EP. 102: THE MAKING OF A HEART SURGEON

Mar 5

WITH CRAIG R. SMITH, MD

The Chair of Surgery at Columbia University Medical Center shares stories of harrowing heart surgeries and how he maintains a moral drive that anchors the daily miracles that define his challenging profession.

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Episode Summary

If you were to rank all the medical specialties by the arduousness of the training required, the technical complexity and high stress of the interventions involved, and the harshness of the working hours, cardiothoracic surgery would be near or at the top of anyone's list.

In this episode, cardiac surgeon and Chair of the Department of Surgery at Columbia University Medical Center Craig Smith, MD takes us into the heart and mind of a physician who regularly cracks open a person's chest to manipulate some of their most anatomically intricate parts in order to save their lives. He is the author of the 2023 memoir Nobility in Small Things: A Surgeon's Path, and famously performed the quadruple bypass surgery that saved former US president Bill Clinton's life in 2004.

Over the course of our conversation, Dr. Smith discusses the joys of exploring the human body, what motivates him to get up at 4 a.m. every day with the same burning passion for his work, why his family is one of the most important elements of work life balance, how he deals with mistakes and adverse events in the operating room, and more.

Craig R. Smith, MD earned his MD at Case Western Reserve University in Cleveland, Ohio, going on to a general surgery internship and residency and a vascular surgery fellowship at the University of Rochester Medical Center/Strong Memorial Hospital (1977-1982). He completed his cardiothoracic surgery residency at Columbia-Presbyterian Medical Center in 1984, immediately joining the faculty of the Columbia University College of Physicians and Surgeons.
He was Director of Cardiopulmonary Transplantation at Columbia-Presbyterian Medical Center during 1986-1996 and was appointed Chief of the Division of Cardiothoracic Surgery in 1996. He became a full professor of surgery in 1998. In 2010, Dr. Smith became Chair of the Department of Surgery.
Dr. Smith's clinical specialties include medical support for pre- and postoperative transplant recipients, use of bioartificial support devices, and alternative immunosuppressive strategies. His research interests focus on mitral valve repair, transmyocardial laser revascularization, long-term heart and lung transplantation outcomes, preoperative risk factors for stroke after CABG, and adaptation in cardiac transplantation. Dr. Smith was named Practitioner of the Year for 2004 by the Society of Practitioners at Columbia University Medical Center.
In this episode, you will hear about:
• 2:23 - Dr. Smith’s initial path to medicine
• 4:43 - What drew Dr. Smith to the field of cardiothoracic surgery and how he handles the high-stakes nature of the work.
• 15:47 - What happens when a surgery goes not go according to plan
• 18:54 - Dr. Smith’s approach to comforting and connecting with patients prior to surgery
• 22:24 - Dr. Smith’s experience performing surgery while struggling through what he later learned was a very early case of COVID-19 in early 2020
• 29:03 - How Dr. Smith views work-life balance
• 34:17 - The role of spirituality and religion in Dr. Smith’s work
• 35:51 - How Dr. Smith has retained his sense of purpose and calling throughout his career
• 45:28 – A patient story that encapsulates why performing surgery is so meaningful for Dr. Smith
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] If you were to rank all the medical specialties by the arduousness of the training required the technical complexity and high stress of the interventions involved, and the harshness of the working hours. Cardiothoracic surgery would top just about anyone's list. Well, except maybe those of the neurosurgeons out there. In this episode, cardiac surgeon and chair of the Department of Surgery at Columbia University Medical Center, Doctor Craig Smith takes us deep into the heart and mind of a physician who regularly cracks open a person's chest to manipulate some of their most anatomically intricate parts in order to save their lives. He is the author of the 2023 memoir Nobility in Small Things A Surgeon's Path, and famously performed the quadruple bypass surgery that saved former US president Bill Clinton's life in 2004. Over the course of our conversation, he discusses the joys of exploring the human body, what motivates him to get up at 4 a.m. every day with the same burning passion for his work? Why his family is one of the most important elements of work life balance. How he deals with moments when things go wrong in the operating room, and more. Doctor Smith, welcome to the show and thanks for joining us.
Dr. Craig Smith: [00:02:22] Thank you.
Henry Bair: [00:02:23] To start us off as we usually do. Can you share with us why you initially were drawn to a career in medicine?
Dr. Craig Smith: [00:02:30] Well, for me, it goes back a long way, even though the path ended up twisting a bit. I had two medical grandparents, one a pediatrician, one a surgeon. They were revered by their family and by the community. Then that was amplified by all the experiences I had as a patient. I know it doesn't always work this way, but at least for me, that endowed hospitals as sort of a shrine of eternal vigilance. They gave him this aura of comfort and security and safety from harm. So I always felt very comfortable there. I deviated from that path late in college, when I was essentially seduced by the art I could see in pure science, and I decided to be a science PhD. I must say that romance didn't last long. The motivation that comes from something that feels larger than yourself is important, and it just wasn't there. And I allowed myself sort of to slide along, meeting the basic requirements, and distracted myself with pipe organ and skiing and things like that. After about two years, I was ready to admit to myself and the people around me that I was, at least to my wife, that I was reorienting towards med school. And med school turned out to be the easiest four years of my life, so that was a good choice.
