The Little Book of Aphorisms & Quotations for the Surgeon 9781910079959, 9781910079966, 9781910079973, 9781910079980, 1910079952

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This book is the last to join the two former collections of surgical aphorisms: Aphorisms & Quotations for the Surgeon, with its 1500 quotations, and the slimmer A Companion to Aphorisms & Quotations for the Surgeon. Since their publication, both books have become steady bestsellers. Surgeons use the books to ‘decorate’ their lectures or manuscripts with relevant smart or entertaining entries; some like to quote from the books during teaching rounds or conferences; many simply enjoy them for their collective and eternal surgical wisdom and wit. As before, these aphorisms and quotations are retrieved from multiple sources: journals, books, lectures and, more and more, gathered from surgical friends around the world. The decision to include any entry is based on personal taste. Some would question the wisdom or accuracy of individual entries; others may not ‘get’ the humor or may object to political incorrectness. These aphorisms will help readers to (re)discover that surgical truth is old, that what they think is a novel idea has been said before, and that what they observe around them — has been observed years ago. It may contribute to their humanity and humility, perhaps even add maturity to their surgical personality and practice. In addition, with a bit of luck, it may increase their sense of surgical humor — for how can one survive a lifelong surgical career without possessing some of it.

ISBN 978-1-910079-95-9

9 781910 079959

The Little Book of Aphorisms & Quotations for the Surgeon

The last in the trilogy of this international bestselling series...

tf m

Aphorisms & Quotations for the Surgeon The Little Book of

Edited by Moshe Schein

“A rule of thumb is that the tumour should be removed by laparotomy and not laparoscopy if it is bigger than the head of the surgeon in question.” David Dent

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Aphorisms & Qforuotations the Surgeon The Little Book of

Edited by Moshe Schein i

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The Little Book of Aphorisms & Quotations for the Surgeon

tfm Publishing Limited, Castle Hill Barns, Harley, Shrewsbury, SY5 6LX, UK Tel: +44 (0)1952 510061; Fax: +44 (0)1952 510192 E-mail: [email protected]; Web site: www.tfmpublishing.com

Editing, design & typesetting: Nikki Bramhill BSc Hons Dip Law Cover photo: © 2020 Evgeniy E. (Perya) Perelygin, MD First edition: Hardback E-book editions: ePub Mobi Web pdf

© 2020 ISBN: 978-1-910079-95-9 2020 ISBN: 978-1-910079-96-6 ISBN: 978-1-910079-97-3 ISBN: 978-1-910079-98-0

The entire contents of The Little Book of Aphorisms & Quotations for the Surgeon is copyright tfm Publishing Ltd. Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may not be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, digital, mechanical, photocopying, recording or otherwise, without the prior written permission of the publisher.

Neither the author nor the publisher can accept responsibility for any injury or damage to persons or property occasioned through the implementation of any ideas or use of any product described herein. Neither can they accept any responsibility for errors, omissions or misrepresentations, howsoever caused.

The author and publisher gratefully acknowledge the permission granted to reproduce the copyright material where applicable in this book. Every effort has been made to trace copyright holders and to obtain their permission for the use of copyright material. The publisher apologizes for any errors or omissions and would be grateful if notified of any corrections that should be incorporated in future reprints or editions of this book.

ii

Printed by Gutenberg Press Ltd., Gudja Road, Tarxien, GXQ 2902, Malta Tel: +356 2398 2201; Fax: +356 2398 2290 E-mail: [email protected]; Web site: www.gutenberg.com.mt

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Contents Foreword

Dedication

Abdominal surgery Academia

viii x

1

7

Appendicitis

13

Assistants, students & residents

19

Assessment Biliary

16

24

iii

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The Little Book of Aphorisms & Quotations for the Surgeon

Cancer surgery

27

Common sense

36

Colorectal surgery Complications Critical care Diagnosis Dogma

Education Errors Ethics iv

31

41 55 61 66 70 75 80

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Contents

General concepts

87

Hemorrhoids

103

Innovations/gimmicks

109

Hernia

Intestine

Judgment

Laparoscopy

Malpractice & law Money matters Obesity

106

116 120 132 144 151 156 v

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The Little Book of Aphorisms & Quotations for the Surgeon

Old age

160

Other disciplines

182

Operating Pathology Patients

Pilots vs. surgeons Politics and admin Practice

Research, writing, reading & publication Surgeons vi

166

187 191 199 204 211 221 244

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Contents

Thyroid & parathyroid

Vessels & amputations

268 271

vii

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Foreword

In the past, I have compiled two books of collected surgical aphorisms: the larger Aphorisms &

Quotations for the Surgeon, with its 1500 quotations, and the slimmer A Companion to Aphorisms &

Quotations for the Surgeon.

Since their publication, both books have become best-sellers. Surgeons use the books to ‘decorate’

their lectures or manuscripts with relevant smart or entertaining entries; some like to quote from the

books during teaching rounds or conferences; many simply enjoy them for their collective and eternal

surgical wisdom and wit.

Now, as I am drifting towards retirement, here is the last in the trilogy of this international bestselling

series — The Little Book of Aphorisms & Quotations for the Surgeon. The quotes collected within this little book have been gathered since the publication of the last two books in the series.

As before, these aphorisms and quotations have been retrieved from multiple sources: journals,

books, lectures and, more and more, gathered from surgical friends around the world.

The decision to include any entry is based on my personal taste. Some may question the wisdom or

accuracy of individual entries; others may not ‘get’ the humor or may object to political incorrectness. viii

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Foreword

But I hope that most readers, especially younger surgeons, will discover that surgical truth is old, that

what they think is a novel idea has been said before, and that what they observe around them — has

been observed years ago. It may contribute to their humanity and humility, perhaps even add maturity to their surgical personality and practice. In addition, with a bit of luck, it may increase their sense of surgical humor — for how can one survive a lifelong surgical career without possessing some of it:

Common sense and a sense of humor are the same thing, moving at different speeds. A sense of humor is just common sense, dancing. Those who lack humor are without judgment and should be trusted with nothing.

Clive James (1939-2019)

Now let me conclude with a ‘mother’ of medical aphorisms: From inability to let well alone, from too much zeal for the new and contempt for what is old, from putting knowledge before wisdom, science before art and cleverness before common

sense, from treating patients as cases and from making the cure of the disease more grievous than the endurance of the same, good Lord deliver us.

Sir Robert Hutchison (1871-1960)

Good luck! Moshe Schein MD FACS FCS (SA) Ladysmith, Wisconsin

ix

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Dedication

I wish to dedicate this book to Professor David Dent

of Cape Town, South Africa: a great surgeon, a wise man

and a master surgical aphorist!

x

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ABDOMINAL SURGERY

1

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The Little Book of Aphorisms & Quotations for the Surgeon

I cannot see what harm has been done if the appendix has been

removed. The perfect man is the man without an appendix.

R. H. Harte (?1899) 2

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Abdominal surgery

If you don’t eat, you don’t shit. If you don’t shit — you die!

Barry (Baz) Alexander 3

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The Little Book of Aphorisms & Quotations for the Surgeon

Considering adhesionlysis: we were all schooled in not

overdoing it with excessive enterolysis. In the laparoscopic

era, it’s often tempting to do adhesion release in the process of an otherwise routine lap cholecystectomy — possibly because it looks so dramatic with a pneumoperitoneum with adhesions on a string. It’s like eating peanuts or snacking on potato chips (crisps for you Brits)... not knowing when to stop. Angus Maciver

4

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Abdominal surgery

I divide interloop adhesions only if there is a discrepancy of size between loops.

Vinay Mehendale 5

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The Little Book of Aphorisms & Quotations for the Surgeon

Be careful with the knots, and do not damage

the suture material with the instruments. The abdomen is like a big fish; a big fish can pull

your knots and break your line—a distended abdomen can do the same. Moshe Schein 6

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ACADEMIA

7

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The Little Book of Aphorisms & Quotations for the Surgeon

Scholarship is not what you

happen to know about a subject; scholarship is what there is to know about that subject.

Harry Austryn Wolfson (1887-1974) 8

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Academia

[About discussants at meetings]

While some are thoughtful, even dialectic, others are

inappropriately sardonic, and others are without substance

or relevance. Some of our colleagues rise for mere recognition of their presence at the meeting, while others go on record to have their abbreviated remarks listed (surprisingly enough)

in their curriculum vita. A majority of discussants parade to

the podium, often sitting in the rear of the hall, seldom using readily accessible floor microphones. Claude H. Organ (1926-2005)

9

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The Little Book of Aphorisms & Quotations for the Surgeon

Let us remember that the responsibility of the discussant is not to ‘stick it’ to the presenter but to aid in the

educational experience of the audience.

