Find yourself a doctor who is dumb and safe
I know that this seems like an odd admonition. But look at it from this perspective: it’s been said that there are only four kinds of physicians in this world:

a) Smart and safe
b) Dumb and safe
c) Smart and dangerous, and
d) Dumb and dangerous

You never want to be the patient of a doctor’s who’s not safe—whether they’re smart or dumb.

The “dumb and dangerous” types are easiest to spot. They are so obvious that they are either weeded out during medical training or they have already self-selected themselves for arenas where their lack of intellect and talent won’t harm anybody. Avoiding dumb and dangerous doctors is fortunately not a big problem for most patients.

On the other hand, the “smart and dangerous” ones are tricky. They’re the most ones difficult for patients to avoid or forego.  That’s because so many of the “smart and dangerous” surgeons are considered to be among the very best in their fields. Acclaimed as icons within their profession, they can be quite seductive and charismatic to patients. But these physicians are dangerous because they really do know a lot about their specialty and have demonstrated great proficiency in their surgical skills. But these “smart and dangerous” surgeons like to “push the envelope,” to try the newest techniques, employ the latest devices, and achieve recognition for accepting the most challenging procedures. The “smart and dangerous’ doctors have an insatiable hunger to be in the limelight. No matter how much acclaim they achieve, they need still more. And who pays for the daring feats carried out by the “smart and dangerous” to satisfy their appetites for recognition? Their patients, of course.

A resident colleague of mine in Boston used to plaster posters up on the walls of our on-call room. He had giant photos of fighter jets, cockpits, and the Navy’s Blue Angels jets streaking skyward in formation. He explained to me that the posters reminded him that surgeons were like pilots--fighter jocks. I was puzzled by this analogy. Fighter pilots have to demonstrate true bravery. They practice their craft by exposing themselves to lethal forces. When skill or luck deserts them, they lose their own lives. Maybe some like to think of themselves as heroic fighter pilots but, as surgeons, we never lose our own lives when skill and luck abandon us. When surgeons experience a crash, the patient is the fuselage--the one that crashes and burns. The surgeon gets to eject and walk away from each disaster. Maybe it's a form of courage but I fear it's usually a false bravado.

I often discuss these notions with my medical students and residents. Would they like to be fighter pilots? There are lots of secret grins of bravado. But to carry out the analogy between pilots and surgeons, you really need to take it one step further. Pose the hypothetical question: How willing would you be as a surgeon to forfeit your own life whenever a patient died? In such a context, the surgeon could label him or herself a jet pilot. I ask my medical students to imagine a different, hypothetical world of surgery, where the laws in healthcare require that every unexpected complication experienced by the patient would also have to be recreated in the surgeon who performed the case. So if the patient’s foot were to become infected and gangrenous until a below-the-knee amputation is necessary, then the surgeon’s leg would also be cut off. If infection overwhelmed the patient, then the surgeon would share the same fate. One of my medical students noted: “Such an arrangement would dramatically reduce the number of candidates going into surgery.” And how! I’ve never met a doc who wanted to practice in such a hypothetical world. But try to imagine some of the side effects of such a law of reciprocating injury. Surgeons would exercise the utmost caution in screening and selecting candidates for surgery. Surgeons would only consent those patients with the very highest likelihood of getting through surgery without a hitch. The surgeon’s post-operative vigilance would take on a nerve-wrecking quality as surgical teams would press to eliminate all complications that could befall the patient and, hence, themselves. But think of the profound trust patients could feel knowing that their fate would be shared with their surgeon. Surgery would become a whole different world, wouldn’t it?

A final note about smart and dangerous surgeons. There’s a German proverb that goes: “Too clever is dumb.” Very smart surgeons are often just too clever for anyone’s good. That’s why a physician’s empathy is vital to the practice of safe medicine. It’s compassion that puts the brakes on a doctor and makes him or her prudent. Not brains and training. A keen intellect without a warm heart is a prescription for bad surgical outcomes.
What about the category of physician who is “dumb and safe?” Surprisingly, this is a physician with whom all patients should feel comfortable, secure, and safe. The dumb, safe surgeon is the one who’s aware of intellectual shortcomings; does not attempt procedures that are unknown or unproven.  He or she creates elaborate algorithms, checks and balances, redundant mechanisms so that nothing will be missed, nothing will go wrong. This is the kind of doctor who will bring in any number of consulting sub-specialty physicians to assist, ensuring the absolute best advice for the patient. Fortunately, most of our best physicians fall into this category.

Last comes the physician who is “smart and safe.”  Obviously, we would all like to find such a physician but they belong to rare species indeed. In my entire life as a clinician, I’ve only met two or three individuals who fit this category, so there’s little chance of finding one. I don’t number myself amongst these special few. I’m just dumb and safe. And I’m proud of it. I’m honored to be counted among that group. I’m usually able to avoid preventable complications, the ones I can predict might occur. My patients usually do well not because I rely on my smarts but because I am obsessively compulsive. I‘ve had to develop an iron-willed discipline and an elaborate set of ritualized steps to guard against committing errors. For the patient, it is only the outcome, not the means, that matters. So when you go into your surgeon’s office, don’t only look at the diplomas on the walls. Look into their eyes too.