Henry Bair: [00:03:45] I know you did write about that in your book, and I did want to ask about that, because few people say that medical school is the easiest years of their life. In what way was it easy for you?
Dr. Craig Smith: [00:03:54] It was easy because it was. The challenge was very straightforward. There was a body of knowledge to learn. I just had to learn it. There were no motivational issues. I knew why I was there, I knew what I was doing, and it's just learning.
Henry Bair: [00:04:08] So earlier you mentioned that you were drawn to medicine because the drive to be a part of something bigger than yourself was there. I'm wondering if you can tell us more about that. Was that what sustained you through medical school? Was it a clear thread throughout your entire training?
Dr. Craig Smith: [00:04:24] In the early stages of my orientation towards medicine, I wasn't deep enough to think about things that are larger than myself. Maybe. I think that's a much more retrospective adult perception of the game, but there's probably some kernel of that that's present in the attraction early in life to.
Henry Bair: [00:04:43] Well, so then you eventually go on to complete training to become a cardiothoracic surgeon, right? Which is a pretty specific, you know, pretty grueling journey, at least from those of us who are not in it. We often look at cardiothoracic surgery as one of the most taxing branches of medicine to go into, both in its length and in the complexity of its procedures. What drew you to that branch of medicine?
Dr. Craig Smith: [00:05:09] Yeah, it is all those things. As far as the choice of cardiac surgery in specific, that was very easy. I had never seen cardiac surgery as a med student. And then very early in my internship, I was exposed to the unique complexities of post op physiology and the management of ICU patients who were recovering from heart surgery, and that not long after that, I actually saw an open heart procedure in the operating room and I was hooked. Never looked back.
Tyler Johnson: [00:05:37] So I want to ask though. So, I'm a medical oncologist. It's not as if I don't participate in care that is, in its way very dangerous, right? I mean, the argument can be made that my job is to give poison to people and very carefully titrated doses. Right? I mean, that's a lot of anyway, what we do. But having said that, I remember when I did my surgical rotations in medical school, I remember very distinctly being in the operating theater. Right. You're just getting used to scrubbing in and sterile field and all of the sort of the atmosphere of being in the operating room. But the thing that I remember the most was being there, watching the operations as they were happening. And any time there would be something that started to go wrong. Right. So let's say that blood is starting to flood the field, and at least at the beginning, nobody is sure where the blood is coming from. I mean, I know you know this, but just to paint the picture for our viewers, right? If you're in the middle of an operation and especially if you're, let's say, close to the aorta or some other main vessel and you start to see blood coming and you don't know where it's coming from, depending obviously on how fast it's coming and whatever this could be, a person's life is ebbing out in front of your eyes. And if you don't figure out what the problem is and how to fix it, sometimes very, very quickly, the person can die as they're there under your care. Right? And so this is just to say that whenever these kinds of things would happen and I would watch them, I could immediately feel my palms begin to sweat. I would feel a little bit, you know, sort of almost unstable or unsteady. And I would just think to myself, oh my gosh, I cannot imagine being the person who is, you know, where the buck stops, who is ultimately responsible for the fate of this human being who is completely prostrate under your care. Right.
Tyler Johnson: [00:07:31] So all of that is to say, can you explain for us what is the difference between you and me, where you walk into an operating room and see, you know, unquestionably those I mean, for heaven's sake, in cardiothoracic surgery, those same kinds of things, you literally have a person's beating heart that you are operating on. And yet your reaction to that is to say, yes, that's what I want to do. I want to be the person in control of that operating field, like talk us through what that's like.
Dr. Craig Smith: [00:08:01] Well, you've described it very eloquently. I can't improve on that. It sounds like it wasn't for you. I can I can agree with you there. And I'm not sure that the psychology that underlies choices, like the choice I make to do cardiac surgery, are entirely flattering. I think I have a deep need to do something that's unequivocally important and difficult and consequential. I've never thought I had the confidence, frankly, and the self-possession to do something that's just for me. I mean, even though people now, they now then call me an author, which still shocks me, is like writing and things like that. I never imagined I would have the ability to sit down and do that. Or it could be I'm just a closet navel gazer who has controlled my tendency for self-absorption by immersing myself in these externally compelling activities. But you've described the situation very well. And, you know, if if you're inclined to deal with that, you deal with it.
