I run. Some days the run beats me — the legs go, the lungs go, and I stop short of the distance I set out to cover. That beating, everybody can see. The worse one is the beating nobody sees.
I learnt that from a friend. A very close friend.
There was a dispute between two colleagues, the ordinary kind that every workplace produces, and he asked me to give him the chance to settle it. I agreed. I trusted him; that was the whole point of agreeing. Instead of settling anything, he went person to person, gathering material, telling people the environment had soured — lighting fires and creating smoke, and all of it behind my back. By the time I understood what was happening, the dispute was no longer the problem. The problem was that the man I had trusted to put out the fire was the one carrying the matches.
I won't pretend I took it well. The thinking process, the emotional upheaval, the inability to sleep. Lying awake wondering what you did wrong when you did nothing wrong. You didn't harm the person. You were fair to him. But still people took advantage of you. I've always tried to be fair and just to everyone, and I could not make that fact sit beside what had happened. Coming to terms with it took time, and it took a huge mental toll on my thinking and my abilities.
And it was not the only time. Very close friends have betrayed me more than once, for reasons I still find vague. It took me years, and more than one of these wounds, to build the thing I now use when one lands. I'll give it to you in full further down. First I want you to see the injury for what it is, because most surgeons don't — and that is precisely why it does so much damage.
Medicine already accepts that the doctor can be wounded. Twenty-six years ago Albert Wu wrote in the BMJ about the clinician after a medical error — the "second victim" — and the phrase stuck because everybody in the profession recognised the person he was describing. We made room for the idea that the surgeon who erred also bleeds.
We haven't made the same room for the surgeon who is attacked. And the attacks are not rare. In a 2021 survey published in JAMA Internal Medicine, 23.3% of physicians reported being personally attacked on social media. Among women physicians, 16.4% reported online sexual harassment, against 1.5% of men. That is not a freak event happening to an unlucky few. That is an occupational exposure, the way a needle-stick is an occupational exposure. If you put your face and your opinions anywhere in public, you will eventually get hit.
I got hit online too. Some time ago I wrote a post about juniors sometimes not respecting seniors. A senior surgeon from another specialty appeared to take it personally. From then on he was on every post. Every one. "Here comes the one who knows it all." Mocking me as the truth-teller, post after post, for a long stretch. I've written about it before. It affected me more than I let on.
A creator I follow said something that finally cut through. Sometimes you simply block these people and don't let them near your posts. I blocked him, and I'll tell you later why that was the correct clinical decision and not a sulk.
You've probably had your own version. A WhatsApp group where a senior made a joke at your expense and the whole group saw it. A colleague who says one thing to your face and another in the corridor. You've lain awake running the replay, drafting the reply you should have given, wondering whether you were somehow at fault. If you have, you already know what I mean by the injury nobody can see.
Here is why I'm writing about this in a newsletter about the business and craft of surgery, and not leaving it to the wellness people.
This is not a feelings issue. It is a patient-safety issue.
In a randomized simulation study published in Pediatrics in 2015, Arieh Riskin and colleagues put 24 neonatal intensive care teams through a simulated emergency. Some teams heard a few mildly rude remarks from a visiting expert who was supposedly observing them — not abuse, not shouting, just mild rudeness. Those teams performed worse on both diagnosis and procedures. A follow-up study in 2017, with 39 teams, had the rudeness come from an actor playing a patient's mother, and the damage persisted across the rest of the day's simulated cases.
The mechanism isn't mysterious. Christine Porath and Amir Erez found, in work on rudeness and task performance, that the drop was explained by cognitive disruption. The incident keeps running in the background and eats the working memory you needed for the task in front of you. The argument keeps running in your head, and your head is where you operate from.
When I said the betrayal took a huge toll on my thinking and my abilities, this is what I meant. You know what a fixation looks like when your mind is half somewhere else. You know what a full OPD feels like when you didn't sleep.
So here is the knife-turn. You scrub for five minutes. You double-glove for an arthroplasty. You have a written protocol for a needle-stick, and if you stuck yourself tomorrow you would know within minutes exactly what to do — wash, report, test, prophylaxis, follow-up. Nobody would expect you to invent the response while bleeding.
For the exposure that actually reaches your judgement, you have nothing. You improvise. And you improvise at the worst possible moment: while it hurts.