Jonathan van Heerden 10

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Academia

Dr. Will Mayo many many years ago stated that every lecture should fulfil 4 criteria:

1. Tell the audience what you are going to tell them; 2. Tell them;

3. Tell them what you have just told them; 4. Keep it short.

Jonathan van Heerden 11

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The Little Book of Aphorisms & Quotations for the Surgeon

I have evolved two inviolate rules for meetings: 1. Never go to a session if you don’t understand the title;

2. Avoid all short paper sessions

unless your resident is speaking. Mark Cheetham 12

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APPENDICITIS

13

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The Little Book of Aphorisms & Quotations for the Surgeon

There are three types of patients with acute

appendicitis: those who do well no matter what we do; those who don’t do well no matter what we do; and those in whom our management

actually makes a difference. As most fall into

the first category... every surgeon believes that what he does is the right thing to do. Magnus Bergenfeldt 14

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Appendicitis

More than 100 years after the

first appendectomy the natural history of untreated acute appendicitis is unknown.

15

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ASSESSMENT

16

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Assessment

‘Open’ referees’ reports are not worth the paper they are written on. They usually convey the idea that the

candidate is a blend of Michael de Bakey, Albert Schweitzer and Sister Theresa. Closed and ‘confidential’ ones are also rather fulsome; perhaps they fear the candidate

may see them? On the other hand, well targeted phone calls yield amazing info, some good and some dirt. David Dent 17

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The Little Book of Aphorisms & Quotations for the Surgeon

Oddly in the U.S. we seem to have an aversion to writing anything in anybody’s evaluation that is bad; we would rather cloak it in ‘nice

wording’ and hope that the person reading it gets the undertone. For

example, a student who is a loudmouthed braggart who does not take criticism well would be evaluated as “independent” or “has strong

opinions”. Someone who is lazy as hell would be evaluated as “nice

personality” or “laidback”. The worst thing is if you are labeled as “a

pleasure to work with” without any other specific positive comments. Program directors know this is bad news. Karen Draper

18

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ASSISTANTS, STUDENTS & RESIDENTS

19

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The Little Book of Aphorisms & Quotations for the Surgeon

The best surgical assistant is

mute, catatonic, and transparent.

Charles G. Rob (1913-2001) 20

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Assistants, Students & Residents

I’m on a high-protein diet today. I just chewed a resident’s butt.

James H. Duke (1928-2015) 21

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The Little Book of Aphorisms & Quotations for the Surgeon

To medical students in the OR:

just allow a peek but not a poke!

Andy Gage 22

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Assistants, Students & Residents

Hell has a special place for lousy assistants.

Dean Lutrin 23

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BILIARY

24

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Biliary

When I was a resident all GBs with stones were “chronic

cholecystitis”. In my early years all GBs without abnormal

findings were “normal” (no surgeon ever liked this). In my mature years if I see two lymphocytes kissing it’s “chronic cholecystitis”! I don’t know any surgeons who take out normal GBs unless it was just in the way.

Miles J. Jones 25

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The Little Book of Aphorisms & Quotations for the Surgeon

Jaundice is ‘medical’ when you are too

surgically focused, and ‘surgical’ when you are too medically focused.

B. Ramana 26

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CANCER SURGERY

27

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The Little Book of Aphorisms & Quotations for the Surgeon

Telling a radical node resecting surgeon that

his results are mere artefact, due to a powerful stage migration effect, is like telling a radical religious person that their views are flawed.

David Dent 28

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Cancer surgery

Nor breast nor colon nor stomach.

Chasing lymph nodes in adenocarcinoma is like obliterating the tire marks where the car has been. It’s the mets that kill; no one has ever died of nodes. David Dent 29

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The Little Book of Aphorisms & Quotations for the Surgeon

There is no evidence that lymph node removal alters prognosis at any site.

The axillary debates in breast cancer are merely storms in an armpit.

David Dent 30

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COLORECTAL SURGERY

31

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The Little Book of Aphorisms & Quotations for the Surgeon

Certainly perianal Crohn’s disease can look alarming; however, the temptation to treat

alarming appearances with aggressive surgery must be resisted if the situation is not to be made worse by iatrogenic morbidity. Allan A. Keighley 32

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Colorectal surgery

Fistula-in-ano surgery is challenging. Unlike most surgery where success

rates are compared, fistula surgery is assessed by failure rates!

John Thanakumar 33

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The Little Book of Aphorisms & Quotations for the Surgeon

As I tell all my patients I know when the

colonoscope is in the rectum and the ileum but ensuring any location anywhere else in the

colon is a crapshoot. So even if you are God’s gift to colonoscopy, mark the site of bleeding. Jonathan Efron 34

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Colorectal surgery

It’s funny that the patient poops and the surgeon is relieved.

Amjad Siraj Memon 35

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COMMON SENSE

36

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Common sense

Common sense in not commonly

practiced nowadays, particularly when it goes against the recommendation of ‘experts’.

Samir Johna 37

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The Little Book of Aphorisms & Quotations for the Surgeon

Evidence is the base of medicine but common sense is the salt of it.

Slava Ryndine 38

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Common sense

No sensor should be allowed to

completely replace common sense.

Kuldip Pandey 39

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The Little Book of Aphorisms & Quotations for the Surgeon

Common things are common except common sense.

Yasser Mohsen 40

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COMPLICATIONS

41

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The Little Book of Aphorisms & Quotations for the Surgeon

We hate complications even though they love us.

Hanafy Hanafy 42

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Complications

Anastomotic leakage is a completely

avoidable complication; providing you don’t perform an anastomosis.

Brendan Moran 43

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The Little Book of Aphorisms & Quotations for the Surgeon

Those who opened the retroperitoneum

on a renal fracture still talk of this with

sobs in their voice. B. Ramana 44

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Complications

Surgeon: “It’s amazing how the family members of doctors always get complications.”

Nurse: “But Doctor, all of your patients get complications, you only remember the family members of doctors.”

Dean Lutrin 45

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The Little Book of Aphorisms & Quotations for the Surgeon

If it can get infected, it will.

Patrick A. Stone 46

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Complications

If your stats are too good, just operate on a health care professional’s family member.

Patrick A. Stone 47

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The Little Book of Aphorisms & Quotations for the Surgeon

When things are going bad,

i.e. there’s blood in the water,

don’t wait to see the sharks to call for help.

Patrick A. Stone 48

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Complications

Ileus and wound infection

means a leak until proven otherwise.

Dean Lutrin 49

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The Little Book of Aphorisms & Quotations for the Surgeon

The Shit Surgeon Syndrome (SSS): any postoperative complication is blamed on a triad of:

a) Someone else — “the resident did the anastomosis”; b) The kit — “the new staple guns are shit”; c) The patient — “they were too fat”.

We’ve all heard the same excuses a hundred times — in my case frequently in my own head, from the devil on my shoulder. Simon Shaw

50

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Complications

I used to get angry when we lost a

patient until one day my chairman,

Dr. Jack Bloch, gave me his take on it: “you cannot make chicken salad out of chicken shit.” Samir Johna 51

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The Little Book of Aphorisms & Quotations for the Surgeon

It doesn’t matter what you put on a

bedsore as long as it is not the patient.

52

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Complications

10% of patients seem to get 90% of the complications.

53

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The Little Book of Aphorisms & Quotations for the Surgeon

Il medico pietoso fa la ferita infetta — the pitiful doctor makes the wound infected.

54

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CRITICAL CARE

55

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The Little Book of Aphorisms & Quotations for the Surgeon

This is the reality of intensive care: at any point, we are as apt to harm as we are to heal.

Atul Gawande 56

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Critical care

An extra hour of shit in the abdomen — an extra day in the ICU.

John Edington 57

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The Little Book of Aphorisms & Quotations for the Surgeon

About CPR:

If you can’t keep them alive when they’re alive,

you can’t keep them alive when they’re dead. Angus Maciver 58

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Critical care

The patient is in intensive care but still alive.

Javier Pérez de Cuéllar 59

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The Little Book of Aphorisms & Quotations for the Surgeon

The C in the ATLS ABC is for CIRCULATION — not for CHOPPER.

Moshe Schein 60

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DIAGNOSIS

61

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The Little Book of Aphorisms & Quotations for the Surgeon

Beware of the surgeon with only one differential diagnosis.

John Santaniello 62

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Diagnosis

It sounds better in German:

“Wer viel misst, misst viel mist” —

people who test too much tend to get bullshit.