Tyler Johnson: [00:08:57] But let me ask you then, a I think, logical follow up question to that, which is this even the most talented surgeon things sometimes go wrong, right? Either because of human mistake, which, you know, everyone is human, everyone makes mistakes. But even if you don't make mistakes, right? Just the vagaries of anatomy and physiology, some things are. Sometimes things are just not going to turn out the way you wish they turned out. And so I guess my sort of follow up question is, you know, because in my field, it's not as if I haven't had patients who I give to whom I give chemotherapy, who get very sick. Certainly I have had that right. I have taken care of patients who've died after doses of chemotherapy. And and that's its own thing. But the difference, in my view, is there is always a comfortable distance between the medical decisions I make and their consequences, because it takes days for chemotherapy to take effect and so many things happen. And then usually they get admitted to the hospital and, you know, and there's there's a way to sort of distance yourself from the consequences of your decision. But if you're there in the operating room, things are happening literally in front of your eyes, right? Or then they happen in the, you know, one or 2 or 3 days post-operatively or whatever. All of which is just to say, as someone who clearly cares about your patients and cares about doing good in the world, how do you cultivate the stamina to keep going when such weighty consequences are hanging on the sometimes millimeter wide decisions that you're making in real time in the operating room?
Dr. Craig Smith: [00:10:35] That's a complicated question, and I'll try to answer it without wandering too widely. But. One element of that is dealing with the crisis in the moment. Now, I guess, as an aside, I would say for me that seems to be where the juice is. So that's why I do this, because it has those it has that edge. But one way, I think I have a gift that I can't take any credit for. I think I was born with it, that when the pressure goes up, generally speaking, my thermostat turns itself down. And that is just about always been true. And so that's what tends to happen if I'm in the operating room and you see one of those things you were describing bleeding from some unknown corner of the chest. I deal with it. I mean, for one thing, the option to run screaming from the room is not on the table. You just can't do that.
Tyler Johnson: [00:11:32] We're glad that's not your response.
Dr. Craig Smith: [00:11:34] So I'm not sure I've explained it very well, except the other part of it obviously, is you do it forever. You know, I've done it thousands and thousands of times. And before I was the lonely guy on the, you know, on the right side of the table, taking all the responsibility. I had done it on the other side of the table in various levels of graduated responsibility for seven years. So it's a long process.
Tyler Johnson: [00:11:59] I mean, I have to say that in your memoir, there's a part in the prolog you're not discussing yet the details of being in the operating room. You're discussing more generally, being a surgeon and then responding to the Covid pandemic. But in any case, there is a section there you mentioned that you never have journaled except during some very specific times in your life, but there is a part where you did keep a journal briefly, and then you quote from your own journal writing about bad things that might happen while you're a doctor and in particular a surgeon. You write. Still, one goes through a familiar process of wishing whatever the bad thing is, that wishing it weren't happening, feeling mentally and physically incapable of handling the thing, then settling into a cold, calm space in which the options start to roll out out of habit, starting with the thing it could be that terrifies you most. You think of how to rule that out. If it rules out, you may be on a path to smoother sailing, and you're entitled to feel a little bit of relief. If it rules in, well, you're already there. Mentally, it can't get much worse. Keep moving down the differential along a gradient of greater to lesser terrors. Do this test if A then B, then this test. If not x, then y. Then there you are committed again when it's possible. The intelligent thing to do is to pass off the entire responsibility to someone who's had a different few days behind them and has less up ahead. That strikes me as fascinating, because you mentioned the gift that you intuit that you have, that when the heat goes up, your thermostat turns things down, and that idea of settling into that place of cold calm and then sort of going through this process of starting with the most terrifying thing and then going from there, strikes me as a fascinating way to describe what's happening in real time, whether what you're doing is facing the person who's bleeding on the table, or whether what you're doing is facing the pandemic.
Dr. Craig Smith: [00:13:57] Well, I'm glad you enjoyed that. I mean, that's the way I see it. I wasn't writing a screenplay here. That was that's in that particular moment. That's kind of how it played out. I had to decide what to do with this guy.
Henry Bair: [00:14:09] So one of the things that we often talk about on this podcast, especially with non surgeons, we talk about connecting with patients at a very human level. We talk about storytelling. We talk about building that rapport. At the same time, we've also had conversations with neurosurgeons, for example, who say that their response, when things especially, are taking a wrong turn in the middle of an O.R. in the middle of a case, is actually to shut off that humanistic connection, to stop thinking about this person as a person and just focus on how do I fix this broken machine. And in some ways, I can see psychologically why that would help steady your nerves. Do you resonate with that, or how does that play out in your mind when you are in the middle of something that is happening very quickly in the operating room?
Dr. Craig Smith: [00:15:00] I definitely resonate with that. What else can you do? Really? Your job. You're there to fix the problem, and even if things go awry, you have to fix the problem. When you end up as the attending surgeon, there's nobody else. I mean, there are times, yes, you could call somebody to come in and look at things with you, but basically most of the time if you can't fix it, nobody can fix it. You just have to do that. And remembering that it's a, you know, a charming guy with a big family and so on doesn't help you at that point. And I must say, it rarely crosses my mind when you're in the operating room. It might be a source of conversation when things are going very well, and there might be some chit chat about what an important person this is, or something like that. But in the soup you don't think about who it is in there with you.
