The Making of a Plastic Surgeon: Two Years in the Crucible Learning the Art and Science
Chapter 1: The Journey Begins
“Give me six hours to chop down a tree and I will spend the first four sharpening the ax.”
Abraham Lincoln
The training of a plastic surgeon is unique in medicine. No other medical specialty combines art and science in remotely the same fashion. The word plastic is derived from from the Greek word plastikos, which carries the meaning of something that is malleable and can be molded or shaped.
Plastic surgery’s roots are difficult to trace but it is an ancient practice. Surgery utilizing skin grafts and flaps has been described as early as 3500 B.C. in Egypt. In 800 B.C. India, the practice of amputating noses as a punishment for a crime or for simply being on the losing side of a battle provided a ready population of people seeking nasal reconstruction. Remarkably sophisticated procedures to reconstruct a nose were devised by the Koomas, a caste of potters and tile makers. How potters came to perform reconstructive surgery is a fascinating mystery, but apparently their expertise molding and shaping clay translated well to working with flesh and blood. Some of their techniques, such as nasal reconstruction using skin from the forehead, are still used today.
My career path was determined by a lifelong love of science and an appreciation for art, coupled with the legacy of Dr. Abel Tavares de Lacerda (August 22, 1884- July 8, 1966). Dr. Lacerda was a physician who was born in the small town of Leopoldina in the state of Minas Gerais, Brazil. He lived out most of his life in Rio de Janeiro. He did it all, practicing general medicine and performing surgery, including reconstructive surgery, in those days before plastic surgery was a distinct specialty. He wore many hats: as a decorated military doctor in the Brazilian army, who served in France during World War I; a hospital administrator; a physician in private practice; and a public health officer, who was honored by the Brazilian government for his contributions in the national campaign to eradicate Yellow Fever. He was my maternal grandfather
.In 1970, the year I graduated high school, a book was published that made a huge impression on me. The Making of a Surgeon, by William Nolan, MD. Reading Nolan’s fascinating and highly entertaining account of his training to become a surgeon greatly influenced me to consider a career in medicine. Until then, I had planned to become a marine biologist and sail the world’s oceans with Jacques Cousteau. By the second year of college, however, after working as an assistant in a marine lab for a year and a half and finding the reality of research to be less engaging than anticipated, I switched my major to pre-medical studies.
Competition for medical school acceptance in the 1970s was fierce. It seemed everyone around me wanted to be a doctor. I was accepted to the University of Miami, School of Medicine and began my studies on July 1, 1974, planning to pursue family medicine. In the tradition exemplified by the television show, Marcus Welby, MD, I wanted to do it all- perform surgery, deliver babies, treat medical illnesses, and care for patients from cradle to grave. Family practice was the closest thing to the venerable general practitioner of yore, like my grandfather, who did a little bit of everything. The broad scope of family practice was appealing.
The first two years of medical school consisted largely of soporific classroom lectures in the basic sciences in a large auditorium interspersed with weekly forays into the hospital where we would interact with patients to learn how to perform physical examinations. These outings were humbling because the patients sometimes knew more about their conditions than we did. Our real hands-on clinical education began in the third year, with hospital rotations on such core clinical services as pediatrics, internal medicine, radiology, anesthesiology, psychiatry, orthopedics, obstetrics/gynecology, and surgery. As the year progressed, I crossed off one specialty after another as unappealing and the goal of a family practice career became increasingly leas attractive. The result was a welling panic toward the second half of the year as the real possibility loomed that perhaps medical school had been a mistake and a waste of nearly three years.
General surgery was the last and most rigorous rotation of the junior year. As medical students we stayed on call overnight in the hospital along with the resident and intern on the surgical team. There was never a lack of surgical emergencies and trauma. It was a rare night that the on-call team did not take one or more patients to the operating room. Medical students alternated who would get up to go to the operating room in the middle of the night. Getting up in the wee hours to go to the operating room and hold retractors, usually from a vantage point where one could not see much of the actual surgery, did not excite most medical students. All of us were chronically sleep-deprived, and relatively few were interested in becoming surgeons.
Early one morning, the trauma team admitted a young man with a stab wound in his left thigh. The assailant was a notorious individual, responsible for much of the mayhem presenting to the emergency room, known simply as “some dude.” In case after case when questioning victims of an assault or some other injurious event we would ask, “Who did this?” or “How did this happen?” only to hear the reply, “Some dude.” Prominently displayed in the emergency room was a wanted poster some wag had drawn. Across the top, in bold letters it said: “Wanted: Some Dude” and then below this was a list of various violent crimes and misdemeanors. In place of the usual facial mug shot, there was an anonymous figure of someone running away.
