The Attending Is a Haunted House

Early in my career as an attending, a surgical colleague asked me to come into his operating room.

He had encountered an unexpected finding involving one of the patient’s testicles and wanted my recommendation about whether it needed to be removed.

It was not a straightforward question.

I paused to examine the situation and think through the options. I was newly out of fellowship, still close enough to training that careful uncertainty could easily slip into self-doubt. I also understood that what I recommended could permanently alter the patient’s body.

My colleague grew impatient.

“Either you give me your recommendation, or I’ll call your Chair to come down here and give me the recommendation himself.”

I remember the internal alarm that went off.

There was tension, defensiveness, and an immediate flash of anger. My first instinct was to confront him about how aggressively he was speaking to me. I am proud that I remained calm, although my patience was hanging by a thread.

Calmness and peace are not the same thing.

Calling out a senior male colleague in the middle of his operating room was complicated territory for a newly minted female surgeon. I was still learning how firmly I could inhabit authority before confidence was renamed arrogance or composure was mistaken for weakness.

I had also entered the room with ghosts of my own. Residency had left me with a combativeness that was still fresh. Part of me knew exactly how to meet aggression with aggression.

What frightened me most was not the disagreement itself. It was the threat of having my Chair summoned.

I imagined the call creating doubt about my competence. I worried that my hesitation would be interpreted as evidence that I did not know what I was doing, rather than evidence that I understood the weight of the decision.

The pressure did not help me think more clearly.

It made the room smaller.

Part of my attention remained with the patient. The rest was suddenly occupied with defending my right to be standing there.

I recommended preserving the testicle.

Waiting, I believed, would leave open the possibility that it could be salvaged without placing the patient in danger. The surgeon accepted my recommendation. In postoperative follow-up, the testicle remained viable, and my judgment proved correct.

My hesitation had not been evidence that I lacked an answer. It had been evidence that I understood what the answer could cost.

The incident stayed with me, although I doubt the other surgeon remembers it.

Over time, I came to know him differently. We collaborated on cases. I found him to be technically talented, clinically sound, and deeply service-oriented. He was the kind of surgeon who took on difficult problems and cared for patients with complex general surgery needs. I began sending him some of my own challenging referrals.

He remained gruff. My patients occasionally noticed it. But he never mismanaged a consultation I sent his way, and I came to respect both his judgment and his willingness to help.

That made the memory more interesting, not less.

He could not be reduced to the role of the intimidating surgeon in someone else’s story. He was a good surgeon who had used intimidation in a difficult moment.

I began to wonder what had entered the operating room with him that day.

Who had taught him that intimidation was the quickest route to clarity? When had urgency become inseparable from aggression? Had someone once spoken to him in exactly the same way? Had it happened so often that it no longer registered as remarkable?

Perhaps this is one of the ways surgical culture survives.

We do not inherit only technique. We inherit tempo, posture, language, and ideas about what authority should feel like. We learn which emotions may be shown and which must be hidden. We learn whether uncertainty will be treated as thoughtfulness or weakness.

We absorb what happens in operating rooms long before we are given the responsibility to lead one.

The attending is a haunted house.

Every surgeon carries traces of the rooms in which they were trained. Some are inhabited by teachers whose voices still steady our hands. Others contain humiliations we believed we had left behind. There are locked rooms, old alarms, and behaviors we promised ourselves we would never repeat.

Then the pressure rises, and somewhere inside us a door opens.

Long before either of us entered that operating room, American surgical training had already been built around hierarchy, endurance, and immersion.

William Stewart Halsted established one of the earliest structured surgical residency systems at Johns Hopkins in the late nineteenth century, drawing heavily from European training models. Residents lived in the hospital. Responsibility was granted gradually through a steep hierarchy. Many entered the pyramidal system, but very few reached its highest level. Total devotion to surgery was treated not only as a practical requirement, but as a moral one.

Halsted was also dependent on cocaine and later morphine. Historians have argued that the layered structure of his residency program may have allowed the surgical service to continue functioning during periods when he was impaired, while also helping conceal the full extent of his addiction.

The architecture was European.

The floor plan may have been Halsted’s.

This does not mean surgical residency was created solely to hide one man’s addiction. The historical record is more complicated. Halsted’s system advanced surgical education, scientific rigor, patient care, and the concept of graded responsibility.

But every architect leaves something of himself in the building.