Tyler Johnson: [00:15:47] So can I ask? And I recognize this is a vulnerable question, but can you talk us through a time when things didn't go to plan, when, in spite of your best efforts, things did go awry? And maybe even more importantly, tell us, what is it like to be the surgeon, the person in charge when things don't go to plan?
Dr. Craig Smith: [00:16:10] I do tell a couple of stories in the book, and I won't try to improve on those one a long time ago, but I remember as vividly as if it was yesterday was, as it usually is, a series of errors, not just one, beginning with my me and my colleagues, actually, but ultimately my failure to completely resolve all possible loose ends in the pre-op workup. And that was exacerbated by my failure to recognize what was going on in relationship to that oversight. And then once I knew what was going on. I made a choice to try some conservative, more simple maneuvers to solve the problem. When I think in retrospect, tackling it directly would have been potentially more effective faster, but was definitely a higher risk thing to do. I won't bore you with all the technical details, but that was a series of mistakes and the patient died. Another not dissimilar case. I was reopening a previous operation. There are several considerations that go into that, and one is how to avoid injuring structures that are stuck to the breastbone. Again, in this in this instance that went awry. Was it entirely avoidable? Arguably. And although I got that patient through the operation and repaired what we were there to repair, she died several days later of serious brain injury, so there was too much bleeding for her to tolerate.
Dr. Craig Smith: [00:17:50] So how do you deal with that? Well, you have to look at it in the face. These are things I touch on in the book a bit. I mean, you look where your footprints are and you say some of these events come right back to me and you take responsibility for those, and then you have to forgive yourself for those errors because you have to go back and do the job. So you forgive yourself, but you remember what went wrong so you don't do it again. That can sound kind of simple and mechanical, except that it's obviously not that simple emotionally. But as I also emphasize at one point in the book, I think this is where the fact that almost everything we do is well-intended has some bearing on how you should feel about it. So I tell myself, I never quit. I went and worked as hard as I could to solve this problem. What happened, happened. But I had the best of intentions and what happened, happened, and I can live with that. Now that just what you have to do.
Henry Bair: [00:18:54] So given the complexity and the high acuity of the problems that you fix, right. Like we're talking about things like bypass surgeries for completely clogged heart vessels, we're talking about damaged aortas. We're talking about damaged heart valves. Like these are things that if you don't fix in a patient, they might just die, like immediately. Like these are urgent emergent cases, right? So I would assume that many of the patients you meet are in a very vulnerable place. They're terrified of what might be happening. Can you tell us how you approach comforting patients and connecting with them when they are in that really dark place?
Dr. Craig Smith: [00:19:39] Well, the truth is that most of the procedures I do and the most of the most of the procedures that any busy heart surgeon does are a little bit more elective than how you describe the situation. It is sometimes that way. Yes. You know, hair on fire crisis rushed to the operating room emergency those do occur. And then in that case, the discussion with the patient or equally often not with the patient at that point, but with the family is in a little bit different category. You impart as much information as you have time to impart and do what has to be done. Far more common, though. It's a little less of a crisis, but it is nonetheless a serious undertaking. So personally, I think it's best done. Absolutely best done face to face in a comfortable setting, either in my office or at the patient's bedside should involve not just the patient, but family or friends or somebody who can help them absorb the message. And I just lay it out. I do, though, try to end. With the balance tilted towards optimism, because I think they need that now as a practical matter, the thing I always mention in the prelude to any open heart procedure are the possible complications of death and stroke, because those are irreducible risks of heart surgery, and unfortunately, they're very infrequent, but they're also the things we can't fix. So I always mention that. So it might be 2 or 3%. So not a big number I've learned over the years. I don't dwell on that much longer list of other things that can go wrong, which are often much more frequent, but much less consequential. And almost all of them can be fixed in one way or another. They might add hospitals time, they might add discomfort and other other things that are not insignificant. But they're fixable more or less. So I don't dwell on those. If patients ask that, I'm happy to go into the full list and I will, right up to the point they stop asking. But I don't dwell on that.
Dr. Craig Smith: [00:21:45] I do want to leave them feeling more optimistic than worried, and the final encounter I have with them is usually in the holding area right before they go into the operating room, and that is very much, you know, a pat on the back encouraging. Don't go over a lot of that other stuff. Just want to make them feel good, optimistic, confident as they go into the operating room. One of the most flattering compliments I ever got from a patient. And it wasn't very long ago, actually was a guy who said he'll answer ten questions in five words and leave you satisfied.
