A novel for future orthopaedic surgeons, among others
What book should you read, if considering a career in orthopaedic surgery? Perhaps even a career in academic orthopaedic surgery? Maybe like so many others, you have encountered an orthopaedic surgeon as a patient, and are curious enough to read a novel set in our world? Giving a book recommendation is typically hard, and certainly it depends on who is asking. A new arrival on the scene and a strong contender, whether for a future orthopaedist or anyone looking for a good story reflecting deep knowledge of the joys and madness of our field, I cannot more highly recommend Dr. Ron Turker’s “The Wandering Jew of St. Salacious.”
From no doubt his own rich experience in the field, this book really speaks to some central themes of life in medicine — perhaps especially as an orthopaedic surgeon.
I will not spoil the story here, which involves an orthopaedic surgeon wandering through his own career in and out of academics as well as in and out of trouble. Spoilers, to quote the book, would be “A concrete task for an abstract moment.” Rather I want to talk about some notable themes:
Hearing Mentors in your Head
We are barely into the book when a crucial concept of surgical training comes to the fore — that unbroken line from our mentors to our trainees. It is a chain-link that runs backwards and forwards in time. We see Dr. Fischer giving memorable quips to a resident, while nearly simultaneously hearing a mentor of his own shout, “A firm hand on a leaky vessel saves more lives than any heart-lung machine.” These voices inside our heads, and our desire to achieve wisdom inception into those who follow, is something I love about academic medicine. Never a day goes by in which I do not hear one of my mentors in my head — be it a caution, a truism, advice or even just a shared memory. Likewise, there is little higher praise than when a graduate gets in touch because they recalled something I’d said as they approached a particular patient or problem. This book captures this bit of our culture well, and it made me quite happy as they popped up throughout the story.
This concept even makes the acknowledgements, with Dr. Turker writing, “if my voice rings as loud and true in my students’ heads, I’ll have retired a small fraction of the debt I owe.” Such truth in those words!
We also hear our family or friends, even if can’t always follow them: “The first day is the hardest, Until the sun comes up again.” From the wise Zaydeh, whose quips adorn each chapter. These quotes reminded me of my own father who once asked me, as I considered getting a Masters Degree or PhD in addition to an MD, “Aren’t you ever going to get a real job?” or when cautioned me against “using those 25 cent words.” There is a difference between knowledge and wisdom.
What work do these voices do? “Zaydeh’s voice, his father’s sighs, and his mother’s gentle prompts each had a place in Marty’s head. Directional beacons, one and all. If only he were better at following directions.” Perhaps in our darkest moments, and times of need, the collection of these beacons are the nameless helper, the quiet conscience that guide our hands to do good work. Maybe in these moments it even seems as though someone else, rather than ourselves, is really the source of inspiration.
The Hospital Environment
Space is typically at a premium around a hospital, and in every place I have trained or worked, it is as if new buildings are grafted onto/over/around existing structures more often than not. Sometimes in walking from one ward to another, you can be transported through time and across several buildings even while on an apparently unbroken path. Like a connection between eras of medicine and generations of healers, but with goals that hopefully never change, “Marty walked through the shuttered ‘Old Hospital.’ The original cornerstone of University Hospital read, ‘Caring hands, dedicated to the care of all — 1890.’” As is mentioned though, sometimes these old busy halls become “little more than asbestos-walled storage” as shiny new wards are built. The role of the built environment looms throughout the novel, with descriptions reminding me of various places I’ve spent time and how their structure influences function — itself is a major orthopaedic principle
In addition to the built, the grown and tended hospital Gardens are nearly their own character in the story. Most hospitals have one, if perhaps in an older area or tucked into a corner. They can be a refuge, for patients or those who care for them. As a surgeon, as a trainer of surgeons, as well as when father to a patient, I have sought out these little spaces of serenity both for conversation and for silence. It is fitting that a hospital garden is the scene for many major moments in the novel.
Relationships with our Patients
“Marty’s drive to fix everyone, even the unfixable, had driven him nuts. Soo had warned him. The medical system would never be Marty’s “egalitarian fairy-land.”
Patients are the heart of clinical medicine, and are also at the center of this novel. In the course of care, sometimes the truisms of life find us. “Sometimes we don’t get choices,” a surgeon says — to which his long-time patient wisely responds, “Or maybe the choices we got are all bad.” Speaking of bad, Marty’s struggles with a particular patient, and all the reasons why, form an emotional part of this story and provide several of its most poignant moments. You’ll have to read the book to get the details — it gave me a whole range of conflicting feelings, and that happens sometimes in clinical care. In several moments in the book, patients seem like pawns in a game between physicians and administrators. In the end, though, a higher force reminds us that, “The battlefield surgeon treats both friend and foe.”
