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Surgical Perspectives

Free Solo Surgery

Merrill, Andrea L. MD

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doi: 10.1097/SLA.0000000000005499
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For the first time ever, it is my name on the surgery board. It is a simple excisional breast biopsy but nothing seems simple anymore when I am the surgery attending of record. I have done this operation a hundred times before yet, I have never done this before. At least not this version, the one where I am completely in charge. I arrive at the operating room early to meet the team and review the setup. As I step foot inside the cold, unfamiliar room I am peppered with questions from the well-intentioned staff, “What kind of local anesthetic do you want? Do you want it on the field? Mixed?” Suddenly I am faced with all of these small, but crucial, decisions I had not quite anticipated while focused on performing the actual operation. I fumble through, hoping I appear competent to everyone else in the room. The operation goes smoothly and I feel elated that my first operation was a success. And then I realize that I get to do this all over again the next day, not just the operating, but the decision-making. Everything going forward now is 100% my responsibility.

A few months into my new job, I watch a documentary that resonates with me. It is called “Free Solo,” about the professional rock climber Alex Honnold and his attempt to free solo “El Capitan,” a 900-m vertical cliff in Yosemite National Park. Free solo climbing is done alone without any safety equipment such as ropes or harnesses. It is just the climber on the side of a steep cliff with nothing to hold them there should they fall. It sounds crazy to attempt it. One tiny misstep and he could plummet to the ground, likely to his death. But here I am as a surgeon, taking off the safety harness of my training, taking someone else’s life in my hands. Maybe I am the crazy one? While my missteps in the operating room affect someone else, my patients, the effects of a complication can be emotionally traumatic and long-lasting to the surgeon too.1

The documentary follows Alex as he trains. He has climbed “El Capitan” before, but never like this. He practices small, difficult portions of the cliff repeatedly, first with a harness, and then solo, without. Similarly, as a surgery trainee, I started out with small portions of the operation, first holding retractors and learning to make the incision, then to close the incision, and gradually the steps in between. As a surgery intern, the attending, our “harness,” watch our moves like a hawk, critiquing every step. By chief year, they give more leeway and may let us start to “free solo” portions of the case, even leaving the room occasionally. But we know they are always nearby, a quick call if we feel we might fall. There is always a safety net to keep us on the cliff should danger emerge.

As Alex climbs, he documents his course and moves in a journal, much in the way I used to write out the steps of an operation, to practice and remember each portion. He knows which foot to put on which rock, which hand should grab which crimp just as I have learned which instrument to ask for when dissecting a lymph node or which way to retract the thyroid to expose the superior vessels better.

“Does it feel different to be up there without a rope?” Alex asks rhetorically, “When you’re climbing without a rope it’s obviously a much higher consequence … It’s a whole different experience.” Being a new surgeon attending is also a whole different experience. Despite 9 years of training and board certification in general surgery and surgical oncology, it almost feels like I am starting over again as an intern; I know infinitely more now, yet, each decision takes on much more weight. That responsibility looms larger over my head. The so-called easy parts that I overlooked as a trainee, like where exactly to place the incision or which suture to use, now become agonizing decisions. My hands have done all of these operations before, either in their entirety or piecemeal, without any problems. But as soon as that harness was removed, it became exponentially more challenging, even though they were the same motions I knew by heart and had practiced hundreds of times. “There are a lot of things that you can physically do on a rope,” Alex says “but then the idea of taking the rope away, you’re like I don’t know if I’d want to trust that little foothold.” It is time for me to trust my hands and years of knowledge and practice.

Throughout Alex’s training, he had a few complications. The first fall causes a back injury, and the second, a toe injury. My first complication occurs a few months after an emergency case while on call. When there was a complication as a trainee, I chalked it up to bad luck or patient factors that made it inevitable. But now, I blame myself for the fall. It feels infinitely worse since I have so few solo operations under my belt with which to reassure myself of my surgical skills. Without a harness, the landing is hard and the aftereffects long-lasting. I am sure that over time I will have a few complications out of hundreds of cases. But right now, early in my career, when the N is 10 to 20 cases, each complication feels like a gut punch to the stomach leading to intense self-blame.

It is hard to move past this feeling of guilt and I wonder if I really belong here. How did they let me make it this far? Surely someone along the way must have known I was not cut out for this job? These thoughts spiral in my head. Is this imposter syndrome? Do other surgeons feel this way when they start out?

I think back to other new surgery attendings I worked with as a trainee. In my mind, they all seemed so confident. But a few months in I talk to a mentor I admired. I remember her as a very capable surgeon from the get-go. Apparently, my memories are warped or she hid it well. She tells me of her anxiety starting out as an attending which matches my own. Although I do not remember this well, she often called her senior partner for help in the beginning. I start to talk to other colleagues, both male and female, some more senior than me and others at my level. The anxiety and doubts I am feeling are common. It is not just me—this is not “imposter syndrome.” This is a very real and valid feeling many of us have when making the final leap on the cliff from trainee to attending. While we talk about this privately amongst ourselves, it is not something we often acknowledge publicly. No one wants to be the surgeon with doubts or anxiety. No one wants to be the slow surgeon or the surgeon who calls for help. There is a stigma against it and against talking about it.

The reality of it is that even though we are all now “free soloing” as attending surgeons, we are rarely ever completely alone. The secret that I did not realize in training, is that we all ask for help. My partner starts calling me into the OR occasionally to ask for my opinion. My friend has a complication after a challenging operation and runs it by her 2 colleagues for advice. My former co-fellows and I have a group text where we ask each other for guidance.

I have now been an attending surgeon for over a year. Some weeks go very smoothly and I climb that cliff alone smoothly with no problems; my hands know exactly where to grab. Other weeks are more challenging and I need to temporarily put that harness back on to get through a tough pass or an unexpected torrential downpour. The learning curve of being an attending is steep but I have accomplished and grown so much in the past year. I still feel a little bit like a failure when I call my partner in to assist in a case, but I reassure myself that I am doing the safe thing.

I know when I see my first patient with a cancer recurrence, I am going to take it personally and blame myself when I maybe should be blaming the disease. That part of me that deeply cares for my patients and their outcomes, will never change. But I can slowly feel my confidence as an attending growing. It may not always be an upward trajectory, but the overall path is to the top. I now realize that we are all on the same cliff. We may all be “free soloing” our own portion of the cliff, but just around the corner is another surgeon who can help or throw us a rope to get us to the top.


1. Bohnen JD, Lillemoe KD, Mort EA, et al. When things go wrong: the surgeon as second victim. Ann Surg. 2019;269:808–809.

surgical training; surgical education; surgical perspective

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