Tyler Johnson: [00:22:24] I feel like that's an astute summation of the way that a lot of the surgeons that I know operate not meaning in the operating room, but how they function in the in the medical system. Let me ask you a question. So you tell this story in the book of most people probably don't know that you were arguably, even if undiagnosed at the time, the index case of Covid in the eastern United States. Right? I mean, it's hard to say because maybe other people were having similar experiences in other places. But the point is to say that right around the time that people were starting to glom on to the pandemic being a thing in the United States, you had an illness, of course, of an illness that at least seems very much like Covid pneumonia. And then early on, when antibody testing became available, you were positive. So, you know, it stands to reason that you had Covid, even though nobody knew it at the time. But the thing that is striking to me about that story, and you referenced this a little bit in your description, is that you're feeling sick and yet you get up at 430 in the morning, you're in the hospital by five, seeing your patients before your patients you'd already operated on or whatever before you go into the hospital or into the operating room. And then over the course of this day, when you have operations that are sort of punctuated by various administrative meetings and whatever you're doing, things like doing an operation, going back to your office, hopping, you know, going to a meeting for a minute and then lying down on the couch by the windowsill because you're so exhausted from you didn't know it at the time, but probably from Covid that you can hardly keep standing up, then going to the operating room and spiking a fever while you're in your surgical scrubs, operating, sweating through your, you know, your scrubs and then the fever breaking and all of this is happening while you're, I don't know, replacing someone's mitral valve or something to that effect.
Tyler Johnson: [00:24:19] And you comment on in the book how pretty much everybody who hears you tells some version of that story. The reaction is some version of what in the world were you doing in the operating room while you're sweating through your scrubs from Covid? Or you know, you're coughing and the whole nine yards, which, as you recount in the book, apparently nobody was infected, in case people are worried about that, but that the infectious complications aside or the contagiousness complications aside. Talk a little bit about that, because I think for most people in medicine, that does seem a little, uh, it's almost hard to believe that someone would feel that sick, that they almost literally couldn't stand up. And yet they go and do one of the more mentally and dexterity demanding tasks in the human repertoire, which is to replace somebody else's heart valve. Right? Like, why would you do that?
Dr. Craig Smith: [00:25:17] Well, you're focusing on something that I thought would get more attention than it has. The truth is that I wasn't that sick. I was sicker over the weekend, and this relapse on Tuesday or Wednesday was pretty sudden. I threw most of that day. I had hadn't had any reason to believe I couldn't just soldier on. And two things about, I mean, I mentioned that the sort of the history of people like me, anyway, is that we just work through it. We never take a day off. And I'm not that unusual in that respect. You don't want to reschedule patients who've been scheduled for a month and wait, and you don't have to put them off, and it's inconvenient for them. It messes up lots of things. So you just soldier on and do the job. That tends to be how we react. The other part of it, though, is that a thing like heart surgery and it's not unique to heart surgery, I'm sure is. So focusing that you don't notice that other stuff. I mean, I've suffered through a lot of other aches and pains in my career my back, my neck, my, you know, you name it. I've had two knee replacements. All that stuff hurts, but it doesn't hurt that much. While you're in the operating room. Yes, you can kind of notice it, but it doesn't stop you. It's just very compelling stuff to do and you tend to get through it. But it sounds like I may have exaggerated, at least in your interpretation of I may exaggerated how sick I really felt that afternoon.
Tyler Johnson: [00:26:44] Well, in fairness to you, I'm not directly quoting right. You, as you correctly point out, now, you lay out a sort of a litany over the course of, I don't know, 5 or 7 days or something where you had ups and downs. And so I don't mean to suggest that necessarily in the moment that you were going into the operating room, that you were feeling lightheaded or something, but but certainly in very close proximity, you had been really pretty sick. You know, I don't know how sick, but sick enough that I think a lot of people I think that it's just, you know, in the same way that I mean, I know when I watch the Olympics, right? It's just remarkable to me that a human being is capable of that. It's remarkable to me that human beings are capable of operating on each other to begin with, let alone that they're capable of doing that in a position of maybe not quite extremis, but something that's going in that direction. I think that for most of us, that kind of surgery is a lot like watching somebody play a Rachmaninoff piano concerto, right? That I just as not a pianist, I have absolutely no sense, like, I don't know what I don't know about what's required to learn a Rachmaninoff piano concerto, except that I know that it's dazzling and must be harder than I can imagine. Right? And I have to imagine that doing heart surgery or brain surgery or hepatobiliary surgery or whatever is a similar kind of thing, let alone if you're sick.
Dr. Craig Smith: [00:28:09] Yeah, no, I hear you, and I'm sort of a pianist, and I can tell you that that's one thing I can't do under pressure. But operating I've done I've done this for so long. I've done this so many times. It's hard to think of something I'm. In a pinch. More comfortable doing than falling back on what it takes to do an operation.
Henry Bair: [00:28:32] Yeah. And you know, the way that you describe, regardless of how you were feeling specifically during Covid, the way you describe how everything sort of just gets tuned out when you are in the zone, when you are in the operating room is quite indicative of this, I guess, for lack of a better tum this this gift that you have for for thriving in that environment. You mentioned earlier how your tendency is just to work through things like you don't really take breaks when you don't feel up for it. Throughout your career, that's just been how you operate through life. I'd love to ask more about something that I think comes to the mind of people, certainly in medical training, when they think about cardiac surgeons. And that's a question of work life balance. And, you know, of course, I in your book, you often reference your relationship with your wife, and I'm wondering if that has ever been an issue that you've come across, or do you consciously approach your work life balance in a way to make it sustainable? What has that been like for you?