Always learning, or Always a Resident
Marty’s relationship with his beat-up old car really spoke to me. When his friend asks, “Do you even know what a new car smells like?” the reply comes quickly: “Burnt money?”
I have written separately about my salvage title cash-bought 2002 Subaru Forester that I drove through residency and for many years after. I drove it straight into the ground and then donated it to public radio. Maybe it is the student loans. Maybe it is good advice from The White Coat Investor. Loyalty grew out of shared nights, mornings, trips and challenges together, that car and me. This book doesn’t disappoint in the poignant prose department — “Even mechanical dogs love their owners” — and we love them too. Especially when juxtaposed with a cadre of luxury-car owning, probably house poor orthopaedic surgeons who love their hyper-elective practice and flagrantly eschew being available when on call (ie., “a nationally recognized ligament surgeon who doesn’t dirty his hands with pus”. This crew is appropriately spared few-if-any punches (my advice: don’t be like these surgeons).
The Blurred Line between Life and Work
Perhaps a flaw (or best attribute, taken at times to its destructive extremes) of the book’s main character is how he embraces a role of him against the world, whatever it takes, for a patient or for the truth — especially if it is at the expense of his own life or wellbeing or happiness. No wonder he appreciates a sputtering fireplace in a cold office: “Marty felt an odd kinship with the tiny hearth, spitting all its energy into a cold world that barely seemed to notice.”
Is this what it takes? It is a bit of an unanswered question, in the book and in life. I’d like surgeons to be more like Marty and less like Gerrity — that is for sure. Yet as Marty himself cares for patients but not himself, he has not exactly what the career I would want for my trainees in several ways. Marty works himself to exhaustion and even collapses in a hallway… maybe he needs some sleep. Clearly he hasn’t seen a PCP himself, and he does not take any wellness days.
Even far out from training, he still lives right next to the hospital, taking the concept of ‘resident’ nearly back to its origins: “Just a mile away, the lights of the university were visible through the thick fog. The short distance had always blurred the boundaries between home and work, but Marty thrived in his tight little orbit.”
There are characters in this book, none really ideal (at least none of the surgeons). Thinking of their paths can help us find our own, or at least avoid perhaps the rougher patches of theirs.
Clinical Quips
There are lines in here, so meaningful to an orthopaedic surgeon, and probably nearly meaningless to others. In a world operations, inpatients, and discharges, patients need to mobilize following our operations to safely get home. “The therapist says ‘stairs tomorrow’ then I’m out of here” is a poignant one to us.
It is physical path, and we all have our compulsions. Dressings changes on inpatients were a whole production in my residency. We had dressing supply boxes made from casting material, stuffed to the gills for everything we would need for 4:30am gravity rounds. In this book, however, Dr. Fischer does his own wound care: “Marty’s quirky compulsions, however, drove him to inspect his work. The physicality of the wounds, the sights, the smells, and the pain in his own back as he leaned over the bed. The whole unpleasant experience helped connect him to his patients.” I could almost feel myself trying to reach and raise the hospital bed for him as I read that line — protect your back!
“Music off!” — Certainly I would struggle to operate in a song-less operating room, and take some pride in my specific playlists. Occasionally though, when something gets particularly serious or unexpected, the music goes off and everyone knows what that means. This is a crucial bit of operating room culture I loved seeing in the book.
Some Classic Truisms — Notable Quotes
I love all of these:
“The three A’s of doctoring, Marty. Availability, Affability, and Ability, in that order. You, my friend, are the current definition of available. And you’re pretty damned able, talented even. As far as affability, well, I like you. Little Gerrity’s group, on the other hand, lives by three completely different A’s. Arrogance, Affluence, and self-Absorption.”
“Medicine wasn’t divine. It was a mixture of grit, teamwork, and the parsimonious spilling of blood.”
“Marty’s scalpel moved mercilessly through the necrotic muscle and skin. Old Weingarten’s voice pushed his blade deeper. “Dead is dead! Tickling it with your knife won’t bring it back to life. Cut out the dead and your patient has a shot at living.”
Relationships with our Institutions
Hospitals are big places. With many people. And it can seem, or we can be made to seem, as merely a cog in that wheel. We hear that when a surgeon admits: “He felt so damn replaceable.” My program director in residency often said the same thing — that if they were gone tomorrow, or even the lot of us, that others would come in and the institution would be largely the same. Yet that really isn’t true in the end, in the book or in life. I don’t think my program director really believed that either. Perhaps the reason we are apt to believe this is precisely because we like to feel capable, able, and available. “It was good to feel needed, and he needed to feel good.”
The madness that is hospital committee work is also laid to bear rather effectively, from an misconceived abbreviation to its strange habits that seem far-removed from actually caring for patients.
While relationships with institutions themselves are frought, the book is full of positive relationships with the whole healthcare team. His Urologist friend, an ICU doctor, a hilarious anaesthesiologist, and several nurses who are there for him, and for each other.
