By Robert Pearl, MD | | December 16, 2016

When I was selected to become CEO of The Permanente Medical Group, the Permanente half of Kaiser Permanente, the time required for my responsibilities forced me to give up doing surgery on a regular basis. But every year since then, during the week between Christmas and New Year’s Day, I have returned to the operating room. The timing works, as the leadership demands become minimal and it’s unlikely I’ll suddenly be needed to fly to another part of the country. It’s a magical time for me, contrasting dramatically with my world as CEO. For several hours each day, my focus is not on millions of Kaiser Permanente members—or, for that matter, on all the complexities of healthcare policy, politics and strategy—but, rather, on a single patient at a time.

Surgery involves a complex choreography, and in preparation, the surgeon must memorize the anatomy, the disease process and the exact steps that will be followed. I enjoy that part of the process greatly. What is most essential and fulfilling is the operating room teamwork, the flow that happens when individuals work as one.

Performing surgery is a complex dance, involving multiple sets of partners.

First are the members of the operating room team, beginning with the anesthesiologist and the assistant surgeon, and then the scrub nurse and the circulating nurse. The anesthesiologist turns the dials of the anesthesia machine, administering just the right amount of gas. Too much, and patients will suffer problems with circulation and blood pressure that may put them at risk of a major complication. Too little, and they will experience discomfort. The assistant surgeon influences the success or failure of the procedure. On beat, he or she retracts the tissues and suctions the blood from the wound, tying off clamped vessels along the way. The scrub nurse places the right instrument in the surgeon’s hand at just the right time. The circulating nurse observes all that is happening, always a step or two ahead so she or he has the right supplies, instruments and drugs for the moment they will be needed.

When the team works well, the movements are synchronized, fluid and effortless.

The final, and most important, partner is the patient. Depending on the kind of operation undertaken, the surgeon needs to be prepared to follow as much as lead, ever vigilant for variations in the location of important nerves and blood vessels. Surgeons know that how patients respond to the trauma of a procedure itself, and the length of time they are asleep under anesthesia, will determine the outcome as much as their own dexterity. The patient’s organs and immune system must do the healing.

A Lesson Learned In London

On a recent trip to London to address a medical conference, I had the opportunity to visit two medical museums associated with Guy’s Hospital, the second oldest inpatient facility in England. The first stop was the Old Operating Theater Museum, focused on the history of the operating room itself. Housed inside was one of the first surgical theaters, constructed more than 200 years ago, with a wood table and surrounding observation area reserved for other doctors and trainees. In an adjacent room were the instruments used by physicians in this perilous pre-anesthesia era, including saws, picks and a variety of other gruesome tools designed to enable rapid incision and amputation. Surgery back then had to be completed in less than two minutes, because few people could stand the pain any longer. Amputation to save a person’s life from gangrene was common. The second most frequently performed procedure was fracture reduction for bones protruding through the skin. Both procedures were fraught with the risk of infection.

The second stop was the Gordon Museum of Pathology, part of the medical school at Guy’s Hospital. Here were displaced preserved tissues removed over the past 300 years from bodies either in surgery or at autopsy. It contained thousands of such specimens dating back to the 17th century. Walking among the shelves on which they were stored, I could readily observe the long history and evolution of medicine. There, clearly visible, were the ravages of untreatable disease from centuries past when little could be done for patients with cancer and other destructive medical illnesses. Each specimen was well preserved, with a clearly typed history of the patient and his or her clinical course stored in an adjacent logbook. The histories, some from the 1700s and 1800s, told the tale of medical practice when doctors could do little to address the suffering of their patients.

As I gazed at the instruments of the time, and at the organs removed at death centuries ago, I was overwhelmed with gratitude for the advances in medical care over the past half century and beyond. The delicate instruments I use to repair tiny blood vessels during a microsurgical procedure stand in stark contrast with the intrinsically brutal ones chronicled in the exhibits of the operating theater museum. And the melon-sized cancers of the skin, the jaw and the breast housed in the pathology museum are rarely seen in the modern surgical era. The magic of the current operating room and the opportunities to cure inherent in modern practice contrast sharply with the horrors of the past.

Returning to My Original Calling

As it happens, the path I’ve followed from surgeon to CEO of the nation’s largest physician organization contains more than a modicum of irony. Entering college, I planned to become a university professor. In my first year, one of my professors, a superb teacher, failed to get tenure as a result of his political and personal beliefs. Disillusioned by that experience, I decided to dedicate my career to something that would be relatively apolitical. In my naïveté, I assumed that medicine would fit the bill. After all, outcomes could be measured objectively by whether patients lived or died. I assumed those physicians best able to cure would be recognized for their expertise, with politics playing little or no role. And within the medical field, surgery seemed to offer the greatest objectivity and the least reliance on subjectively assessed results.

For months I look forward to my week performing surgery. Re-experiencing that clarity of purpose and purity of focus that attracted me to surgery years ago works its magic, invigorating me for months after. In those moments when I’m operating, success depends not on whom you know, nor on waging battle with regulators, legislators and competitors, but rather, with your ability to combat the disease compromising the health of your patient. All that matters is your skill and ability to restore health to a single patient.

A Singular Experience, Deeply Satisfying

Reposition the misplaced lip and nose of an infant with a cleft palate, and you can feel the singular satisfaction that comes from knowing your efforts will enhance that child’s life forever.

Cut out a cancer, always careful to remove all that is needed but no more, and you go home rewarded with the assurance that you have provided the patient with the best chance of cure and the least deformity.

Repair a lacerated tendon of the hand as delicately as possible to minimize scarring in the adjacent tissues, and the person suddenly has the possibility of regaining full use of that extremity.

Transfer tissue from the abdomen to the chest to reconstruct a woman’s breast, sewing together the tiny artery and vein of the flap to similar-sized vessels in their new location—using suture thinner than a hair—and you know you will have eased some of the woman’s pain of loss.

In the operating theater, if only for those few hours, nothing else matters, just the flow of the team and the magic of achieving the desired result for patients and their families. If only for those brief moments, the practice of medicine in the 21st century ceases to be a business and is once again a privilege and pleasure.

Happy New Year to all.


This article originally appeared on Dr. Pearl’s blog on