Dr. Craig Smith: [00:29:35] Well, it's a great question. One way I talk about it is to say that I'm not sure balance is the right terme. Balance implies to me sort of a quantitation of percent effort or something that you're talking about. 25% work, 75% at home is the right balance. I think the way I've functioned, and I don't think I'm unique in this respect, is that if I'm working, I want to be 100% working. And if I'm at home, I'm 100% home, with the caveat that there's no such thing as 100%. And if I'm home and I'm 100% at home and I get one of those phone calls, well, then I can switch modes, deal with the phone call and whatever is required as an action arising from the phone call. And if it means I have to hop in the car and race into the Or, I'll do that. But then when I'm back home, I mode switch again and I'm 100%. If you looked at my life as a the other way, as a percent effort exercise, it's quite possible that my work tips over 50%. I really have no idea. Has that been right or wrong? I don't, it's been it's worked for me. I have also a great advantage that maybe few people have. My wife is very strong and very capable in her own right of managing the family and everything else to deal with it, and I think that may give me an advantage.
Tyler Johnson: [00:31:13] I have often wondered, I think many branches of medicine are challenging and demanding, both emotionally and time wise. And it is also true that some branches of medicine are unquestionably even more demanding, or at least more acutely demanding than others. Right? And in the book, what I imagine would also strike many people is that one of the very first things you mention is that, on what I gather, was just a sort of a regular day. You're getting up at 430 in the morning, you know, over to the hospital at five, and then you you don't go into all this detail. But I imagine on a regular day you would spend much of the day operating. And then even after you finish operating, probably go around and check on your patients again and then may not get home until sometime well into the evening. Right. And that's just a sort of a regular day, which, you know, many people even who have demanding jobs, I imagine, are not getting up at 430 routinely to do them. Right. And so I guess that I wonder, is there a sense a little bit among your family members? I mean, it almost feels like there's sort of, you know, sometimes people, when talking about medicine, will talk about the idea of a calling. It almost feels to me like for it to really work, there has to be a familial understanding that the parent or parents who are involved to that degree in medicine do have a almost a sort of a spiritual commitment to what their maybe spiritual is the wrong word, but this sort of holistic commitment to what they're doing in the hospital, that it's it's not the same as if they were going in to be a an investment banker or something, but that because of the nature of what's being done, the family sort of says, we're behind you, and we understand that this is going to require more of you than might be required in other circumstances. Does that does some idea of that resonate?
Dr. Craig Smith: [00:33:13] Yeah, for sure. And another aside, I think you'd find my normal day, which you described very well, is not that uncommon among people who do what I do. Yeah. So it's not like I'm going to hold myself out as some Herculean exception. But sure, in terms of the the family, I think it's got to be helpful if there's a shared sense of mission, a shared sense of a calling, a shared sense of higher purpose. And whether I have succeeded in pulling that off, you'd have to ask my my, my three daughters and my wife. I'd like to think I've succeeded with that to some extent, but I don't know. But it does help. You mentioned investment bankers. I've known a fair number of people who go into the money game. And then ten years in, no matter how much they're making, they find it empty and they want something with a higher sense of purpose. It just helps. Even though they work like some of them work like animals. They work hours like I do, but.
Henry Bair: [00:34:17] The you know, the way you talk about having a calling, answering a call to a higher purpose. It brings to mind the chapter you actually have in your book on specifically on religion. So I'd love to explore a little bit of that as well. Is religion something that has played a role in how you think about your career and your purpose in serving your patients?
Dr. Craig Smith: [00:34:42] I have to say, it has not played a very significant role, and I'll disappoint the religious members of my family and not my immediate family, but and others. Perhaps when I say that even though there may be things I say in the book and in interviews and so on that seem like they merge on spirituality and so forth. Religion as conventionally configured, has never been much of a home for me. I talk about it in the book. For a couple of very specific reasons. One to set up the chapter that follows that which is about error and accountability, but also. To wrap up. The crisis we went through as a family. But at the same time to show. Sort of my on and off relationship with religion. When I was a teenager and. But if you're hoping, I'll give you a really spiritual connection. I have to say I don't think there is one.
Tyler Johnson: [00:35:51] Let me ask a sort of similar question. You know, we talk a lot on the podcast about, well, the initial impetus for the podcast was a recognition of the the epidemic of burnout in the health care workforce, right, which has been written about ad nauseum. And Henry and I have spent many, many hours now talking to all different kinds of people about this. And I think there are some very widely cited systemic causes for the epidemic of burnout. Right. So there's the corporatization of medicine, there's the bureaucratization of medicine, there's the digitization of medicine. I think for those reasons and other related ones, there's no question that over the past, let's call it 20, you could choose your number of years, but anyway, 20 years or whatever, just the logistical reality of what a doctor does from day to day in many respects has changed dramatically in some cases unrecognizably from where it was 20 years ago. But what has also been really striking to Henry and I, which we understand goes along with the things, the forces that we just mentioned. And it's a little hard to know, you know, what's cause and what's effect, but nonetheless is that it does seem that there has been a loss, not a universal loss, but a widespread loss in the medical community of that very sense of mission that you were referring to a few minutes ago.