Lope Estévez-Schwarz 63

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The Little Book of Aphorisms & Quotations for the Surgeon

The certainty that scores give to clinicians

who like to see themselves endowed with higher knowledge from hand-held devices is more

than often frustrated by the stubbornness of individual patients who refuse to follow the way of the score.

Erik Schadde 64

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Diagnosis

We used to use the abbreviation exam NAD (no abnormality detected)

but now I suspect it is exam NAD (not actually done!).

John Leslie 65

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DOGMA

66

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Dogma

He believes in evidence-based surgery, except when he doesn’t.

B. Ramana 67

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The Little Book of Aphorisms & Quotations for the Surgeon

Blind adherence to old dogma is like adhesions following surgery. They

cause obstruction, nausea, vomiting, pain, and constipation.

Francis Seow-Choen 68

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Dogma

How many unfounded dogmas — things

which we are doing without ‘evidence’ — are now being studied over and over again — to

prove that the unproven things are unproven.

Moshe Schein 69

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EDUCATION

70

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Education

The great vice of medical education is its tendency to fix attention on the latest and the best only, to the neglect of

what has been accomplished in the past. At times, the latest book on a subject is not the best… this comes chiefly for lack of knowledge of previous experience.

Leslie Cowlishaw (1877-1943) 71

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The Little Book of Aphorisms & Quotations for the Surgeon

I cannot, for the life of me, figure out why the hours of surgical education are getting easier while the surgical pathology we seek to eliminate is getting more difficult.

Leo Gordon 72

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Education

There is an analogy here to the

self-esteem movement in education.

Educators are afraid of hurting the student’s self-esteem. If this continues, students will feel better and better about knowing less and less.

The result is a graduate who feels great about knowing nothing. Leo Gordon 73

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The Little Book of Aphorisms & Quotations for the Surgeon

During the first ten years you learn how to do the surgery; the next ten years you learn when to perform

surgery, and in the last ten years you learn when to refrain from surgery. Kuldip Pandey 74

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ERRORS

75

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The Little Book of Aphorisms & Quotations for the Surgeon

You must learn from the mistakes of others. You can’t possibly live long enough to make them all yourself.

Sam Levenson (1911-1980) 76

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Errors

I always prefer to be open and honest about my mistakes. There is an art to doing this, as you know. When one falls on the sword,

the sharks tend to swim away.

When one is defensive, it tends to chum the waters.

Bob Goldman 77

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The Little Book of Aphorisms & Quotations for the Surgeon

You are less likely to commit an error

if you consider an atypical presentation of a common condition than a typical presentation of a rare condition.

Wojciech J. Górecki 78

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Errors

To err is human — this adage always seems ‘correct’ if the error has been committed by

yourself, or one of your buddies — the error

appears much less ‘human’ if inflicted on you, or one of your dear ones. Moshe Schein 79

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ETHICS

80

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Ethics

The prime goal is to alleviate suffering, and not to prolong life. And if your

treatment does not alleviate suffering, but only prolongs life, that treatment should be stopped. Christiaan Barnard (1922-2001) 81

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The Little Book of Aphorisms & Quotations for the Surgeon

I had bought two male chimps from a primate colony in Holland. They lived next to each other in separate cages for several months

before I used one as a [heart] donor. When we put him to sleep in his cage in preparation for the operation, he chattered and cried

incessantly. We attached no significance to this, but it must have

made a great impression on his companion, for when we removed the body to the operating room, the other chimp wept bitterly and was

inconsolable for days. The incident made a deep impression on me. I vowed never again to experiment with such sensitive creatures. Christiaan Barnard (1922-2001) 82

12-16AphorismsIII_AphorismsIII20/08/202012:00Page83

Ethics

It is infinitely better to transplant a heart than to bury it to be devoured by worms.

Christiaan Barnard (1922-2001) 83

12-16AphorismsIII_AphorismsIII20/08/202012:00Page84

The Little Book of Aphorisms & Quotations for the Surgeon

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when

doctors bring the cutting edge of technology to bear on a

grievously ill person near the end of life. The patient will

get cut open, perforated with tubes, hooked up to machines,

and assaulted with drugs. All of this occurs in the ICU at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. Ken Murray

84

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Ethics

Under the cover of science, innovation,

progress and surgical solutions to non-surgical issues, patients are still serving as mice in our experiments. Informed consent is a joke when we ourselves are so clueless. Danny Rosin 85

12-16AphorismsIII_AphorismsIII20/08/202012:00Page86

The Little Book of Aphorisms & Quotations for the Surgeon

In some ways the true face of any society

is reflected not by its army, movie industry,

internet connectivity, media, stock exchange, car industry, number of senators

or congressmen — but how well it looks after the sick and poor. Moshe Schein 86

17-24AphorismsIII_AphorismsIII20/08/202015:45Page87

GENERAL CONCEPTS

87

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The Little Book of Aphorisms & Quotations for the Surgeon

I would say that major surgery includes all work

requiring a general anesthetic; all operations which

involve openings into the great cavities of the body; all operations in the course of which hazards of severe

hemorrhage are possible; all conditions in which the life of the patient is at stake; all conditions which require for

their relief manipulations, for the proper performance of

which special anatomic knowledge and manipulative skill are essential. …You will see that there is still left an

abundant field for the practitioner of minor surgery. Lewis S. Pilcher (1845-1934)

88

17-24AphorismsIII_AphorismsIII20/08/202015:45Page89

General concepts

The final success of an operation does not depend upon the suture material

but upon the power of tissue to unite.

George Grey Turner (1877-1951) 89

17-24AphorismsIII_AphorismsIII20/08/202015:45Page90

The Little Book of Aphorisms & Quotations for the Surgeon

Surgery has no parallel in human experience.

The violent intrusion into the body of an accepting

fellow-being for the ultimate benefit of the violated is a powerful experience. After continued repetition, some surgeons become muddled as to which party has the rights and which the privilege.

N. S. Mitchell 90

17-24AphorismsIII_AphorismsIII20/08/202015:45Page91

General concepts

Patients never die of fluid overload on the medical service or

dehydration on the surgical one.

Timothy C. Fabian 91

17-24AphorismsIII_AphorismsIII20/08/202015:45Page92

The Little Book of Aphorisms & Quotations for the Surgeon

The 4 Rs on how to

deal with surgical stress: Religion;

Romance; Running;

Red wine. John Bruni 92

17-24AphorismsIII_AphorismsIII20/08/202015:45Page93

General concepts

One of our great failings is to reduce management into

binary possibilities. You do, or you don’t; you give, or you don’t give; it is black or it is white.

Nature, disease, patients and outcomes are, however, a spectrum of possibilities. So, too, should our management be, and that includes antibiotics for diverticular disease. David Dent 93

17-24AphorismsIII_AphorismsIII20/08/202015:45Page94

The Little Book of Aphorisms & Quotations for the Surgeon

As I tell the students, a lot of things about surgery really suck, but it is still the best job in medicine, and it has a

history, amusing anecdotes, etc. Plus we get to work on the coolest thing on the planet, the human body, and most of

the time if we don’t violate some pretty simple basic rules, it heals just fine and patients are happy.

Albert I. Alexander 94

17-24AphorismsIII_AphorismsIII20/08/202015:45Page95

General concepts

Surgical self-esteem is a fundamental knowledge of surgical pathology

coupled with the skills to treat that

pathology. Achieving that self-esteem takes time and effort. It does not

conform to a clock or a schedule. Leo Gordon 95

17-24AphorismsIII_AphorismsIII20/08/202015:45Page96

The Little Book of Aphorisms & Quotations for the Surgeon

Two of the most powerful

therapeutic agents in surgery

are time, and natural history.

David Dent 96

17-24AphorismsIII_AphorismsIII20/08/202015:45Page97

General concepts

We have all heard of “evidence-based medicine”. But let’s not ignore “enteric-based medicine” —

the thought ‘in your gut’ that this is doing some good. Leo Gordon 97

17-24AphorismsIII_AphorismsIII20/08/202015:45Page98

The Little Book of Aphorisms & Quotations for the Surgeon

The snowball effect of rescue procedures,

and the different attitudes of the different groups involved: Rescue teams — get ‘em to hospital alive; ER — get ‘em out of here alive;

OR — get ‘em to the ICU alive;

ICU — we must keep ‘em alive whatever. But who sees the overall picture? Barry (Baz) Alexander 98

17-24AphorismsIII_AphorismsIII20/08/202015:45Page99

General concepts

As you know, holding fire is much more difficult than shooting.

This is true for the police force,

the Marines, the IDF and surgeons.

Moshe Schein 99

17-24AphorismsIII_AphorismsIII20/08/202015:45Page100

The Little Book of Aphorisms & Quotations for the Surgeon

Avoid the fog of transfer.

