ox itself. After three years I no longer saw the whole ox*. And now — now I go at it by spirit and don’t look with my eyes. Perception and understanding have come to a stop and spirit moves where it wants.

I go along with the natural makeup, strike in the big hollows guide the knife through the big openings, and following things as they are. So I never touch the smallest ligament or tendon, much less a main joint.

A good cook changes his knife once a year — because he cuts. A mediocre cook changes his knife once a month — because he hacks. I’ve had this knife of mine for nineteen years and I’ve cut up thousands of oxen with it, and yet the blade is as good as though it had just come from the grindstone. There are spaces between the joints, and the blade of the knife has really no thickness. If you insert what has no thickness into such spaces, then there’s plenty of room — more than enough for the blade to play about it. That’s why after nineteen years the blade of my knife is still as good as when it first came from the grindstone.

However, whenever I come to a complicated place, I size up the difficulties, tell myself to watch out and be careful, keep my eyes on what I’m doing, work very slowly, and move the knife with the greatest subtlety, until — flop! the whole thing comes apart like a clod of earth crumbling to the ground. I stand there holding the knife and look all around me, completely satisfied and reluctant to move on, and then I wipe off the knife and put it away.”

“Excellent!” said Lord Wen-hui. “I have heard the words of Cook Ting and learned how to fully live life!”

Note: Books (and hence much more than I can encapsulate within article) could be written about exactly what’s being described in that passage (e.g., living life through the spirit). I do however wish to mention that many of the most talented physicians I have come across agree this passage describes the evolution of their practice of medicine and likewise, that I’ve found it aptly summarizes exactly what happens when you connect with a needle and navigate exactly where to place it within the body (e.g., for prolotherapy).

The Art of Surgery

During my medical training, I spent a few weeks assisting a group of OBGYNs who did a lot of C-section surgeries and was able to observe the myriad of differences in their techniques. One surgeon, an older asian man caught my eye because of how graceful his hands were and how much smaller the injuries from his incisions were.

At one point, I talked with him in the break room and he shared with me that he was a lifelong Tai Chi practitioner and that this practice had caused him to become much more connected with his scalpel. In turn he said that anytime he cut someone, he always made a point to feel connected to each layer of tissue he was cutting and conversely lamented that he had seen numerous cases of a babies being cut (e.g., on the face) by a typical OBGYN who did not make the point to be continually connected with their scalpel throughout each C-section.

Note: facial lacerations are estimated to occur in between 0.7-3% of C-sections and are understandably more common in emergency ones (as you have to get the baby out quickly to save its life).

That conversation really stuck with me and had a huge influence on my medical career.

Electrocautery

Two common methods exist to cut through tissue. One is to use a sharp blade (the scalpel) to directly cut tissue and the other is to use a blunt metal blade which (through electricity) is heated to a high temperature and then, due to its heat, causes the tissue it contacts to bubble and break apart.

Electocautery is often preferred because it cauterizes tissues and thereby solves one of the most common problem in surgery (blood loss). Because of this, a surgeon can be much less mindful or connected when they create an incision, proceed through the surgery at a much faster rate and not have to be anywhere near as worried about the blood loss which would result from a poor surgical technique.

Note: the amount of blood loss which occurs during surgeries varies depending on the skill (and finesse) of a surgeon— surgeons who have ‘good hands’ are both faster and lose less blood (e.g., they have half the blood loss and take a third of the time for a surgery), as surgeons who go slower are typically compensating for their less astute anatomical awareness. These are not absolutes however (e.g., a fast clumsy surgeon is a disaster, and certain surgeries like liver resections have to be done slowly to reduce blood loss).

I previous explored this because the mRNA vaccines have made many become concerned about receiving transfusions of vaccinated blood, and I believe you can significantly reduce your need for blood during a surgery if you pick the right surgeon to work with. Unfortunately the surgeon gets the final say on what the estimated blood was and is understandably biased to underestimate it (which we’ve both seen firsthand and what has been repeatedly proven in previously conducted studies). Because of this, a surgeon’s reported blood loss isn’t actually a good outside metric to assess their performance, and you must instead depend upon the perspectives of people who have been in the OR with the surgeon (which is understandably not something people outside the medical field have access to).

When I first was exposed to electrocautery, I notice that unlike conventional surgery (with a scalpel) it was as though I “felt” the pain of the body as its tissue was seared apart by the device. This in turn led me to wonder how safe electrocautery actually was.