Tyler Johnson: [00:37:21] It's audible in the in the way that you talk about you and your family, sort of, you know, dedicating this large portion of your life to what you do. That sense of mission shines through clearly. Right. And so I guess what I wonder is, if you were talking to undergraduates who are thinking of entering medical school or medical students who are just getting started, or maybe to, you know, residents and fellows who are now approaching the cusp of practicing independently. And if they were to say, look, you know, we feel this sort of fire at our feet right now, this fire in our belly for what we're going to do, but we look all around us and see all of these doctors who are leaving the practice of medicine or who just don't feel that fire anymore. How have you kindled that fire over the many years that you've been doing this? So much so that you that it still urges you to get up at 430 in the morning and go in and do the same things that you've been doing for all of those years, like how, how, how do you tend to that flame?
Dr. Craig Smith: [00:38:26] Well, that's very complicated in a way. Series of questions. And this general line of inquiry threatens. Having me stand right on one of your third rails about burnout and so forth.
Tyler Johnson: [00:38:45] Go ahead and stand on it.
Dr. Craig Smith: [00:38:47] first of all, I have some difficulty with the methodology behind a lot of the burnout studies, which I have looked at in some depth. Sure, but I also ask myself from a distance, and this may get to what keeps my flame burning. Tell me. When we were in the Elysian fields of perfect euphoria and medicine. Uh, was that the Pre-antibiotic era? Was it, uh, you know, Paracelsus and Galen? I mean, tell me when things were so perfect. I agree with your broad strokes and the way you described all the specific new and some of them new pressures. But when was it perfect? And there's a growing sense, at least I think, that this is sort of a binary thing. You're either in perfect wellness or you're burned out. Whereas I think there's a lot of acreage between those two states, and that's where we all live, is in those acres in between. But this is not a viewpoint that's making me popular with the medical school. So.
Tyler Johnson: [00:39:54] I mean, I actually in spite of the impetus for the podcast, I think we agree with you that it is worth I mean, we can only respond effectively to the problem if we realistically estimate its scope. Right? And I think you make good points. On the one hand, another guest recently pointed out to us that there it's actually a very privileged idea to somehow assume that you should never be burnt out at your job. I mean, who assumes that, right? I mean, depending on how you define burnout and whatever, a lot of it is in the terminology, but it's a little bit strange to think that you could do something for 30, 40, however many years and never feel, you know, frustrated, worn out, alienated, whatever. Right? Especially if you're somewhere in that middle neighborhood that you mentioned. And then by the same token, it is also true that one of the other ways that things have changed a lot recently is that with the rise of social media and the internet age in general, there's just a lot more widespread conversations about things that previously were swept under the rug. And one byproduct of that may be that it's not so much that there is an epidemic of a new problem, so much as that there is a much wider and deeper discussion of what may have been a problem, at least to some degree for a long time.
Tyler Johnson: [00:41:13] Right. And so I think that at least those two points are worth recognizing, because we don't want to. Mischaracterizing the problem doesn't help anybody. Um, but I do still think my original question is an important one, which is whatever the acreage is in between, quote unquote. Well, and quote unquote burnt out, what I hear in your writing and in the way that you talk about your job, even currently, is that you have found a way to keep going back to the well, right? Like the well where the meaning is and the sense of mission and whatever. I mean, I would think you would have to do that to do what you've done in his grueling away, as you've done it for as many years as you've done it, without coming to just hate it. And so still, how do you try to cultivate that sense of mission and meaning?
Dr. Craig Smith: [00:42:02] Well, I hope I don't completely disappoint you in my ability to give a straight answer to that I. It just doesn't strike me as difficult at least doing what I do. It's a very compelling thing. It's not an exaggeration to say, to say that I have the privilege of dealing with life and death sometimes, and you can make an enormous difference in people's lives, and that's a privilege. And how can you not be stoked for that when you have the opportunity to do that? So it may be that I'm just not as sympathetic as I need to be for the pressures that. That fall on other people. I mean, I realized. I mean, the other some of the other specialties are just different things, like emergency medicine, where it's just a at least as I see it, a conveyor belt of eventually soul killing encounters with semi-anonymous people. And there's no stop to it. And it just has. You can't do that like I do what I do. There has to be a change in shift. You have to be on and then off, and then somebody else has to pick up the ball and run with it for a while. And then they put the ball down and somebody else picks it up. It almost has to work that way, at least as I see that specialty. And there are others like that. And that's where I think I would have a harder time maintaining the excitement.