It was my turn to go to the operating room that evening. The stab wound was actively bleeding, and its location made it likely that a large blood vessel in the thigh had been injured. Once the patient was asleep, the plan was to make a larger incision, extending the stab wound, and carefully explore the path of the knife blade to search for the site of bleeding. In this case, the senior surgical resident was doing the surgery and I was first assisting, giving me a rare ringside seat to the operation. He incised the skin with a scalpel and laid out the anatomy as he followed the track of the knife into the depths of the thigh. At that moment, I experienced an epiphany.
As the normal world slept, I was hunched over a thigh, which had been violated twice, first by some dude with a knife and then by the surgical resident with a scalpel, and I was totally enthralled. The operating room staff were talking and joking, each doing their job with practiced efficiency. There was an unspoken, shared pride in doing a challenging job as a team of professionals. The anatomy we had so laboriously learned in the first year of medical school now had direct clinical application. There was no passive waiting for a drug to take effect or squinting at shadows on an x-ray. The dissection, exposure, and repair of the injury was hands on treatment in the most literal manner possible. My career path suddenly came into focus. I’ll never forget that moment for, from then on, I knew I wanted to be a surgeon.
One memory from medical school stands out because it became relevant years later. I was walking across the medical campus one day when an outrageous sight stopped me dead in my tracks. An older man wearing a hospital gown was walking outside the hospital pushing a wheeled IV pole from which hung a bag of fluid. Ambulatory patients often did this to get out of the confines of the hospital. From his face to his shoulder there ran a tube of flesh. It swayed like the trunk of an elephant as he walked. It was the most outlandish thing I had ever seen. I did not know that I was looking at a tube flap, a very popular technique for transferring skin and fat to distant sites on the body dating back to the early days of plastic surgery. I was to encounter these again later.
The senior year flew by with elective rotations on various surgical specialties and I put in my application for a residency in general surgery. As I was on a Navy scholarship for medical school I was accepted as a surgical intern at the U. S. Naval Hospital, Oakland, California.
Upon graduation in June of 1978, I headed to California for my internship. The internship was rigorous and demanding. My time on various surgical and non-surgical services further cemented my intention to pursue general surgery.
After my intern year, I was assigned as a general medical officer aboard the U.S.S. Wabash (AOR-5), a Navy oiler/supply ship. That year included a nine-month deployment to the Western Pacific and was a nice break from the intense schedule and stress of medical school and internship. The year was a wash professionally as there really wasn’t much for a doctor to do on a ship with a crew of 500 mostly healthy young men and I was largely marking time before I returned to start my surgical residency. Daily clinic duties, known as sick call, were handled primarily by my corpsmen.
Wabash did have brush with fame in July 1979. A directive came down earlier from President Jimmy Carter that the U.S. Navy would render all necessary assistance to South Vietnamese refugees who were taking to the sea by the thousands in small boats. They were fleeing the communist government that was rounding up those who had allied themselves with the U.S. during the Vietnam War. The Wabash was the first ship in the fleet to take onboard some of these refugees- a group of 45 men, women, and children in a leaky boat. Correspondents from all the major news agencies flocked to our ship to interview them, and us. For a few short weeks, Wabash and her crew were international celebrities.
During this period, I undertook the only notable episode of actual medical care for the entire cruise when an alert member of our crew spotted a 16-year-old Vietnamese boy clinging to a piece of wooden wreckage. He had been in the water for three days after Thai pirates attacked the boat carrying his family and several others. He was the sole survivor. He was suffering from severe sun burn, hypothermia, dehydration, and developed pneumonia in both lungs. He was my first truly sick patient in nearly a year. We resuscitated him with intravenous fluids, warmed him, and started antibiotics for his double pneumonia. By the time Wabash arrived in Pattaya Beach, Thailand and we transferred him to a hospital in Bangkok, he was on his way to recovery. I never learned his fate after that, but over the years, I thought about those refugees often and wondered what became of them.
In 2014, Doan Ha, a cardiac sonographer living in Southern California, turned forty. Something about that watershed birthday led him to try to track down and thank those who were instrumental in saving his family from their sinking boat and providing them with the opportunity to come to the U.S. In his online research of the U.S. Naval archives, my name came up as the medical officer of the USS Wabash and he did what anyone today would do. He went to Facebook.