Note: I have since concluded the cervix contains some of the most “sensitive” tissues of the body as it was quite difficult for me handle being around it when a particularly intense electrocautery procedure was done. A particularly brutal form of electrocautery (known as a loop electrosurgical excision procedure) is done to approximately 500,000 American women a year to treat suspected cervical cancers, and for those who would like to see what it does to the body, a (somewhat graphic) video of it can be viewed here.

Since then I’ve investigated this more and found (like many of my colleagues) that the scars from electrocautery are significantly more traumatic to the body (e.g., they are more likely to create permanent health issues for the patient unless they are treated with neural therapy, which is discussed in more detail here).

Likewise, I’ve come to appreciate there are significant consequences with the dead (cauterized) tissue electrocautery leaves in the body. This is best quantified by the frequent observation electrocautery has a higher rate of post-surgical infections (as the dead tissue is easier for bacteria to colonize).

I’ve also seen a few cases where something much worse happens after electocautery. For example, the immune system is not only responsible for eliminating infections, but also suppressing cancer cells, removing debris from the body, and repairing damaged tissue. In turn, I distinctly remember a patient with a stable cancer who a mentor warned about getting an abdominal surgery (done with electrocautery) get the surgery and not long after succumb to the cancer (which rapidly grew out of control after the surgery).
Note: a reader also reported observing this in an endometrial cancer that had been stable for years which then suddenly killed them shortly after they had a hernia surgery.

Modern Surgery

As technology has advanced, it has made many thing which were once impossible in medicine become possible. Conversely however, it’s taken away the innate skill many doctors used to reply upon and replaced them with expensive products which can be sold.

For example, many common conditions patients come to the hospital with (e.g., appendicitis) can be diagnosed either with a thorough physical examination or with imaging (e.g., a CT scan). In turn, as time has gone forward, the standard of care more and more has been weighed towards those diagnostic procedures (which I’ve long suspected is in part due to the fact all of those procedures make a lot of money for the medical industry).

This has created the sad situation where the physical exam has become somewhat of a lost art, and in practice I frequently see patients who had conditions which were missed by each previous physician because while the patient got an extensive number of tests, they never got the detailed physical examination which was necessary to correctly diagnose them. Likewise, a certain percentage doctors who enter their post graduate training (medical residency) each year come from outside of the United States (12% in 2023), and we’ve repeatedly observed medical residents who went to medical school in much poorer countries (where they could not afford those expensive diagnostic tests) were dramatically better at physical diagnosis than their American trained counterparts.

Note: many doctors try to move here because America pays its doctors 10-100 times as much as they make in many other countries.

In the case of electrocautery, since it makes it so much easier to do surgery (as you don’t have to have the finesse to feel exactly what’s going on under your scalpel), as it entered the training programs, I noticed the younger doctors who were primarily trained in electrocautery were much worse surgeons in the operating room. This was particularly true for doctors like OBGYNs for whom surgery was a part of their specialty rather than its primary focus.

When I asked James Miller (a surgeon) his thoughts on how electrocautery compared to traditional surgery, he shared the following with me:

The data is unequivocal that cautery creates dead tissue that is a nidus for future infection, immune weakening, etc. and has worse outcomes with more use.

Realistically, cautery is effective of getting through cases and fast and ubiquitously used with major cases.  You can pretty much tell in recovery, the post-op floor or in clinic which surgeons use more or less cautery because of their patient outcomes.

However, there are some situations where you really can't easily get away with not using cautery, such as for liver resections, gallbladder removal, electrodissection of warts, some retroperitoneal dissections like pancreatectomy—particularly if the patient has previously had the retroperitoneum violated.  There are some alternative technologies like ultrasound dissection, but they are also imperfect in different ways. 

James Miller

When I first started this publication, I connected with a brilliant trauma surgeon who had recently been kicked out of Washington because he had advocated for the unvaccinated when everyone else was actively discriminating against them and denying them essential medical care. From talking with Dr. Miller, it became very clear to me he had the rare capacity to see things for what they were and break from the crowd in order to do the right thing (a capacity which I’ve found characterizes the most talented doctors I’ve known). Because of this, when he asked me to help publicize his story, I was happy to, and before I knew it, he (and this Substack) ended up on national television.