Dr. Craig Smith: [00:43:24] This relates a little bit also to controversy. Might be too strong a word, but I think in medicine, in life there are differences between the kinds of things I do and many other people do, and vigilance tasks. Vigilance tasks are just different. You know, the classic example of a vigilance task is watching a radar screen. This was actually studied quite a bit at the end of World War two, trying to improve performance in vigilance tasks. Everybody burns out in 30 minutes watching a radar screen, and you have to keep them focused, stimulated and so on. That's much more like being the person in the emergency room who's trying to pick up that one case of optic neuroma that comes in with the visual disturbance, or pick up that one rare thing, or the pediatrician in the office who's got to be vigilant to that awful thing. It might be when 99% of the time it's something else that's a vigilance task. Or the anesthesiologist watching the monitor vigilance task. What I do is the opposite of that. So hard not to sustain the excitement, the interest.
Henry Bair: [00:44:32] Well, I mean, I think your response absolutely does capture your perspective and your mindset of how you keep the meaning there.
Tyler Johnson: [00:44:39] I actually really love that terme vigilance because I often think to myself, but I've never had the words to describe it before, that the easiest part of being a medical oncologist is that I don't have to worry about missing the worst thing, because the worst thing is the reason they're seeing me, right? It's not being the generalist who has to sort out, you know, a hundred people who have abdominal pain. That doesn't matter from the one person who has abdominal pain that is colon cancer, because if they're seeing me, they already have cancer, right. And so my job, though very different in its nature in many ways from yours, is responding to the problem, not finding the problem, which actually relieves an enormous amount of psychological burden because you're not doing that constant surveillance looking for the one bad thing.
Dr. Craig Smith: [00:45:27] Mm.
Henry Bair: [00:45:28] So you've mentioned a lot of patient encounters in your book, and we've talked about just now, even how you can't help but not find meaning in playing such an important role in someone's life. I'm wondering, is there a patient story you can share? I'm sure there are a lot, but is there one you can share? Now that sort of encapsulates why this work is meaningful for you.
Dr. Craig Smith: [00:45:54] Well, what's tough. About that is that there's so many. I suspected the sad fact is you tend to remember the the few that die and shouldn't have you remember them. You never forget those and the ones that sailed through, even if it was a tour de force virtuoso technical performance of some kind. They did well and then they go off and you sort of lose track of them. I mentioned a case in the book that stands out because it was such a long terme success in such a surprising, long terme success. He was a young man when I originally did his heart lung transplant, but he was back in the early days of heart lung transplantation, a very difficult operation. I was probably foolhardy to take that on when I was such a junior surgeon. Be that as it may, I took it on. We got the program going. He was one of my earliest patients, and he went on to live 29 years and became kind of a friend. He started having anniversary dinners with me and my some of my people, and he was quite a story in his own right. Very interesting background. I tell a little of the story in the book, but that's one that's a combination of a great long terme outcome, a challenging and satisfying operation up front. But that's again, I probably sound like I'm proselytizing, but that's why it's easy to stay hooked on what I do. There are so many of them.
Henry Bair: [00:47:19] That's wonderful to hear. Just in our closing moments here, I'd like to ask you about the title, actually, of your book, Nobility in Small Things. What is the significance of the title?
Dr. Craig Smith: [00:47:29] Well, actually, that title was not my invention. That was plucked out of one of my updates, which we haven't talked about, but the. The communiques or whatever you want to call them. I happen to call them updates that I wrote during Covid.
Henry Bair: [00:47:42] The first three months of Covid. Right. You were writing this?
Dr. Craig Smith: [00:47:44] Yeah, exactly. That got this ball rolling in this in any event, that was plucked from one of the updates by one of the. An editor worked with me early in the process, not my ultimate editor, but she plucked that out of one of the updates I'd written. She just liked the phrase, and I agreed with her that it was a good phrase. But the scenario was one of my general surgeons working as all my surgeons did in the ICU during Covid, taking care of dying patients in the ICU, not doing surgery. This was a time when there were no visitors allowed, and she used her phone, her iPhone, to FaceTime a patient with his family so they could see him before he died. And that seemed like sort of a small thing. Technically, although it it didn't seem so small at the time, but it was a huge thing to do for the patients and their families. And so I was saying, this is a small, noble thing. That might be what gets us through this mess. That nobility in small things is what will get us through, I think is what I said in the update. But that's where it came from, and I ended up liking it as the top as a title.
Henry Bair: [00:48:56] Yeah. Well, I mean, I think it's reflective in many ways of moments of beauty that can be found in a career in medicine. It's opportunities to discover the nobility in small things are everywhere if we just choose to engage and pay attention.
Dr. Craig Smith: [00:49:09] Totally agree.
Henry Bair: [00:49:10] With that, we want to thank you so much again, Craig, for taking the time to join us in conversation. Thank you so much for your incredible work and for sharing sort of what goes on in the mind of of a cardiac surgeon. Yeah, we appreciate it so much.
Speaker4: [00:49:24] Well, thank you for having me.
Henry Bair: [00:49:29] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.theDoctorsArt.com. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:49:48] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:50:02] I'm Henry Bair
Tyler Johnson: [00:50:03] I'm Tyler Johnson. We hope you can join us next time. Until then, be well.