100

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General concepts

An asymptomatic patient is

likely to become symptomatic after the operation.

101

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The Little Book of Aphorisms & Quotations for the Surgeon

Magnitude of bleeding: see, hear, or feel…

102

17-24AphorismsIII_AphorismsIII20/08/202015:45Page103

HEMORRHOIDS

103

17-24AphorismsIII_AphorismsIII20/08/202015:45Page104

The Little Book of Aphorisms & Quotations for the Surgeon

The similarity between smartphones and piles:

ultimately every asshole gets one.

Vinay Mehendale 104

17-24AphorismsIII_AphorismsIII20/08/202015:45Page105

Hemorrhoids

Prolapsed hemorrhoids:

if you let it subside spontaneously

the patient will have pain for 7 days,

but if you operate the pain will last a week.

Simon Shaw 105

17-24AphorismsIII_AphorismsIII20/08/202015:45Page106

HERNIA

106

17-24AphorismsIII_AphorismsIII20/08/202015:45Page107

Hernia

The humble umbilical hernia

remains a simple yet complex issue.

Lawrence T. Kim 107

17-24AphorismsIII_AphorismsIII20/08/202015:45Page108

The Little Book of Aphorisms & Quotations for the Surgeon

Laparoscopic umbilical hernia repair is like going to the center of the earth to plant a seed near the surface.

Rolando Ramos 108

17-24AphorismsIII_AphorismsIII20/08/202015:45Page109

INNOVATIONS/GIMMICKS

109

17-24AphorismsIII_AphorismsIII20/08/202015:45Page110

The Little Book of Aphorisms & Quotations for the Surgeon

Every year sees methods of treatment tried over again which were tried and found

wanting many years before, and fresh discoveries vaunted which are only rediscoveries.

This waste of effort and time arises from ignorance of what has been accomplished before.

Leslie Cowlishaw (1877-1943) 110

17-24AphorismsIII_AphorismsIII20/08/202015:45Page111

Innovations/gimmicks

I don’t believe medical discoveries are doing much to advance human life.

As fast as we create ways to extend it we are inventing ways to shorten it.

Christiaan Barnard (1922-2001) 111

17-24AphorismsIII_AphorismsIII20/08/202015:45Page112

The Little Book of Aphorisms & Quotations for the Surgeon

NOTES

(natural orifice transluminal

endoscopic surgery) is NUTS. SILS

(single-incision laparoscopic surgery) is SILLY. Mark Cheetham 112

17-24AphorismsIII_AphorismsIII20/08/202015:45Page113

Innovations/gimmicks

Soon there will be a specialist for the right

nostril and another specialist for the left one.

However, when a casualty is admitted with a

wound of both nostrils, until the two specialists arrive, there will be no more nose left. Moshe Hashmonai 113

17-24AphorismsIII_AphorismsIII20/08/202015:45Page114

The Little Book of Aphorisms & Quotations for the Surgeon

This procedure is very good.

Yes, it has a long learning curve.

You have to f*** up a large number of unsuspecting patients before you can master it. Kuldip Pandey 114

17-24AphorismsIII_AphorismsIII20/08/202015:45Page115

Innovations/gimmicks

There are many factors determining if a change in practice will ‘catch’ on.

Saving money, doing less, and thinking more are not among the immediate suspects.

Danny Rosin 115

17-24AphorismsIII_AphorismsIII20/08/202015:45Page116

INTESTINE

116

17-24AphorismsIII_AphorismsIII20/08/202015:45Page117

Intestine

In my experience, the diagnosis of

gastroenteritis in the emergency ward is often incorrect as to raise a serious question whenever the emergency

physician comes to this conclusion. Zachary Cope (1881-1974) 117

17-24AphorismsIII_AphorismsIII20/08/202015:45Page118

The Little Book of Aphorisms & Quotations for the Surgeon

I would rather leave a piece of mesh on the bowel than a

piece of bowel on the mesh.

Moshe Schein 118

17-24AphorismsIII_AphorismsIII20/08/202015:45Page119

Intestine

Beware of the diagnosis of

gastroenteritis in the elderly.

119

17-24AphorismsIII_AphorismsIII20/08/202015:45Page120

JUDGMENT

120

17-24AphorismsIII_AphorismsIII20/08/202015:45Page121

Judgment

The surgeon who strives for perfection needs some basis for patient selection. He would like to be sure

there’s a good chance for cure before he starts the resection. Elwood G. Jensen 121

17-24AphorismsIII_AphorismsIII20/08/202015:45Page122

The Little Book of Aphorisms & Quotations for the Surgeon

Surgeons frequently have tunnel vision which only sees the nail, which they are

tempted to smite with a hammer; they do not see the whole structure behind it, or ask why the nail is protruding. David Dent 122

17-24AphorismsIII_AphorismsIII20/08/202015:45Page123

Judgment

Evidence-based clinical decision-

making may require input from a

multidisciplinary group of experts, as opposed to a ‘consensus of one’.

Laurent G. Glance 123

17-24AphorismsIII_AphorismsIII20/08/202015:45Page124

The Little Book of Aphorisms & Quotations for the Surgeon

It is judgment not genital

insufficiency driving a surgeon to pack his patient’s abdomen.

David J. Richardson 124

17-24AphorismsIII_AphorismsIII20/08/202015:45Page125

Judgment

Some correct decisions cannot be

judged by retrospective knowledge.

Danny Rosin 125

17-24AphorismsIII_AphorismsIII20/08/202015:45Page126

The Little Book of Aphorisms & Quotations for the Surgeon

The first thing to go when you are tired is your judgment.

Dean Lutrin 126

17-24AphorismsIII_AphorismsIII20/08/202015:45Page127

Judgment

It’s better to be an optimist

who is sometimes wrong than a pessimist who is always right.

John Leslie 127

17-24AphorismsIII_AphorismsIII20/08/202015:45Page128

The Little Book of Aphorisms & Quotations for the Surgeon

He used to tell his patients while taking consent for any operation

“Sir or Madam, I am a pessimistic realist.” Not the worst thing to be for a surgeon.

Mathias Kalkum 128

17-24AphorismsIII_AphorismsIII20/08/202015:45Page129

Judgment

Indications can be stretched like

chewing gum or the brain of surgeons. Unfortunately arteries are not as pliable.

Moshe Schein 129

17-24AphorismsIII_AphorismsIII20/08/202015:45Page130

The Little Book of Aphorisms & Quotations for the Surgeon

Clinical experience has been defined as making the same mistake with increasing confidence for an impressive

number of years in contrast to evidence-based medicine which involves perpetuating other people’s mistakes instead of your own.

130

17-24AphorismsIII_AphorismsIII20/08/202015:45Page131

Judgment

One of the rarest things that we do is think. I don’t know why people don’t do it more often. It doesn’t cost anything. Think about that.

131

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LAPAROSCOPY

132

17-24AphorismsIII_AphorismsIII20/08/202015:45Page133

Laparoscopy

Laparoscopy shares many similarities

with the emperor’s cloth. If you do not join in the choir of praises, you are

either stupid or unfit for the job. But someone needs to tell the truth. Roland Andersson 133

17-24AphorismsIII_AphorismsIII20/08/202015:45Page134

The Little Book of Aphorisms & Quotations for the Surgeon

Laparoscopic surgery is the one case where a resident can destroy the remainder of a

patient’s life, and your mental health and well-being with one squeeze of the clip applier or one cut of the shears. Jeffrey Young 134

17-24AphorismsIII_AphorismsIII20/08/202015:45Page135

Laparoscopy

Even in teaching, laparoscopy takes longer than open surgery.

John Santaniello 135

17-24AphorismsIII_AphorismsIII20/08/202015:45Page136

The Little Book of Aphorisms & Quotations for the Surgeon

A rule of thumb is that the tumour

should be removed by laparotomy and

not laparoscopy if it is bigger than the head of the surgeon in question.

David Dent 136

17-24AphorismsIII_AphorismsIII20/08/202015:45Page137

Laparoscopy

If you can’t do it with the laparoscope alone, you shouldn’t do it with the robot.

If you can do it with the laparoscope, you don’t need the robot.

Mark Pleatman 137

17-24AphorismsIII_AphorismsIII20/08/202015:45Page138

The Little Book of Aphorisms & Quotations for the Surgeon

Laparoscopic cholecystectomy:

a nickel and dime operation with a million dollar complication.

Nathaniel Soper 138

17-24AphorismsIII_AphorismsIII20/08/202015:45Page139

Laparoscopy

The most important aim of cholecystectomy is not to injure the CBD;

the second most important aim is to relieve any sepsis;

the third — if it can be done safely — is to remove the gallbladder. Kristoffer Lassen 139

17-24AphorismsIII_AphorismsIII20/08/202015:45Page140

The Little Book of Aphorisms & Quotations for the Surgeon

Laparoscopy is a path, not a goal. The goal is a safe outcome.