Note: a longer interview about Dr. Miller’s experiences can be viewed here.

In my correspondences with Dr. Miller, we discussed each of the previous points in, and recognizing his unique insights into these subjects, requested his permission to share them. I would thus like to share his thoughts on the Dextrous Surgeon:

The growing detachment of physicians from actual tactile experience has developed into a real problem, and I genuinely fear for our medical culture.  The hands follow the mind.  

There are myriad examples that could be discussed, but I will start with a few anecdotes.

I graduated from medical school in 2000, and around that time the robotic operating systems began being heavily marketed.  To the best of my knowledge there were zero studies, even those sponsored by the industry, in which any meaningful clinical outcome was improved by using the robot (lots of data showing insignificant improvements in outcomes, except everything that really mattered—like cancer cure, incontinence after prostatectomy, etc.—were worse with the robot).  However, the robotic systems were heavily marketed to physicians and patients, and its use became standard of care despite inferior outcomes and increased cost.    

These robotic systems result in an uncoupling of tactile feedback between the patient and the surgeon.  I worked with them early in my training and found it a fundamentally flawed technology for the care of people and rejected further use as I matured.  My practical experience mirrored a truthful reading of the literature.

For anyone who works with their hands (musicians, machinists, artists, carpenters, etc.), over time and with extensive practice, a deep intuition and flow develops, allowing for the steady progression towards expertise and excellence. This is why surgical specialty training programs require a minimum of 5 years of supervised guidance - leading towards gradual independence.  And after that there are years of diligent work needed that allow some to progress to become true masters.  Feeling the tissues and organs, gently moving and manipulating them, while struggling to heal the whole person, all lead to developing pattern recognition beyond what is written and becomes an instinctual understanding. Instincts which, after mastering competence, allow for creativity and a very special form of healing. 

Because of the heavy marketing, and a medical system largely without integrity, robotic surgery has now become the standard of care in almost every major abdominal or thoracic operation for urologists, gynecologists, general surgeons, and thoracic surgeons.  Because of this market capture by the industry, patients expect it and so most of the recent graduates from surgical programs now no longer know how to competently perform open operations using their actual hands to meaningfully touch and heal actual patients.  These new physicians are uncoupled from the touch and feel of human tissues.  Since that switch happened in about 2015, there are many instances in which most surgeons just don't know what to do when a procedure is not routine and when the robotic technology is not applicable. Not only do they lack creativity, they lack basic competence.  They are captive to the crutch of technology and the subsequent decoupling that has occurred. 

This decline in performance came to my attention over the past approximate 10 years in ways I could not avoid seeing.  It became apparent that the overwhelming majority of younger graduates from most procedural-based specialties remained simply inadequate in the OR and rather than continuing to progress towards greater competence and excellence like was previously expected. They tended to stagnate.  Their patients experience multiples higher rates of infection than what was previously the standard, preposterously longer operating room times (which is a marker for bad outcomes and a greater risk for patient complications), and a tendency to be completely 'lost' doing operations that require creative thought.  This is true of robotic, laparoscopic, and open approaches to the same operation.  

Here are some brief examples of how preposterous it became:  

I was working at a hospital from 2014- 2022 which had 7 or 8 urologists on staff doing what are considered 'big' operations (nephrectomy, prostatectomy, etc.).  One of the newer urologists, who was identified as a rising star, had a large number of preventable complications when he operated.  I personally had to manage (fix) a lot of them as he usually was unable to manage the complications he induced with his operative technique.  On one occasion, he had performed a robotic nephrectomy and the next day (post op day 1), I, as a general surgeon and not a nephrologist, had to manage one of his complications. During the robotic procedure, the patient's bowels became trapped in an incision from where the patient's kidney had been extracted.  This urologist had no idea how to close the muscle fascia, a fundamental lesson for any abdominal operative procedure.

As it has been done in surgery since the beginning of medicine, more experienced physicians are obligated take time to train and orient less experienced physicians, so I called him to the OR to show him what had happened and how his setup and approach could have been optimized to prevent this problem and result in a good outcome.  Even though he had finished 6 or 7 years of post-medical school training, he seemed completely naïve to these realities.  He acted as if touching the tissues, respecting how they moved, and closing the muscle layers so they could hold the bowels into their correct compartment were novel concepts which he had never learned.