“Dr. Bosshardt, you have to see this Facebook post,” said Amy, our patient coordinator, “it gave me goosebumps.” The post included a photograph taken when I was on the Wabash and was of me examining a 5-year-old Vietnamese boy that we had taken aboard with his family after they had been at sea in a tiny, leaking boat that our boatswain’s mate deemed unseaworthy. The caption read, “I am the 5-year-old boy that you see with Richard Bosshardt. My family and I would not be where we are today if it weren't for what you guys did that day. On behalf of my family and all that was on board that wooden ship, I would like to say THANK YOU from the bottom of my heart. If you were on the Wabash at the time and remember this. Please comment below so I could thank you personally.” Of course, I responded. Doan and his family had thrived in the U.S. Doan and his five siblings all had college degrees, good jobs, and were passionate about their adopted country. He and his wife visited me in Florida less than a year later and our friendship continues to this day.
My year on the ship also yielded one memorable surgical experience. As surgery went, it was minor, but it served as a huge object lesson. For me, it was to know my limitations. For the patient, it was to choose their surgeon wisely. My best friend on board, Jim, our supply officer, came to me one day.
“Rick,” he said, out of the blue, “I want a vasectomy and I want you to do it.”
Flattering words to be sure but they ignored two salient facts: my lack of proper training and inexperience. I had assisted on several of these while rotating through the department of urology for a couple of weeks during my internship, but my experience doing one myself was exactly zero.
“Jim, why don’t you go up to the hospital and have one of the urologists or urology residents there do it,” I said. If only I had left it at that.
“No way,” said Jim, “it’s you or nobody. I wouldn’t trust anyone else.”
If I am honest, I felt a twinge of pride at the compliment. I thought about a vasectomy. How hard could it be? The ones I had seen took all of 15-20 minutes to complete and seemed simple enough. The thought of doing some surgery after a year of relative inactivity on the ship was appealing. Jim was adamant and, after a suitable interval of somewhat insincere protestation and feigned reluctance, I agreed.
I was not going to do even such minor surgery in our ship’s operating room, in port, when the hospital was close by. Thank God I had enough sense to realize that. I prepared by reading up on the procedure ahead of time. I reserved time in the minor surgical suite in the department of urology at Oaknoll Hospital and on the appointed day, drove Jim over for his procedure.
The vas deferens are small, paired tubes about the diameter of spagetti that transport sperm from the testicles to the base of the penis. In a vasectomy, a segment of the vas tube is cut out and the ends are tied, rendering a man sterile. Properly done, a vasectomy provides nearly fool-proof birth control.
The procedure began promisingly enough. Jim lay on the operating table in the small room. I set up my instruments and a syringe of local anesthetic, painted the skin of his scrotum with an antiseptic iodine solution, and draped the area with sterile towels. The most important part of the procedure is to get a good grasp of the vas through the scrotal skin and bring it up near the surface. The vas can be easily felt as a firm cord, but grasping and holding it between your thumb and index finger is another thing altogether. Squeezing it too hard can make the patient feel as though he has been kicked in the balls. Grip it too loosely and it will slip through your fingers.
At first, I kept gripping too loosely for fear of hurting Jim and so struggled for several minutes just to get the vas securely in my grasp. With each slip, I pinched a little harder trying to balance between a secure grip and Jim’s body language, which served as a barometer to his level of discomfort. If Jim noticed I was struggling, he considerately did not say a word. Once I had the vas pressed firmly against the skin, the next step was to inject some local anesthetic to numb the area, including the skin and the vas itself. Oops! It slipped out of my grasp again- and again. Finally, I had it. The needle went in, followed by the anesthetic, and accompanied by a brief, searing pain that caused Jim to squirm and utter an involuntary “ouch!”
Once the anesthetic was in, I applied a towel clamp through the scrotal skin to grasp the vas securely. This is a clamp normally used to clip sterile towels to each other on the surgical field. It has pointed, curving jaws that slightly overlap at the tip. The towel clamp securely pinches the skin and vas together. With the vas secure against the skin, the surgeon can make a small incision in the skin with a scalpel to expose it. The towel clip can then be repositioned to grasp the vas alone. From this point, it is a slam dunk to snip out a piece, tie off the ends with a suture, and cauterize them before releasing it to retract back into the scrotum. Of course, you guessed it, when I tried to reposition the towel clip, I let the vas slip and back into the scrotum it went!