Vinay Mehendale 140

17-24AphorismsIII_AphorismsIII20/08/202015:45Page141

Laparoscopy

I know lots of anaesthetists who rely upon anecdote

to judge us surgeons. Almost to a man (or a woman) they regard laparoscopic surgery as a means by

which straightforward operations that used to be done quickly now take hours and inevitably involve vast quantities of disposable kit.

John MacFie 141

17-24AphorismsIII_AphorismsIII20/08/202015:45Page142

The Little Book of Aphorisms & Quotations for the Surgeon

I never saw a patient dying because he was converted to open;

I saw them dying because they were not converted.

Moshe Schein 142

17-24AphorismsIII_AphorismsIII20/08/202015:45Page143

Laparoscopy

Laparoscopic cholecystectomy should take as

long as it takes to do it safely; and if it takes too long it only means that the surgeon should

have attempted subtotal cholecystectomy or ‘converted’ to open earlier. Moshe Schein 143

17-24AphorismsIII_AphorismsIII20/08/202015:45Page144

MALPRACTICE & LAW

144

17-24AphorismsIII_AphorismsIII20/08/202015:45Page145

Malpractice & law

Informed consent is not the

piece of paper, it is the process of

understanding, and the agreement.

David Dent 145

17-24AphorismsIII_AphorismsIII20/08/202015:45Page146

The Little Book of Aphorisms & Quotations for the Surgeon

Shit happens, but the patient needs to be given some reasonable money; lawyers must not get ANY money;

the surgeon must not be made out to be a criminal. Court time and resources need to be used properly.

Anil Thakur 146

17-24AphorismsIII_AphorismsIII20/08/202015:45Page147

Malpractice & law

Shit does happen but it

comes usually from arseholes.

Barry (Baz) Alexander 147

17-24AphorismsIII_AphorismsIII20/08/202015:45Page148

The Little Book of Aphorisms & Quotations for the Surgeon

I am amazed, in every trial I’ve had, how a jury can see

through a difficult situation and find for the doctor if two things are proven to them: first, you know what you’re

doing, which is easy to prove, and second, that you care. If we are able to prove that to the jury, they will excuse the most unbelievable things.

Curtis Diedrich 148

17-24AphorismsIII_AphorismsIII20/08/202015:45Page149

Malpractice & law

The increasingly politically correct

medical system wishes us to “hear no evil, see no evil, do no evil”. The results:

evil is being committed, people see it but pretend they do not;

they speak about it — but behind the back. Moshe Schein 149

17-24AphorismsIII_AphorismsIII20/08/202015:45Page150

The Little Book of Aphorisms & Quotations for the Surgeon

The “standard of care” is a

good place to hide if you don’t have a better idea and the talent to execute it.

150

25-29AphorismsIII_AphorismsIII20/08/202015:51Page151

MONEY MATTERS

151

25-29AphorismsIII_AphorismsIII20/08/202015:51Page152

The Little Book of Aphorisms & Quotations for the Surgeon

The principal object of the patient is to get cured;

the principal object of the surgeon is to get paid.

Henri de Mondeville (1260?-1320) 152

25-29AphorismsIII_AphorismsIII20/08/202015:51Page153

Money matters

There are only four forms of incentive that I now, in my 27th year as a surgical chair, recognize:

cash, money, cash money, and everything that can be converted into cash money. Josef E. Fischer 153

25-29AphorismsIII_AphorismsIII20/08/202015:51Page154

The Little Book of Aphorisms & Quotations for the Surgeon

Patients are viewed as biological

cash-producing units, with a cynical reimbursement system that makes it all the more lucrative. The system works like this everywhere. Jon Lloyd 154

25-29AphorismsIII_AphorismsIII20/08/202015:51Page155

Money matters

One of the things about the U.S.

health care system is that it defies the

laws of economics, and of gravity. Once the price is high, it just stays there.

Naoki Ikegami 155

25-29AphorismsIII_AphorismsIII20/08/202015:51Page156

OBESITY

156

25-29AphorismsIII_AphorismsIII20/08/202015:51Page157

Obesity

If the poor overweight jogger only

knew how far he had to run to work off

the calories in a crust of bread he might

find it better in terms of pound per mile to go to a massage parlor. Christiaan Barnard (1922-2001) 157

25-29AphorismsIII_AphorismsIII20/08/202015:51Page158

The Little Book of Aphorisms & Quotations for the Surgeon

For the vast majority of patients today, there is

no operation that will control weight to a ‘normal’

level without introducing risks and side effects that over a lifetime may raise questions about its use for surgical treatment of obesity.

Edward Mason 158

25-29AphorismsIII_AphorismsIII20/08/202015:51Page159

Obesity

There are no difficult operations, only fat people.

Stephen Clifforth 159

25-29AphorismsIII_AphorismsIII20/08/202015:51Page160

OLD AGE

160

25-29AphorismsIII_AphorismsIII20/08/202015:51Page161

Old age

When a surgeon is old enough to

have experience that’s all he’s got going for himself.

Matt Paneth (1921-2011) 161

25-29AphorismsIII_AphorismsIII20/08/202015:51Page162

The Little Book of Aphorisms & Quotations for the Surgeon

It’s just that as an old general surgeon,

I usually reserve optimism until the day after discharge, or often until the first

post-op visit. Until then I plan for the next worst potential problem. Jerry Kaplan 162

25-29AphorismsIII_AphorismsIII20/08/202015:51Page163

Old age

They say that a surgeon’s

‘expiry date’ is tattooed on

the back of his neck where he can’t see it, but everyone else can.

David Dent 163

25-29AphorismsIII_AphorismsIII20/08/202015:51Page164

The Little Book of Aphorisms & Quotations for the Surgeon

There is nothing like a

major operation to make

someone show their real age.

Jeffrey Matthews 164

25-29AphorismsIII_AphorismsIII20/08/202015:51Page165

Old age

The ‘generational gap’ between today’s young and old surgeons:

the young need to see everything; the old have to feel everything.

Moshe Schein 165

25-29AphorismsIII_AphorismsIII20/08/202015:51Page166

OPERATING

166

25-29AphorismsIII_AphorismsIII20/08/202015:51Page167

0perating

There is no value to an operation that only one surgeon can do.

Berkeley George Andrew Moynihan (1865-1936) 167

25-29AphorismsIII_AphorismsIII20/08/202015:51Page168

The Little Book of Aphorisms & Quotations for the Surgeon

Classification of an operation according to Moosa:

Type I — a difficult operation made to appear easy; Type II — a difficult operation made to look even more difficult by the operator;

Type III — an easy operation made to look difficult. May you always have Type Is.

Abdool R. Moossa (1939-2013) 168

25-29AphorismsIII_AphorismsIII20/08/202015:51Page169

0perating

Meticulous surgical technique:

a touch of a lady; allergic to blood.

Jonathan van Heerden 169

25-29AphorismsIII_AphorismsIII20/08/202015:51Page170

The Little Book of Aphorisms & Quotations for the Surgeon

A small scar doesn’t matter in the coffin.

Ari Leppäniemi 170

25-29AphorismsIII_AphorismsIII20/08/202015:51Page171

0perating

The key is to make an incision. If it is the wrong incision,

then make another incision.

Matthew Reeds 171

25-29AphorismsIII_AphorismsIII20/08/202015:51Page172

The Little Book of Aphorisms & Quotations for the Surgeon

SLICE surgery:

Single Large(r) Incision Cost-Effective surgery.

David Wattchow 172

25-29AphorismsIII_AphorismsIII20/08/202015:51Page173

0perating

I once asked my boss why he tied his knots seven times:

“Last time I did six, it didn’t hold.”

Bernard Cristalli 173

25-29AphorismsIII_AphorismsIII20/08/202015:51Page174

The Little Book of Aphorisms & Quotations for the Surgeon

There is slow and there is slow.

It can result from slow, continuous, confident

and accurate movements, or from unnecessary

repetitive, inaccurate and ineffective movements. I accept the first option as fully legitimate; the second is not to be praised.

Danny Rosin 174

25-29AphorismsIII_AphorismsIII20/08/202015:51Page175

0perating

If you haven’t seen it done before, there is a reason why.

Patrick A. Stone 175

25-29AphorismsIII_AphorismsIII20/08/202015:51Page176

The Little Book of Aphorisms & Quotations for the Surgeon

If you don’t like how it looks like today — you sure won’t tomorrow.