Adapting and learning to use effective new technologies and techniques is necessary, but had always been in addition to mastering the foundational principles and practices and having the ability to see how what you are doing to the patient should actually benefit the patient.  Surgeons have been expected to know when and how to “fall back” to tried and true methods when technology is unable to meet a patient’s needs. We were trained that plan A may not always be achievable and should think through and consider a plan B, C, and at least D prior to taking a patient to the OR.  And a true master has the most backup plans to best benefit their patients. But that is so often lacking now.

To his defense, this young surgeon may have never learned this very basic reality.  It is quite possible that he was actually inadequately trained.  Perhaps the rise in self-identified “imposter syndrome” that is endemic amongst the younger physicians is accurate and is a result of this decoupling from touch and honoring palpable experience.  The part that really shocked me to watch is that rather than improve, those who suffered from these inadequacies seemed to spend most of their energies on redefining success rather than overcoming weaknesses.  If that is the case, shame on the training programs for graduating  untrained physicians without the tools to thrive and shame on the professional associations which allow it.  What are the implications for our patients and their loved ones? Our practice is supposed to be for them, not ourselves.  

I witnessed countless acts that breach a surgeon’s professional duty along these lines.   

Some months after the above example, there was a patient who needed a nephrectomy for an otherwise incurable kidney infection, and it had to be done open; the robot couldn't be used because of the patient's anatomy.  There were no (zero) urologists in town of the 7 or 8 who were on staff and paid to remove kidneys, who said they were comfortable doing an open (without a robot) operation for removing a kidney.  They all expressed an inability to use their actual hands to do a fundamental procedure within in their specialty.  Therefore, I was given 'emergency' privileges by the chief of surgery so I could perform this open operation, even though that is not typically what general surgeons do.  Although not a urologist, I understand patient anatomy and can achieve the necessary ends.

Sometime later, these same group of surgeons who expressed incompetence at the most fundamental levels of taking care of their own patients, became leaders of the medical safety committees in our hospital.  Rather than recognize the holes in their training/knowledge/skills and take initiative to learn/train how to care for the needs of their patients, they became administrative leaders.  As such, they subsequently chose to redefine “competence” or "good patient care".

The new definitions of competence did not have anything to do with patient outcomes or surgical ability, but instead they developed a new dystopian 'culture' which resulted in eliminating anyone who spoke out advocating for clinical competency, merit, data and good outcomes, or putting the outcomes of patients first.  "Good care" became equivalent to being a physician socialized to the intellectually dishonest status quo, the patient was removed from the equation.  And then they drove out most dissenters.

I could write books of example after example which are as bad, or worse, than what is described above which I have personally experienced representing almost every surgical specialty.  This is just a recent instance that came to mind that had a grim punchline, when the incompetent becomes a 'leader' and then redefines what is good to make themselves not appear as inferior.

And here is a resulting problem many now face: to have the privilege of helping people through surgery, which is something I loved and felt called to do, I had to compromise bits of excellence at regular intervals to work in these systems and tolerate 'bad care' being labeled as 'good care'.  

This is a difficulty of living a life and a medical practice of trying to be in touch with The Spirit or The Way. One needs to be working in a place with minimal (maybe no) cognitive and moral dissonance to have excellent outcomes and to be connected.  When we work in an extremely flawed system and a fallen world, there is always an inherent tension to be connected to Truth.  But now the gap of reality has become staggering in healthcare.  It is extremely difficult to stay in standard health care and remain without overwhelming cognitive and moral dissonance.  In truth, it isn't welcome anymore.  Few are called and able.  I could not anymore, and I chose to live without the dissonance and transition to a different facet of healing.  For those who can stay and stay true, I have a fierce admiration.

Conclusion

In a recent article, I discussed the scandalous spinal surgery industry, where (owing to spinal surgeries being one of the most lucrative areas in medicine) patients are denied effective treatments for back pain and instead are repeatedly pushed into unnecessary and dangerous spinal surgeries. Sadder still, reckless spinal surgeons periodically pop up who significantly injure (or kill) large numbers of patients. Remarkably, when their honest colleagues (e.g., those who only perform spinal surgeries they know will help their patients) complain about the danger these surgeons present, again and again administrators chose to side with these reckless surgeons because of how much money their high volume of (rushed and improperly supervised) surgeries make for the institution.

