“He who wishes to be a surgeon should go to war.”  Hippocrates

“He who wishes to be a surgeon should go to war.”  Hippocrates

Since the very beginnings of modern medicine, once civilizations started to understand that a person could intervene to heal injuries and cure sickness, it was recognized that cutting into the human body in order to heal required profound dedication and commitment by practitioners.   

The quote “He who wishes to be a surgeon should go to war” captures the essence of the demanding journey one must go through to become a surgeon.  War is intense and brutal.  War tests a soldier’s resilience, their capacity to meet challenges, overcome adversity, and make critical decisions under pressure.  It exposes them to the fragility of life.  Soldiers navigate through chaos and struggles, watch fellow combatants suffer and die, yet still must remain committed to success. 

“Going to war” is a metaphor for engaging in something known to be difficult and challenging, something that will be a life changing experience, testing one’s capacity and limits, pushing one towards excellence.  The practice of surgery requires one to be totally committed, with resolute devotion to understanding human anatomy, physiology, and how injury and disease interacts with the human body.  But the role of a surgeon is not just to cut and heal, but to have empathy for suffering, to exhibit compassion, to understand and appreciate the value of human life and human dignity.  Like a soldier at war, a surgeon must work through adversity, face challenges, witness sacrifice and witness suffering.  Training to become a good surgeon demands unwavering commitment, precision in mastering technical skills, and the ability to make critical decisions under pressure.  Both the soldier and the surgeon will experience death at a close, personal level, which will be profoundly impactful. 

Hippocrates’ quote suggests that the experience of war instills qualities vital for the practice of medicine.   War should allow one to develop empathy, compassion, and a deeper understanding of the value of life.   As we witness suffering and sacrifice, we should realize the imperative to alleviate pain and restore wholeness.

The idea of “going to war” extends beyond a battlefield to encompass the inner struggles and conflicts inherent in the pursuit of excellence within any field.  Becoming a successful surgeon requires courage to understand one’s limitations, humility to acknowledge mistakes, and perseverance to overcome obstacles.   Just as soldiers at war endure adversity and forge strong bonds for support, surgeons navigate the complexities of disease and surgery with determination and teamwork.

The idea of someone “going to war” to become a surgeon captures the nature of the transformative journey one goes through to achieve the role of “surgeon”.   There are challenges that seem insurmountable, death and suffering that seem too great to bear, and personal sacrifices that can be crippling.  But there are triumphs and victories along the way, successes that save lives and shape the skills that allow a surgeon to endure. 

I believe the art of surgery is a calling, a noble profession that requires a combination of technical skill, knowledge, empathy and compassion.  Years of hard work must go in to developing these skills to achieve success as a surgeon.

Sometimes I worry that this art of surgery is dying.  I am among the last generation of surgeons trained the old-fashioned way, who “went to war” to learn how to wield a scalpel. I trained before the era of work hour limitations, before anyone cared if the surgery intern was too tired to function, before anyone in charge cared about a resident’s “well-being”. No one worried if the surgery resident felt they had a good work-life balance, or felt fulfilled and appreciated. These were all totally foreign ideas throughout my training, as the only thing that mattered was getting as much experience as possible, doing the cases, and staying until every last detail of every patient under your care was managed to the satisfaction of your chief resident and your attendings. How we train surgeons has undergone some drastic changes over the last two decades.

In 1889, Johns Hopkins opened the first medical residency training program in the United States.  Residents lived at the hospital, and were expected not to marry – hence the term “residency”.  For the next century, residents worked with no work hour limitations, routinely putting in over 100 hours per week.

In 1975, medical residents in New York City went on strike, and were able to get hospitals to reduce being on call from every other night to every third night.

In 1981, the ACGME (Accreditation Council for Graduate Medical Education) was formed to regulate resident education.  This council suggested that hospital duties should not be so consuming as to preclude time for other phases of training or for personal needs.  Work hours remained unregulated.

Residency training was profoundly changed by an event occurring in October of 1984.  An 18 year old female presented to New York Hospital with fairly minor symptoms.  She was admitted, and within 24 hours died due to a little known drug interaction that caused her to have a fever up to 107 degrees, leading to cardiac arrest and death.  Her father was an attorney and a writer for the New York Times.  Her death was blamed on overworked, tired residents with little supervision, and became the catalyst for in depth investigations into working hours for residents.

By 1987, New York State’s Bell Commission recommended an 80 hour work week limitation on medical residents, with no more that 24 consecutive hours on call.

In 1990, the ACGME set an 80 hour work week limit in several specialties – internal medicine, dermatology, opthamology, and preventive medicine.

I started my General Surgery Residency in 1994 in Connecticut, and towards the end of my residency, the General Surgery Residents in New York City were just starting the 80 hour work week limitations. As a senior resident, I did several rotations at Memorial Sloan Kettering Cancer Center in Manhattan.  The Cornell University surgery residents we worked with were subject to the work hour limitations, but since we were not New York residents, we were not subject to those rules. It was a source of envy, but also a source of pride to watch them go home after their 24 hour shift, while we stayed late into the night taking care of patients.

I completed my training in 2000, routinely working between 90 and 132 hours per week.  I was on call every other to every third night. We worked all day the day after call, until the work was complete, and all patients were tucked in and safe for the night. When we took weekend call, we came in on Saturday morning and went home Monday night, after the regular Monday work was done.  Those were my 132 hour weeks.  If we had the weekend off, we rounded on Saturday morning, then got to go home, with an entire Sunday off.  These were my good weeks, averaging around 80-90 hours.