“Aren’t personalities peculiar?” — perhaps the wisest line in the book, and from a good source. Certainly it refers to the cares as well as those they care for. And institutions are peculiar as well. We see in the book all the human complexity. These medical troubles exist within particular humans, in particular systems, and are treated by particular teams of humans… and all in their own ways peculiar. And sometimes tragic.
Why read this book, especially if considering this field?
- Some knowledge of our challenges may well be a bulwark against them. As is often said of reviewing imaging studies like x-rays or an MRI: You only see what you look for, and you only look for what you know. Perhaps some pre-exposure prophylaxis will prevent the development of “Chronic Righteous Indignation.” Given the book’s acknowledgements, perhaps this concept was itself a driving reason for the book: “Each year 28,000 students enter U.S. medical schools. These up-and-coming healers know little of what lies beyond the cap and gown. Since graduating in 1987, I’ve watched many physician friends and colleagues trade their passion for security…”
- Additionally, perhaps this book would be an interesting topic to discuss during residency interviews!
How about this for a quote — “Knowledge comes from books… Genius comes from here…” says Dr. Fischer, as he shows his hands. I love this quote, and doubly so because it is relates to a garden, and I’m in the camp that thinks orthopaedic surgery is more like gardening than carpentry. - A nice solid recognition of the truth, which is that surgeons exist to treat infection, and everything else is a bonus. If you are not prepared to embrace this, then I would respectfully suggest another career. “The forever fight, thought Marty. Our big cells versus their little cells, whose only crime was their natural inclination to sire their own bacterial children. Marty had always told his students, ‘We’re all players, like it or not. And Nature has no referee.’”
Other Books on the List to Consider
House of God: While I’ll admit to initially laughing my way through Dr. Samuel Shem’s “The House of God,” a re-read about a decade later made me hesitate to recommend it to medical students or residents. While it has some great characters and pierces the medicine/residency culture quite well, it is a little grotty. I wouldn’t want a reader to be turned off from a career in medicine. It can still be a valuable read, maybe towards the end of medical school, but my go-to recommendation will certainly now be “The Wandering Jew of St. Salacious”
While Dr. Turker’s book is not without its romance and sexual tensions — thankfully not nearly as crass as in “The House of God.” At times these foibles seemed to remind me of how we take these students-for-life and bring them into a stressful world — impossible to avoid some socially awkward moments.
Hot Lights, Cold Steel: This autobiographical book by Dr. Michael Collins spans his time in orthopaedic surgery residency, and captures the tribulations pretty darn well. I read it medical school. While much is generalizable, parts of the story understandably relate to the author’s own experience and situation. We could use more stories like this one, and I commend the author and all who share their stories of residency.
Rearticulations of Orthopaedic Surgery: I’m just joking. Don’t read this ‘book’ — it was my medical school thesis published in book form. It was part of my own investigation as part of a larger project on the history of the field, and to help me answer the questions, “What is orthopaedics? Where did it come from, and where is it going?” as I was considering joining the field. It was interesting learning about the field’s past and development, but this is a dry work of scholarship/nonfiction.
Disclosures
I will admit my bias here — I know Ron Turker. It is a privilege of mine to see him around the hospitals, to benefit from his infamous “Short Notes Save Lives” lecture, and to hear innumerable secondhand stories from generations of residents who worked with Dr. Turker. I have also heard his humor and wisdom recounted in the form of graduation speeches he gave for several of our trainees. I am impressed, but not surprised, that he also has managed to be a wonderful novelist. As I approach 100 books read this year (mostly audiobooks during my commute or while working in the garden), it is “The Wandering Jew of St. Salacious” that is most notable. I hope that more stories of Dr. Marty Fischer are in the works.
And how in our world of overwork, clocking a minimum of 65 hours/week (over 90 hours when on call for a weekend), with multiple email inboxes overflowing — let alone Epic InBaskets and entering my password dozens of times a day — did I have time to write this review? It should really tell us something that few if any shows or movies or even books spend time describing the tedium and drive-sucking state that is the email hyperactive hive mind (please read Cal Newport’s “A World without Email” to learn more). As a brief further aside, a notable exception is an excellent chapter on ‘The Sith of Datawork’ by Ken Liu in the first collection of “From a Certain Point of View,” which happens to explain how C3PO and R2-D2 managed to get to Tatooine in an escape pod circa Episode 4. But to answer the above question, the reason is that after nearly four years I finally lost my COVID Squid Game Card and tested positive following a trip to a medical conference. The brain fog has lifted a bit, though probably not enough to write clearly, and I have been sidelined clinically this week as a result. And one can only catch up on so much email, in part because They Will Never Let You Catch Up (credit to one of my mentors, Dr. Bruce Sangeorzan), so I decided to write this instead.