Patrick A. Stone 176

25-29AphorismsIII_AphorismsIII20/08/202015:51Page177

0perating

The first scary experience you will encounter: when you look across the table and realize that you are the most

experienced surgeon in the room.

Patrick A. Stone 177

25-29AphorismsIII_AphorismsIII20/08/202015:51Page178

The Little Book of Aphorisms & Quotations for the Surgeon

You want a fast trauma surgeon and a slow cancer surgeon.

Dean Lutrin 178

25-29AphorismsIII_AphorismsIII20/08/202015:51Page179

0perating

In Sweden we say:

“Går det lätt så är det rätt, är det rätt så går det lätt.”

If it is easy, it’s the right thing to do,

if it’s the right thing to do, it will be easy. Roland Andersson 179

25-29AphorismsIII_AphorismsIII20/08/202015:51Page180

The Little Book of Aphorisms & Quotations for the Surgeon

“Find safety in the heart of danger”

— unveil the hidden traps so as better to avoid them or control them.

Kristoffer Lassen 180

25-29AphorismsIII_AphorismsIII20/08/202015:51Page181

0perating

There are two rules to safe surgery — see what you are doing and leave a dry field.

181

25-29AphorismsIII_AphorismsIII20/08/202015:51Page182

OTHER DISCIPLINES

182

25-29AphorismsIII_AphorismsIII20/08/202015:51Page183

Other disciplines

When the internist wants an operation — think twice.

And make sure you do the correct one, not what he suggests. And if he doesn’t —

then there may be a real indication. Danny Rosin 183

25-29AphorismsIII_AphorismsIII20/08/202015:51Page184

The Little Book of Aphorisms & Quotations for the Surgeon

An orthopedic surgeon and an internist trying to stop the elevator:

the internist puts his hand in the door;

the orthopedic surgeon puts in his head.

184

25-29AphorismsIII_AphorismsIII20/08/202015:51Page185

Other disciplines

Hand surgeon:

one who wants to put his hand on all cases.

185

25-29AphorismsIII_AphorismsIII20/08/202015:51Page186

The Little Book of Aphorisms & Quotations for the Surgeon

The rectal tone of the

anesthesiologist varies with the patient’s O2 saturation.

186

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PATHOLOGY

187

30-34AphorismsIII_AphorismsIII20/08/202012:29Page188

The Little Book of Aphorisms & Quotations for the Surgeon

The only thing more complex than human pathology is the system we have designed to

identify and to treat human pathology. Leo A. Gordon 188

30-34AphorismsIII_AphorismsIII20/08/202012:29Page189

Pathology

A x P = c.

The Law of Anatomy and Pathology

states that the product of anatomy and pathology equals a constant: the more

pathology you have, the less anatomy you get.

Amram Ayalon 189

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The Little Book of Aphorisms & Quotations for the Surgeon

The more complex the pathology — the simpler the surgical solution should be.

Moshe Schein 190

30-34AphorismsIII_AphorismsIII20/08/202012:29Page191

PATIENTS

191

30-34AphorismsIII_AphorismsIII20/08/202012:29Page192

The Little Book of Aphorisms & Quotations for the Surgeon

When a patient writes a letter of praise it

should not be read, but that when a letter of the opposite type is received, in which our

demerits are carefully depicted, we should go over it with great care, because we would probably learn something. Charles Mayo (1865-1939) 192

30-34AphorismsIII_AphorismsIII20/08/202012:29Page193

Patients

You can listen your way into your

patients’ lives better than you can talk your way into that relationship.

Antonia Novello 193

30-34AphorismsIII_AphorismsIII20/08/202012:29Page194

The Little Book of Aphorisms & Quotations for the Surgeon

It is often the difficult patient who survives, when the submissive and suffering good

patient dies of natural causes or medical errors, because these difficult patients tend to have a fighting spirit. Bernie Siegel 194

30-34AphorismsIII_AphorismsIII20/08/202012:29Page195

Patients

There is nothing biologically different

about a pope or a president, and there is no need to alter one’s thinking in caring for them.

Jay A. Block 195

30-34AphorismsIII_AphorismsIII20/08/202012:29Page196

The Little Book of Aphorisms & Quotations for the Surgeon

I find that an increasing percentage of my practice is dedicated to convincing patients they don’t need the operation they were referred for, and relieving their anxiety after being exposed to horror stories of what can happen. Danny Rosin 196

30-34AphorismsIII_AphorismsIII20/08/202012:29Page197

Patients

The operation is not over until the patient is home eating his favorite meal.

Dean Lutrin 197

30-34AphorismsIII_AphorismsIII20/08/202012:29Page198

The Little Book of Aphorisms & Quotations for the Surgeon

To reassure the patient you must be sure.

198

30-34AphorismsIII_AphorismsIII20/08/202012:29Page199

PILOTS VS. SURGEONS

199

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The Little Book of Aphorisms & Quotations for the Surgeon

Pilots may have more incentive than surgeons to be perfect, right or wrong.

When they botch a landing, it’s usually their last. Fortunately, modern day aircraft are a lot

more predictable and reliable than any of our patients. Any pilots will tell you that.

Tim Eldridge 200

30-34AphorismsIII_AphorismsIII20/08/202012:29Page201

Pilots vs. surgeons

Pilots don’t fill out a form documenting that

they put a landing gear down. This is another

fundamental difference in the two professions. We (surgeons) obsess about documentation;

aviation worries about getting the wheels down. Richard C. Karl 201

30-34AphorismsIII_AphorismsIII20/08/202012:29Page202

The Little Book of Aphorisms & Quotations for the Surgeon

I do know that it is harder to

control bleeding from the back

side of the portal vein than it is to

land a 737 with an engine on fire.

Richard C. Karl 202

30-34AphorismsIII_AphorismsIII20/08/202012:29Page203

Pilots vs. surgeons

If you deviate from a rule (e.g. ‘standard of care’),

it must be a flawless performance (e.g. if you fly under a bridge, don’t hit the bridge).

203

30-34AphorismsIII_AphorismsIII20/08/202012:29Page204

POLITICS AND ADMIN

204

30-34AphorismsIII_AphorismsIII20/08/202012:29Page205

Politics and admin

Clichés, stock phrases, adherence to conventional,

standardized codes of expression and conduct have the socially recognised function of protecting us against

reality; that is, against the claim on our thinking attention

which all events and facts make by virtue of their existence.

Hannah Arendt (1906-1975) 205

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The Little Book of Aphorisms & Quotations for the Surgeon

Administrators become Executive Directors, etc., until they finally arrive as “President and C.E.O.”. Joe boys and girl fridays get

sequentially elevated to “Vice President”...in charge of such bizarre portfolios as “patient experience”, “strategic corporate planning”, “interprofessional relations”...wtf is next? Vice President of Laundry, Vice President of Food Services, Vice President of

Parking… They breed like maggots feeding off a decaying corpse.

Angus Maciver 206

30-34AphorismsIII_AphorismsIII20/08/202012:29Page207

Politics and admin

The furies that populate committees, requiring more and more documentation, that reduce the time for one on one connections… we become

detached from those who become ‘problems’ and ‘cases’, rather than unique fellow humans. Barry (Baz) Alexander 207

30-34AphorismsIII_AphorismsIII20/08/202012:29Page208

The Little Book of Aphorisms & Quotations for the Surgeon

Advice from an old fart:

play the facts not the person.

Matt Oliver 208

30-34AphorismsIII_AphorismsIII20/08/202012:29Page209

Politics and admin

Ideal hospital for the administrators:

no doctors, no patients, lots of money. Ideal hospital for the doctors:

many patients, lots of money, no administrators. Bernard Cristalli 209

30-34AphorismsIII_AphorismsIII20/08/202012:29Page210

The Little Book of Aphorisms & Quotations for the Surgeon

Try to attend important meetings; if not at the table you will be on the menu.

210

30-34AphorismsIII_AphorismsIII20/08/202012:29Page211

PRACTICE

211

30-34AphorismsIII_AphorismsIII20/08/202012:29Page212

The Little Book of Aphorisms & Quotations for the Surgeon

The concept that one citizen will lay himself horizontal

and permit another to plunge a knife into him, take blood,

give blood, rearrange internal structures at will, determine ultimate function, indeed, sometimes life itself — that

responsibility is awesome both in true and in the currently debased meaning of that word.

Alexander J. Walt (1923-1996) 212

30-34AphorismsIII_AphorismsIII20/08/202012:29Page213

Practice

Unfortunately, the practice of

surgery today is as much a business as it is a science and art.