It wasn’t until 2003 that the ACGME enforced an 80 hour work week, with no more than 24 hours on call at a time, with at least one day off per week.

Since then, there have been additional limits and reductions in work hours, with increased focus on resident well-being, and work-life balance. 

There are many arguments on both sides as to whether these changes have been beneficial or detrimental to patient care and safety.  While residents are not working as much, and may be less fatigued, there are now many more turnovers of care during treatment when residents sign out to the next shift of residents.  Residents in training are likely more rested, but are not seeing as many patients, doing as many surgeries, or getting the volume of experience they had with longer work hours.  Is this creating a generation of surgeons who will be less capable and less experienced?  Will the new generation of surgeons feel compelled to “own” their patients, to see them through to the end of treatment, or simply be shift workers who pass care to the next person?  Will our patients be safer because they are being taken care of by well-rested young trainees who can focus all of their attention on their care because they are not so sleep-deprived?  Will residents who have more time to read and learn through didactics rather than working 100 hour weeks be better prepared for the ever advancing changes that occur in medicine?

Time will tell, but we are now trying to forge a balance between the invaluable experience of taking care of a patient with the need to have a more normal work-life balance without sleep deprivation and exhaustion clouding judgement.

I am the last generation of surgeons trained before the work hour limitations, which is why I felt it important to chronicle my transformative year as a General Surgery intern in Waterbury Connecticut in 1994. 

Hippocrates stated “He who wishes to be a surgeon should go to war.”  I took this quite literally, and joined the United Stated Navy during my third year of residency.  After completing residency, I was deployed on the USS Carl Vinson as the Ship’s Surgeon in 2001.  Our Battle Group was off the west coast of India heading towards the Persian Gulf on September 11, 2001.  As the closest deployed Battle Group, The USS Vinson changed course and launched the airstrikes into Afghanistan in support of Operation Enduring Freedom, the initial stage of the War in Afghanistan.

In 2003, I was deployed to set up and staff an evacuation hospital in support of Operation Iraqi Freedom, the second Gulf War.

In all, I think I have three stories to tell:

“Above the Knife” tells of my experience as one of the last residents trained in a General Surgery residency before the work hour regulations and restrictions.  Early on, my residency program director told us, “Almost everyone goes under the knife, but very few will ever stand above the knife.  You are about to become one of the elite few who stand above the knife, hold the knife, wield its power.  Don’t ever forget the power of what you are about to spend the next six years learning to do.  Don’t ever take for granted that another person is allowing you to cut them open, trusting that you will fix whatever is wrong, close them up, and they will survive.  Not only survive, but be better off than they were before they went under your knife.  You have the capacity to cause death or injury with every cut of your scalpel.  No procedure is without risk.  I have seen people die from an IV in the hand – the site gets infected, then they get bacteremic, then septic.  They go into shock.  Next the kidneys fail, then the lungs, then they die.  All because someone started a simple IV.  Everything you do from now on carries risk to the patient, but they will trust you.  And you will end up killing some of them.  You won’t mean to do it, but it will happen.  You can’t be in the business of operating on people, removing organs and repairing organs and rearranging things inside people without occasionally causing harm.  But you also have the capacity to heal and cure, and fortunately, you will do this much more often.”

“Without a Knife” will detail my experience as a surgeon on board a US Navy Aircraft Carrier.  I was one of few women in that role at the time.  I struggled to find my value, as there was not a lot of surgery that needed done on the aircraft carrier.  I felt lost, like a surgeon without a knife.  I eventually grew to understand my purpose and appreciate that experience.

“Chicks with Knives” will share my experience being deployed to set up and staff an evacuation hospital in support of the second Gulf War, leaving two small children at home with my husband, and the development of a support system that got me through.  During my assignment at Navy Hospital Bremerton, we had the very unusual circumstance of having two female general surgeons, a female urologist, a female orthopedic surgeon, and a female ENT surgeon.  We would periodically meet up in the hospital or go out, and our colleagues dubbed us the “Chicks with Knives” club.

Dr. Carol Sawmiller grew up in Ohio, earning her medical degree at The Ohio State University College of Medicine in 1994.  She went on to complete her general surgery residency at St. Mary’s Hospital, a Yale University affiliated program.  She served in the United States Navy after completing residency.  She was the Ship’s Surgeon onboard the aircraft carrier the USS Carl Vinson in 2001, one of a few women to hold this position. She deployed again in support of Operation Iraqi Freedom in 2003, establishing an evacuation hospital for casualties of the second Gulf War.  She achieved the rank of Lieutenant Commander prior to her honorable discharge.

Dr Sawmiller was in private practice from 2001-2006 in Bremerton Washington, before moving to Dayton Ohio.  She is a Clinical Assistant Professor of Surgery at Wright State University, teaching surgical residents, while maintaining a busy general and robotic/laparoscopic surgery practice in Dayton, Ohio. 

She lives in Bellbrook, Ohio, with her husband, having raised two children.

Dr. Sawmiller is the author of several short stories published in John, P. Ed. (2015) Being A Woman Surgeon: Sixty Women Share Their Stories. Gordian Knot Books.