Over the last few decades, we’ve seen a far reaching push to corporatize the practice of medicine and transfer the power doctors once had to decide what was correct for their patients to corporate administrators (which many of my colleagues believe was the single greatest mistake our profession has made). This loss of power was made clear to everyone throughout COVID-19, where countless doctors were forced to use deadly protocols for their patients (e.g., remdesivir and ventilators) while simultaneously being banned from doing things they knew could save their patients life.

This tragic reality resulted in America having the second highest COVID-19 death rate in the world despite it spending more to stop the pandemic than any other nation. That, in turn, was a result of the fact the hospitals were financially incentivized to push the unsafe and ineffective COVID-19 protocols on their patients. As such, the hospital administrators were willing to go to extreme lengths to protect that revenue.

For example, Paul Marik (a world-renowned ICU doctor) was forced to sue his hospital after he was prohibited from administering lifesaving COVID-19 treatments. Likewise both Paul Marik and Pierre Kory were targeted by their hospitals (detailed here) because they advocated for off-patent COVID-19 treatments (e.g., Paul Marik lost his medical license). Similarly, numerous lawsuits were filed to force hospitals to administer critically ill COVID-19 patients ivermectin. In the 40 which were successful, 95% survived, while in the 40 that were not, 5% survived.

However, rather than take this dramatic difference in survival as in indication the existing treatment protocols should be reconsidered, the hospitals realized they needed to invest in a far more robust legal strategy (as abandoning the heavily-subsidized standard protocols would cost the hospitals a lot of money), and through this investment, our hospitals successfully prevented any further lawsuits from going forward.

One of the things I find the most tragic about Kory and Marik’s situation is that both of these doctors embody the physicians each patient would want to have when they were in the ICU (e.g., Kory has had numerous challenging ICU cases he was able to solve which the other doctors had given up on). However, because they loved the art of medicine and prioritized doing what would be the best for their patient, they were completely incompatible with the managed care system that exists within our hospitals.

Those events (and later ones such as a private and corrupt speciality board taking away the ability of the COVID dissident doctors to practice in hospitals) forced Dr. Kory to transition to his own private practice outside of the medical system. While Kory is personally quite happy with this career change (as he has a much more freedom to do things which will actually help his patients), I think it’s a tragedy that the current political situation is preventing patients from having access to the doctors they most need at the hospitals.

As we conclude, let’s consider Dr. Miller’s situation. For the most part, surgeons can only perform surgery under the umbrella of a hospital and hence only under the dictates of their hospital administrators. Since, as mentioned above, Dr. Miller could no longer tolerate the ethical quagmires practicing under those administrators placed him in, he chose to leave the surgical field entirely and transitioned to working in primary care.

Dr. Miller is personally quite happy he made this switch, as he now has the ability to freely do things he knows will help his patients. At the same time however, that switch is an immense lost—it is a huge investment to train a competent trauma surgeon and when there is a shortage of them, there is no one around to fix the mistakes (like the previously mentioned nephrectomy) less competent surgeons make.

In a recent article about the highly unethical practice of releasing self-spreading technologies into the environment (e.g., so people who don’t want to vaccinate will nonetheless be vaccinated), I argued that the medical profession needs to seriously reconsider its profit-focused approach to medical ethics (much of modern medical ethics now amounts to whatever makes money is the ethical choice).

There, I argued that beyond it being the “right” thing to do, it was also in the industry’s self interest to do so, as if medicine repeatedly violates the fundamental tenets of medical ethics, this will lead to it losing the societal trust it depends upon to sell it’s products to the populace. In that article, I cited the discovery that COVID vaccine mandates had significantly reduced the population’s willingness to get a variety of other vaccinations.

In this article, I’ve tried to show how the public recognizing that the hospitals no longer prioritize patients over profits is undermining their willingness to seek out hospital care. In turn, I would argue that unless measures are enacted to show our hospitals will reward rather than punish doctors who strive to do the best they can for their patients, the hospitals will lose a lot of money, both from declining patient numbers and more importantly, from the loss of charitable donations to the hospitals (e.g., I know numerous huge donors cut off their annual donations to hospitals which continued to enforce the COVID-19 vaccine mandates on their employees).

Postscript: I received two comments from surgeons I wanted to share (along with a comment from a scrub tech I pinned that you should read).

For those interested, a complete index of the articles published on the Forgotten Side of Medicine can be found here.