Thomas R. Russell (1940-2014) 213

30-34AphorismsIII_AphorismsIII20/08/202012:29Page214

The Little Book of Aphorisms & Quotations for the Surgeon

Doctors live in a sea of ignorance surrounding small islands of

knowledge that sustain us until another island appears.

Daniel C. Wilkerson, Jr. (1922-2017) 214

30-34AphorismsIII_AphorismsIII20/08/202012:29Page215

Practice

When I use the words “bad situation” I am

implying an unfavorable outcome, unless you

recognize that for hundreds of years physicians

considered an early death in futile situations as the most favorable outcome. When God puts Her/His hands on, take yours OFF. Kenneth Mattox 215

30-34AphorismsIII_AphorismsIII20/08/202012:29Page216

The Little Book of Aphorisms & Quotations for the Surgeon

You can often get away with a less safe process, but that doesn’t mean it is safe; it just means that you got away with it.

Jeffrey Young 216

30-34AphorismsIII_AphorismsIII20/08/202012:29Page217

Practice

Politically correct, PC, is an artificial behavioural code that is transient; good manners and sensitivity are a basic behavioural code that should be permanent. David Dent 217

30-34AphorismsIII_AphorismsIII20/08/202012:29Page218

The Little Book of Aphorisms & Quotations for the Surgeon

One could compare the practice of surgery to

having unprotected sex with a beautiful whore: you have fun for an hour or so...

then you worry, worry, worry — and occasionally you suffer.

Moshe Schein 218

30-34AphorismsIII_AphorismsIII20/08/202012:29Page219

Practice

Less is more unless it isn’t.

219

30-34AphorismsIII_AphorismsIII20/08/202012:29Page220

The Little Book of Aphorisms & Quotations for the Surgeon

Excellent results don’t just happen — they are earned.

220

35-38AphorismsIII_AphorismsIII20/08/202012:44Page221

RESEARCH, WRITING,

READING & PUBLICATION

221

35-38AphorismsIII_AphorismsIII20/08/202012:44Page222

The Little Book of Aphorisms & Quotations for the Surgeon

Billings’ rules for scientific authors: 1. Have something to say; 2. Say it;

3. Stop as soon as you have said it; 4. Give the paper a proper title. John Shaw Billings (1838-1913) 222

35-38AphorismsIII_AphorismsIII20/08/202012:44Page223

Research, writing, reading & publication

There is a dead medical literature and there is a live one.

The dead is not all ancient, the live is not all modern.

Oliver Wendell Holmes (1841-1935) 223

35-38AphorismsIII_AphorismsIII20/08/202012:44Page224

The Little Book of Aphorisms & Quotations for the Surgeon

I would advise the young surgeon to write papers and in writing to bear in mind what the old minister said: “few souls are saved after the first 25 minutes of the sermon.” Write the paper not to show

how learned you are, or to show the high type man who may be in the audience, that you are in his class. Rather, try to tell those in your audience who perhaps may not know as much about the subject as you, something that may interest and help them. Do not try too many points. William Mayo (1861-1939) 224

35-38AphorismsIII_AphorismsIII20/08/202012:44Page225

Research, writing, reading & publication

To the young surgeon I would say, do not read all surgery and technique, for technique is constantly changing.

Along with surgical literature, read medical articles in high-class medical journals. Do not skim, but here and there select certain articles and read them with care.

William Mayo (1861-1939) 225

35-38AphorismsIII_AphorismsIII20/08/202012:44Page226

The Little Book of Aphorisms & Quotations for the Surgeon

Statistical numbers are like prisoners of war —

torture them enough and

they will admit to anything.

Basil A. Pruitt (1930-2019) 226

35-38AphorismsIII_AphorismsIII20/08/202012:44Page227

Research, writing, reading & publication

A rule of thumb: a retrospective study proves nothing but generates a hypothesis to be proven.

Lew Flint 227

35-38AphorismsIII_AphorismsIII20/08/202012:44Page228

The Little Book of Aphorisms & Quotations for the Surgeon

As far as the surgical literature goes,

use the “Texas mockingbird approach”: eat everything in sight and vomit what you can’t use.

Lew Flint 228

35-38AphorismsIII_AphorismsIII20/08/202012:44Page229

Research, writing, reading & publication

A difference, to be a difference, must make a difference.

Lew Flint 229

35-38AphorismsIII_AphorismsIII20/08/202012:44Page230

The Little Book of Aphorisms & Quotations for the Surgeon

If you can’t see a clinically significant difference, it probably isn’t there

regardless of what the statistics say.

Lew Flint 230

35-38AphorismsIII_AphorismsIII20/08/202012:44Page231

Research, writing, reading & publication

My scepticism is, however, greatest with observational studies from single centres, with famous individual reporters.

David Dent 231

35-38AphorismsIII_AphorismsIII20/08/202012:44Page232

The Little Book of Aphorisms & Quotations for the Surgeon

Statistics is like a bikini: what it shows you is very interesting but what it doesn’t is far more interesting!

Samir Johna 232

35-38AphorismsIII_AphorismsIII20/08/202012:44Page233

Research, writing, reading & publication

To my mind, the trialists (similar to the big

pharmas in medicine and device manufacturers

in surgery) have hijacked the EBM train and as some would say changed “evidence-based

medicine” to “evidence-biased medicine”. Saba Balasubramanian 233

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The Little Book of Aphorisms & Quotations for the Surgeon

In surgery, you don’t get to revise. In writing, you are

revising all the time and you are constantly striving to do something new. If I started following a formula with

my writing, everyone will know it and it will fail. In

surgery, you are trying to do, as much as possible, the same things over and over again, and to perfect what you do, I like having both. Atul Gawande 234

35-38AphorismsIII_AphorismsIII20/08/202012:44Page235

Research, writing, reading & publication

Researchers headed into their studies wanting certain results — and

lo and behold, they are getting them. We think of the scientific process as being objective, rigorous, and even ruthless in separating what is true from what we merely wish to be true. But in fact it’s easy to

manipulate results, even unintentionally or unconsciously… at every step of the process there is room to distort results, a way to make a

stronger claim or to select what is going to be concluded. …there is an intellectual conflict of interest that pressures researchers to find whatever it is that is most likely to get them funded. John Ioannidis 235

35-38AphorismsIII_AphorismsIII20/08/202012:44Page236

The Little Book of Aphorisms & Quotations for the Surgeon

As a general rule, results of

observational studies should be taken with a grain of salt.

Otherwise, one might conclude that gray hair causes heart attacks. Edward H. Livingston 236

35-38AphorismsIII_AphorismsIII20/08/202012:44Page237

Research, writing, reading & publication

Your essays should be like women’s skirts — long enough to cover the subject but short enough to be interesting.

Ms. Jane Ray [Cited by Leo Gordon] 237

35-38AphorismsIII_AphorismsIII20/08/202012:44Page238

The Little Book of Aphorisms & Quotations for the Surgeon

Editorials are not meant to tell readers what to think but to

tell them what to think about.

Richard Smith 238

35-38AphorismsIII_AphorismsIII20/08/202012:44Page239

Research, writing, reading & publication

It may be that their data pass the t-test, but they don’t pass the so-what test.

Erik Schadde 239

35-38AphorismsIII_AphorismsIII20/08/202012:44Page240

The Little Book of Aphorisms & Quotations for the Surgeon

The absence of evidence isn’t the evidence of absence.

Henry Black 240

35-38AphorismsIII_AphorismsIII20/08/202012:44Page241

Research, writing, reading & publication

Only bad writers think that their work is really good.

This applies to surgeons as well.

Moshe Schein 241

35-38AphorismsIII_AphorismsIII20/08/202012:44Page242

The Little Book of Aphorisms & Quotations for the Surgeon

Definition of a double-blind randomized trial:

two surgeons reading an ECG.

242

35-38AphorismsIII_AphorismsIII20/08/202012:44Page243

Research, writing, reading & publication

Gratis asseritur, gratis negatur. That which is asserted without evidence may be denied without explanation.

243

35-38AphorismsIII_AphorismsIII20/08/202012:44Page244

SURGEONS

244

35-38AphorismsIII_AphorismsIII20/08/202012:44Page245

Surgeons

A very ordinary surgeon, by means of selection of cases, aseptic care,

and the kindness of nature, may have a low death rate, and yet benefit his patients but little. Charles Mayo (1865-1939) 245

35-38AphorismsIII_AphorismsIII20/08/202012:44Page246

The Little Book of Aphorisms & Quotations for the Surgeon

Chloroform has done a lot of mischief. It’s enabled every fool to be a surgeon.

George Bernard Shaw (1856-1950) 246

35-38AphorismsIII_AphorismsIII20/08/202012:44Page247

Surgeons

From my surgical teacher, the late Prof. Sir

John Bruce, at the University of Edinburgh: “There is no minor surgery, just minor surgeons.”

