Reclaiming The Forgotten Art of Surgery

What each of us can learn from "the Dextrous Surgeon"

Story at a Glance:

•Living tissue is immensely complex, and many spiritual traditions have provided profound insights as to what occurs when one engages in an art that interfaces with them. The art of surgery for instance is elegantly synopsized by a Chinese classic.

•When performing surgery, radically improves outcomes are attained as one becomes more and more able to directly connect with the body and understands precisely where to separate the tissue.

•Modern surgery has been overrun with new technologies (e.g. electrocautery and robotic surgery) that have been effectively marketed by their manufacturers. Unfortunately, these devices disconnect the surgeon from their patient.

•This loss of connection in the newer generations of surgeons has led to worsened patients outcomes and an inability to deal with challenging situations. Unfortunately, since the new generation has redefined surgical success to conceal their inadequacies, members of the public often have no guidance on how to find the most qualified surgeon for their case.

Shortly before I went to medical school I came across a forgotten Chinese spiritual classic that provided numerous metaphors for meditation. A few months later, a passage from it about a skillful butcher popped into my mind as I began working with cadavers in the anatomy lab and it dawned on me that its metaphors for entering the deepest aspects of our being also applied to surgery.

Since then, I’ve come to appreciate how well it applies to the entire art of medicine. It goes as follows:

Cook Ting was cutting up an ox for Lord Wen-hui. As every touch of his hand, every heave of his shoulder, every move of his feet, every thrust of his knee — zip! zoop! He slithered the knife along with a zing, and all was in perfect rhythm, as though he were performing the dance of the Mulberry Grove or keeping time to the Ching-shou music.

“Ah, this is marvelous!” said Lord Wen-hui. “Imagine skill reaching such heights!”

Cook Ting laid down his knife and replied, “What I care about is the Way, which goes beyond skill. When I first began cutting up oxen, all I could see was the ox itself. After three years I no longer saw the whole ox. And now — now I go at it by spirit and don’t look with my eyes. Perception and understanding have come to a stop and spirit moves where it wants.

I go along with the natural makeup, strike in the big hollows guide the knife through the big openings, and following things as they are. So I never touch the smallest ligament or tendon, much less a main joint.

A good cook changes his knife once a year — because he cuts. A mediocre cook changes his knife once a month — because he hacks. I’ve had this knife of mine for nineteen years and I’ve cut up thousands of oxen with it, and yet the blade is as good as though it had just come from the grindstone. There are spaces between the joints, and the blade of the knife has really no thickness. If you insert what has no thickness into such spaces, then there’s plenty of room — more than enough for the blade to play about it. That’s why after nineteen years the blade of my knife is still as good as when it first came from the grindstone.

However, whenever I come to a complicated place, I size up the difficulties, tell myself to watch out and be careful, keep my eyes on what I’m doing, work very slowly, and move the knife with the greatest subtlety, until — flop! the whole thing comes apart like a clod of earth crumbling to the ground. I stand there holding the knife and look all around me, completely satisfied and reluctant to move on, and then I wipe off the knife and put it away.”

“Excellent!” said Lord Wen-hui. “I have heard the words of Cook Ting and learned how to fully live life!”

Note: this essentially describes the process of living life through the spirit, and many of the most talented physicians I have come across agree this passage describes the evolution of their practice of medicine. Likewise, much of it applies to how I try to dissect seemingly insurmountable medical mythologies.

The Art of Surgery

During my medical training, I assisted a group of OBGYNs who did a lot of C-section surgeries. One surgeon, an older Asian man caught my eye because of how graceful his hands were and how much smaller the injuries from his incisions were.

He shared with me that he was a lifelong Tai Chi practitioner and that this practice had caused him to become much more connected with his scalpel. Anytime he cut someone, he always made a point to feel connected to each layer of tissue he was cutting and conversely lamented having seen numerous cases of a babies being cut (e.g., on the face) by a typical OBGYN who wasn’t connected to their scalpel (which are estimated to occur in between 0.7-3% of C-sections, particularly emergency ones).

Electrocautery

Two common methods exist to cut through tissue. One is to use a sharp blade (the scalpel) to directly cut tissue and the other is to use a blunt metal blade which (through electricity) is heated to a high temperature so it causes the tissue it contacts to bubble and break apart.

Electrocautery is often favored in surgery because it cauterizes as it cuts, reducing blood loss. This allows surgeons to work faster and with less precision. However, when I first encountered electrocautery, it was challenging for me to be around as it was almost as if I could sense the pain of the tissue being seared apart (which was particularly intense with the cervix). This led me to question electrocautery’s safety.

I subsequently discovered that electrocautery scars are more traumatic to the body, often leading to permanent health issues unless treated with specialized therapies that regenerate the scar and reset the nerves within it.

Note: traumatized scars are a frequent cause of chronic illness due to the disruption they create within the autonomic nervous system and I frequently see dramatic results immediately follow the treatment of one.

