Practice even that which you have despaired of mastering
Practice even that which you have despaired of mastering
Marcus Aurelius , Meditations
In reading Meditations by Marcus Aurelius, I have come to find much to reflect upon. As a surgeon I have discovered that much of my practice as it stands, is as much a cognitive effort as it is a physical one. The physical work is well defined, examining patients, tying bandages and suturing wounds are the mainstay of my work. The cognitive work, however, is rarely as straightforward. Much of my surgical practice requires reflection and contemplation, and there are fewer avenues for thinking better than reading and reflecting on ideas from around the world. In some ways, the similarity between surgical reflection and contemplative meditation is stark. I reflect on my operations and patients after every procedure, writing notes about what I have discovered and then, I spend some time doing some form of background research or the other. Promising innovations and changes to surgical technique have made reflective practice almost an ethical demand; to provide the best medical care for my patients, it is my duty to read more and consider the revelations of other surgeons so I am familiar with the best information and moreover, I am familiar with the tools of thinking itself. Grandiose though the ideas of philosophy seem at first glance, they are also a helpful way to overcome the existential hurdles of being a surgeon in unique circumstances. It is on this note that I begin with my first reflection, on the intersection between Stoicism and Surgery, and how I hope to integrate it into my practice.
Surgery requires practice. This is an old dictum, extending back to a mystified beginning that I am yet to discover. However, in speaking to surgeons far more experienced than I am, in countries and systems of work far more varied than mine, the common thread always revolves around practice. In Meditations, Marcus Aurelius points out "Practice even that which you have despaired of mastering". The mastering of any surgical skill is a long process in itself, marked by frustrations of different kinds. The most obvious frustration in my experience has always been the lack of a controlled environment. The mastery of surgery is the mastery of individual tasks, and the mastering them in a strict sequence.
A good example would be suturing, the most basic skill of the surgeon but often the most vital. Suturing begins with the holding of the needle carefully, and then as the needle is driven into the edge of the wound, the needle must move in a controlled manner. The non dominant hand holds a pair of forceps and the dominant hand holds the needle driver. Correctly holding these instruments requires the appropriate loading of the needle, placing fingers along the body of the forceps in an appropriate manner and then, orienting the needle-tip in an appropriate angle. These steps must be mastered individually before the work of bringing the wound edges together and then tying the knot. Over thirty different types of surgical knots exist, each requiring their own sequential actions which require repetitive practice and further experience.
I began my surgical journey practicing on apples. At the beginning of the pandemic in 2020, I found myself quarantined at home. Late one evening, after I discovered that most of our lectures would be held online till further notice, I felt a sense of despair. The world was going up in flames, I thought to myself. Forever the pessimist, I searched for some form of distraction. Reading the news and the climbing death tolls didn't help the pessimism clouding my mind. As a medical student, I had learned to enjoy my lectures and time with my patients. The vast landscape of medicine was only just beginning to open up to me when the pandemic began. As the news of intubations and quarantined wards made it impossible to ignore, I thought to myself that I would have to take charge of my own training.
I reasoned that any form of progress is better than none. I opened a box of sutures (old, expired sutures from my father's surgical department), and I took my father's instruments out. I was already familiar with them, my work as an anatomy demonstrator in the first year of medical school had given me ample time to master instrument handling. With a sense of purpose, fuelled by rock classics from the eighties, I grabbed an apple and got to work. As the smell of apple permeated my nostrils, and I felt the glorious warmth of having placed twenty sutures, I celebrated. I shared the image of my progress with my friends and family. The twentieth suture looked, in my eyes, the pinnacle of perfection.
Now, years and thousands of sutures later, I have lost count of the number of sutures I have laid down. I have progressed from using apples for practice to a silicone suture pad, and even though I have mastered the art of suturing in its most widest sense, there is always more to do. There are different types of suturing techniques, different types of tissues to suture, and different suturing materials. As my armamentarium increases, I find myself admitting to myself that mastery in itself is a demand for more practice, not the abandonment of practice itself. Mastery does not imply that we should abandon practice, but mastery invites us to practice more often. In agreement with Aurelius, I find this simple dictum to be an imperative.