Joe Lemer 247

35-38AphorismsIII_AphorismsIII20/08/202012:44Page248

The Little Book of Aphorisms & Quotations for the Surgeon

Even a drunken pig will

occasionally find a truffle.

This applies to surgeons as well.

Rob Lane 248

35-38AphorismsIII_AphorismsIII20/08/202012:44Page249

Surgeons

The surgeon’s ego does not always recognise when it has been abusive, exploitive or

patronizing. It does not adapt easy to the new ethos of the 90s which heralds teamwork, participative decision-making and decentralised responsibility. N. S. Mitchell 249

35-38AphorismsIII_AphorismsIII20/08/202012:44Page250

The Little Book of Aphorisms & Quotations for the Surgeon

I have many colleagues, all of varying levels of knowledge and skill. But the ones I trust most are the ones that worry. You can see the

concern, sometimes even anguish on their faces. Then... there are the sociopaths... Tom Gilas 250

35-38AphorismsIII_AphorismsIII20/08/202012:44Page251

Surgeons

Not analysed, seldom discussed, and rarely published, is the reality that there are good cutting surgeons

and bad cutting surgeons. Yes, broadly — two kinds. Outside of these normal parameters, there are

also wizard cutting surgeons and surgical butchers. This was, and is, and ever will be.

David Dent 251

35-38AphorismsIII_AphorismsIII20/08/202012:44Page252

The Little Book of Aphorisms & Quotations for the Surgeon

On the surgical ego:

It is nice to be important, it is much more important to be nice.

Jonathan van Heerden 252

35-38AphorismsIII_AphorismsIII20/08/202012:44Page253

Surgeons

About surgeons:

Few professionals are more willing

to discuss, or have more fun discussing patients without expecting financial remuneration for this discourse. Jonathan van Heerden 253

35-38AphorismsIII_AphorismsIII20/08/202012:44Page254

The Little Book of Aphorisms & Quotations for the Surgeon

Do you know the surgical definition of

‘colleague’? A person that has exactly the same profession as me but is a little less good at it.

Danny Rosin 254

35-38AphorismsIII_AphorismsIII20/08/202012:44Page255

Surgeons

Definition of a modern surgeon: one whose ignorant opinion is evidence-based.

B. Ramana 255

35-38AphorismsIII_AphorismsIII20/08/202012:44Page256

The Little Book of Aphorisms & Quotations for the Surgeon

As an historic legacy, surgeons feel obliged to

add a few zeroes religiously against the number of operations they have done. For example, you will rarely find an Indian surgeon who has done less than 15,000 LCs. B. Ramana 256

35-38AphorismsIII_AphorismsIII20/08/202012:44Page257

Surgeons

There are two types of female surgeons:

there are surgeons who shouldn’t be female and females who shouldn’t be surgeons.

Mark Pleatman 257

35-38AphorismsIII_AphorismsIII20/08/202012:44Page258

The Little Book of Aphorisms & Quotations for the Surgeon

After 33 years in the surgery I observe a lot of very happy surgeons, most of them stopped reading medical journals after graduation; they have no complications, they know everything and they are informed only by company representatives handing out glossy brochures.

Marian Littke 258

35-38AphorismsIII_AphorismsIII20/08/202012:44Page259

Surgeons

The four phases of evolution of a surgeon:

1. A surgeon feels insecure and this is justified (beginning of training); 2. A surgeon feels confident but this is not justified (dangerous for the patients...);

3. A surgeon feels confident and it is justified

(after years of training, alas some never reach this stage); 4. And the final stage as the surgeon grows old (he feels insecure but it is not justified). Alexander Schoucair 259

35-38AphorismsIII_AphorismsIII20/08/202012:44Page260

The Little Book of Aphorisms & Quotations for the Surgeon

Surgeons are influenced by

their most recent pleasant or unpleasant experience.

Kenneth Mattox 260

35-38AphorismsIII_AphorismsIII20/08/202012:44Page261

Surgeons

A rich man’s faults are covered with money, but a surgeon’s faults are covered with earth.

Abraham Verghese 261

35-38AphorismsIII_AphorismsIII20/08/202012:44Page262

The Little Book of Aphorisms & Quotations for the Surgeon

Nothing is as holy to the

surgeon as is his own skin.

Klaus Henner Laue 262

35-38AphorismsIII_AphorismsIII20/08/202012:44Page263

Surgeons

Big surgeons are those who are not too big to deal with the small things.

Moshe Schein 263

35-38AphorismsIII_AphorismsIII20/08/202012:44Page264

The Little Book of Aphorisms & Quotations for the Surgeon

A successful surgeon should be a man

who, when asked to name the three best surgeons in the world, would have

difficulty deciding on the other two.

Denton Cooley (1920-2016) 264

35-38AphorismsIII_AphorismsIII20/08/202012:44Page265

Surgeons

I was thinking that surgeons had

to be the happiest people on earth.

To cut people up and get paid for it — that’s happiness, I told myself.

Norman Mailer (1923-2007) 265

35-38AphorismsIII_AphorismsIII20/08/202012:44Page266

The Little Book of Aphorisms & Quotations for the Surgeon

As a surgeon you have to have a controlled arrogance. If it’s uncontrolled, you kill people, but you have to be pretty arrogant to saw through a person’s chest, take out their heart and believe you can fix it.

Then, when you succeed and the patient survives, you pray, because it’s only by the grace of God that you get there. Mehmet Öz 266

35-38AphorismsIII_AphorismsIII20/08/202012:44Page267

Surgeons

At a given instant everything the surgeon knows suddenly becomes important to the solution of the

problem. You can’t do it an hour later, or tomorrow. Nor can you go to the library and look it up. John W. Kirklin (1917-2004) 267

35-38AphorismsIII_AphorismsIII20/08/202012:44Page268

THYROID &

PARATHYROID

268

35-38AphorismsIII_AphorismsIII20/08/202012:44Page269

Thyroid & parathyroid

If the superior gland is missing,

look inferior to the inferior for the superior; and if the inferior is missing, look superior to the

superior for the inferior gland. Jonathan van Heerden 269

35-38AphorismsIII_AphorismsIII20/08/202012:44Page270

The Little Book of Aphorisms & Quotations for the Surgeon

Has the patient renal stones. Painful, brittle, broken bones.

Complaints of thirst and constipation. Next to peptic ulceration.

And you doubt his mental state.

Determine calcium and phosphate.

Sure the underlying the mechanism. Might be hyperparathyroidism. Hajo A. Bruining 270

35-38AphorismsIII_AphorismsIII20/08/202012:44Page271

VESSELS &

AMPUTATIONS

271

35-38AphorismsIII_AphorismsIII20/08/202012:44Page272

The Little Book of Aphorisms & Quotations for the Surgeon

Make claudicators beg for intervention.

Patrick A. Stone 272

35-38AphorismsIII_AphorismsIII20/08/202012:44Page273

Vessels & amputations

Amputation survival is

equivalent to metastatic cancer.

Patrick A. Stone 273

finalaphorismscoverforpress_Layout120/08/202015:01Page1

This book is the last to join the two former collections of surgical aphorisms: Aphorisms & Quotations for the Surgeon, with its 1500 quotations, and the slimmer A Companion to Aphorisms & Quotations for the Surgeon. Since their publication, both books have become steady bestsellers. Surgeons use the books to ‘decorate’ their lectures or manuscripts with relevant smart or entertaining entries; some like to quote from the books during teaching rounds or conferences; many simply enjoy them for their collective and eternal surgical wisdom and wit. As before, these aphorisms and quotations are retrieved from multiple sources: journals, books, lectures and, more and more, gathered from surgical friends around the world. The decision to include any entry is based on personal taste. Some would question the wisdom or accuracy of individual entries; others may not ‘get’ the humor or may object to political incorrectness. These aphorisms will help readers to (re)discover that surgical truth is old, that what they think is a novel idea has been said before, and that what they observe around them — has been observed years ago. It may contribute to their humanity and humility, perhaps even add maturity to their surgical personality and practice. In addition, with a bit of luck, it may increase their sense of surgical humor — for how can one survive a lifelong surgical career without possessing some of it.

ISBN 978-1-910079-95-9

9 781910 079959

The Little Book of Aphorisms & Quotations for the Surgeon

The last in the trilogy of this international bestselling series...

tf m

Aphorisms & Quotations for the Surgeon The Little Book of

Edited by Moshe Schein

“A rule of thumb is that the tumour should be removed by laparotomy and not laparoscopy if it is bigger than the head of the surgeon in question.” David Dent