“Damn!”
“Is everything OK?” asked Jim, who could not help but see that his surgeon was sweating rather profusely in the air-conditioned room.
“Yep, everything is fine. I’ll have this done in just a moment,” I reassured him, as the vas slipped out of sight once again. I am embarrassed to recount how long this went on. Suffice it to say that it was too long. Way too long.
“Is it supposed to hurt this much?”
The local anesthetic was wearing off. I grabbed the syringe and re-injected. “OWWW!”
Jim was clearly reaching the end of both his patience as well as his capacity to lay still. I must have looked as though I was in a sauna, my hair matted down, sweat pooling in my surgical gloves, and scrub top soaked through. Any semblance that I was in control of the situation had long since flown out the window. My good sense finally asserted itself, and not a moment too soon.
“Jim, give me a second and I’ll be right back,” I said over my shoulder as I exited the room. I went in search of help, which I found in the person of Bill Clayton, the Chief of Urology, sitting in his office. Clayton was a Navy Captain and one of the most popular attending physicians at the hospital for his excellent teaching skills as well as his patience and forbearance with the interns and residents. I tried to project an air of calm professionalism and avoid appearing as desperate as I felt.
“Dr. Clayton, could you give me a hand with this vasectomy? I’m having a little difficulty.”
“Sure, Rick, what’s the problem?” he said. I’m sure my bedraggled appearance was not lost on him, but he didn’t comment on it.
“Well, I just can’t quite seem to get hold of the vas.”
“Let’s see what we can do.” He said, rising from his chair. With his help, I completed the procedure in less than ten minutes. Jim’s relief was exceeded only by mine. To his credit, and my eternal gratitude, Dr. Clayton did not belabor the obvious fact that I had no business doing one of these without help as this point in my career. I like to think he knew that I had learned a valuable lesson. He was right.
Fortunately, Jim did well except for a week or so with a bruised, swollen, and tender scrotum. To his credit, our friendship survived as well.
After the year on the Wabash, I returned to Oaknoll Hospital for the remainder of my residency in general surgery. Oaknoll had an excellent residency program. We did our fair share of clinical research. It was staffed with excellent surgeons. Some were highly experienced military surgeons whose wartime surgical experience in Vietnam made them very competent and unflappable. The residency consistently produced graduates who went on to acquit themselves well as surgeons. We had the benefit of rotating through some highly respected medical centers such as the University of California San Francisco Medical Center, consistently ranked among the top ten medical centers in the U.S., and the University of California Davis Medical Center, in Sacramento, where I had my encounter with Dawn. I believe the Navy residents gave a good account of themselves in those institutions and we were welcomed everywhere we went. General surgery was all that I expected it to be- diverse, challenging, and exciting.
One of my rotations as a general surgery resident was on the service of Dr. Bob Cave, the Naval Hospital’s only plastic surgeon. Like Bill Clayton, Cave was a captain in the Medical Corps. He spoke in a southern drawl and was a short, rotund man with a huge belly and a bushy handlebar mustache that he assiduously waxed.
Cave’s service was a nice break from the more frenetic pace of general surgery. His patients loved and his results were good. The other surgical residents did not particularly enjoy their time working with him. The detailed planning of the surgery, even to the extent of drawing out the incision(s) on the skin with a pen, the slower pace of his practice; and the persnickety, time-consuming attention to slow, meticulous dissection and closing the skin incisions precisely with fine sutures, rather than just stapling them, drove the other general surgery residents to distraction. I found all of this very appealing. I only worked with Cave for two months, but it was enough to pique my interest plastic surgery.
During my time with Cave I experienced a dawning realization that much of what we did in general surgery, while often lifesaving, frequently left patients with visible deformities and disfiguring scars. Removing a cancerous breast, for example, saved a woman’s life but left her grossly disfigured. Plastic surgery, on the other hand, was about restoration. Put another way, general surgery was lifesaving whereas plastic surgery was life changing. For me, the appeal was irresistible.
I met and married my wife, Sally, during my residency. By the time I finished my residency, we had a daughter. I was assigned to the U.S. Naval Hospital, Okinawa, Japan for a three-year tour as a general surgeon. It was an accompanied tour, which meant that Sally and Lindsey could come with me. There, I began the process of applying for a residency position in plastic surgery to begin in the fall of 1987. I had no idea what an emotional roller coaster ride this would be.
Richard T. Bosshardt, MD, FACS
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