Halsted’s model helped establish an enduring belief that excellent surgeons are produced through immersion, hierarchy, and sacrifice. Alongside its achievements, it helped normalize a culture in which suffering could be interpreted as commitment, silence as strength, distance as authority, and endurance as proof that someone belonged.

The house outlived its builder.

Generations of surgeons learned inside it and eventually inherited its keys.

Modern surgical training is different in many ways. We have limited work hours, created reporting systems, and developed policies against mistreatment. Yet culture is not transmitted only through written rules. It travels through imitation, through gestures and reflexes that become so familiar we no longer recognize them as choices.

A recent qualitative study described this as a surgical habitus, a collection of deeply ingrained behaviors and assumptions acquired through training. Many faculty surgeons could remember mistreatment from their own years as learners, yet had difficulty recognizing mistreatment in the environments they now led.

Perhaps this is how the haunting works.

We remember what was done to us, but not always what it taught us to do.

I wish I could say that recognizing this has made me immune to it. It has not.

I have felt myself becoming the surgeon from that consultation.

I become frustrated when residents do not remember important details about a patient, when they seem to have forgotten steps from an operation we have performed before, or when my team does not retain preferences I believe I have communicated clearly.

These are not trivial concerns. Details matter. Historical memory matters. A missed fact can harm a patient, and a forgotten step can make an operation less safe.

The danger is not that I care too much about these things. The danger is what can happen to the room when my frustration takes control of how I communicate them.

Being right about the importance of the problem does not make every response to it right.

The surgeon sets the pulse of the operating room.

When we become tense, curt, or visibly unsettled, that energy does not remain contained within us. It moves through the residents, nurses, anesthesiologists, and technicians. The resident becomes quieter. The scrub technician moves faster. The room tightens around the surgeon’s mood.

People become afraid to ask questions precisely when questions are most needed.

Stress is contagious.

So is steadiness.

When I notice myself becoming particularly abrupt, I try to interrupt the pattern. Sometimes I ask for music. Sometimes I name what is happening directly.

“Please excuse me if I am being particularly abrupt during this portion. It is important to get this right, and I appreciate all of you being here doing this with me.”

This is not an apology for having standards. It is an attempt to keep the stress attached to the difficulty of the operation rather than attaching it to the worth of the people helping me perform it.

Afterward, I try to debrief with my residents. We talk about what created the tension and how it moved through the room. I remind them that they are not merely learning how to operate. They are learning how to become the person around whom an operating room organizes itself.

Their demeanor will matter.

The way they respond when they are frightened, frustrated, or uncertain will matter.

I learned another way of holding authority from my reconstructive mentor, Dr. Bahaa Malaeb. He is one of the most skilled surgeons with whom I have ever operated. His expectations are exacting, but he uses humor to keep the pursuit of excellence from creating an atmosphere of fear.

The humor does not make him less exacting.

It allows the room to remain human while he is exacting.

I am not as naturally witty, so I have developed other tools. Music helps. Direct acknowledgment helps. Gratitude helps. Explaining why a moment requires unusual precision helps.

None of these practices makes me perfect.

There are days when I recognize the ghost only after it has already entered the room. There are times when my tone becomes sharper than I intended or my impatience is more visible than I realized.

We operate on bodies that belong to lives, families, histories, and futures. There will always be fear, urgency, frustration, and grief.

The work is to notice our emotions before they begin directing everyone else.

We cannot prevent stress from entering the operating room. We can decide whether we transmit it as clarity or convert it into fear.

Every attending eventually inherits the keys to the house.

We inherit its beauty along with its damage. The discipline, the mastery, the rituals, and the impossible standards that pushed people toward remarkable achievement. We also inherit the locked rooms, the old threats, and the belief that suffering is sometimes the only credible proof of excellence.

Then we invite trainees inside.

We decide which doors they must pass through. We decide which rooms remain closed. We decide whether the sounds in the walls are dismissed as part of surgical training or finally named for what they are.

I hope my residents learn to recognize their own stress without being ashamed of it. I hope they develop ways to lower the temperature of a room without lowering their expectations. I hope they understand that authority does not require intimidation.

I do not know which ghosts accompanied my colleague into the operating room that day.

I know only that the encounter made me more attentive to the ones that accompany me.

We may never fully empty the haunted house.

But we can keep its ghosts inside, rather than unleashing banshees through the operating room.