The dead tissue left behind by cauterization can also lead to a higher rate of post-surgical infections. I've even seen cases where the immune system's ability to contain a longstanding cancer was compromised, leading to fatal metastasis after surgery.

Note: one of the most effective methods for preventing post-surgical infections is ultraviolet blood irradiation.

Modern Surgery

As technology has advanced, it's made once-impossible feats in medicine achievable, but at a cost. The reliance on expensive products has gradually replaced the innate skills doctors once depended on.

Take, for example, diagnosing common conditions like appendicitis. A thorough physical examination used to utilized, but now, the standard of care leans heavily on monetizable approaches like CT scans. This shift has caused the physical exam to become a lost art, leading to missed diagnoses that could have been caught with a hands-on approach (something I frequently encounter with challenging patients who’ve already seen many doctors).

Note: medical residents who come from poorer countries to the US who trained without access to our expensive tests, when compared to their American-trained counterparts often excel at physical diagnosis because their training forced them them to develop that skillset.

Electrocautery is a prime example of how technology can diminish surgical skills. While it simplifies surgery by eliminating the need for finesse, I've observed that younger doctors trained primarily with electrocautery are worse in the operating room, especially in specialties like OBGYN. Likewise, if you have a sizable patient pool or spend time in the recovery area of a hospital, you can often tell which surgeons use more or less cautery because of their poorer patient outcomes.

Note: the amount of blood loss which occurs during surgeries varies depending on the skill (and finesse) of a surgeon— surgeons who have ‘good hands’ are both faster and lose less blood (e.g., they have half the blood loss and take a third of the time for a surgery), as surgeons who go slower are typically compensating for their less astute anatomical awareness. These are not absolutes however (e.g., a fast clumsy surgeon is a disaster, and certain surgeries like liver resections have to be done slowly to reduce blood loss). Unfortunately, since surgeons get the final say on how much blood was lost during their surgery, they frequently underestimate it.

In short, we often find a patients long-term outcomes from surgeries often greatly vary depending on the surgeon (e.g., I saw this a lot in orthopedics) and once you work with them in the OR, it often becomes very clear why this is.

An Awake Surgeon

When I first started my publication, I connected with a brilliant trauma surgeon who had recently been forced to flee Washington because he had advocated for the unvaccinated when everyone else was actively discriminating against them and denying them essential medical care. From talking with Dr. Miller, I saw he had the rare capacity to see things for what they were and break from the crowd in order to do the right thing (a trait shared by the most talented doctors I’ve known). So, when he asked me to help publicize his story, I publicized it, and before I knew it, we’d ended up on national television.

Note: since leaving the surgical field, Dr. Miller has started a holistic primary care practice that’s utilizes the Forgotten Sides of Medicine. In that context, he’s shared with me that he’s seen a variety of extraordinary results with DMSO (e.g., while treating another condition, a patient’s failing lung coincidentally no longer needing a transplant) and that he’s found DMSO makes it possible to profoundly improve the practice of surgery (e.g., by augmenting surgical healing and making it possible to non-surgically treat a variety of severe illnesses). Since surgery often entails significant risks for patients (e.g., they can be lethal and frequently create significant long term complications that are often immensely challenging to reverse), I believe it is critical to find viable alternatives to surgery and have tools available to heal the complications they create.

Here are a few of Dr. Miller’s thoughts on The Dextrous Surgeon:

The growing detachment of physicians from actual tactile experience has developed into a real problem, and I genuinely fear for our medical culture.  The hands follow the mind.  

I graduated from medical school in 2000. At that time the robotic operating systems began being heavily marketed despite there being no studies showing it improved any meaningful outcome—rather it often made them worse.

These robotic systems result in an uncoupling of tactile feedback between the patient and the surgeon.  I worked with them early in my training and found it a fundamentally flawed technology for the care of people and rejected further use as I matured.  My practical experience mirrored a truthful reading of the literature. Sadly, because of that marketing, patients routinely demanded robotic surgery.

For anyone who works with their hands (musicians, machinists, artists, carpenters, etc.), over time and with extensive practice, a deep intuition and flow develops, allowing for the steady progression towards expertise and excellence. This is why surgical specialty training programs require a minimum of 5 years of supervised guidance, after which years of diligent work are needed for mastery of surgery.

Feeling the tissues and organs, gently moving and manipulating them, while struggling to heal the whole person, all lead to developing pattern recognition beyond what is written and becomes an instinctual understanding. Instincts which, after mastering competence, allow for creativity and a very special form of healing. 

Because of the heavy marketing, robotic surgery has now become the standard of care in almost every major abdominal or thoracic operation for urologists, gynecologists, general surgeons, and thoracic surgeons and recent graduates no longer know how to perform those surgeries with their own hands. They hence often cannot handle situations where robotic technology isn’t applicable, lacking both creativity and basic competence.

This is very worrisome as surgeons must be able to know how to improvise when something goes awry during a surgery, but since training has shifted to learning how to use each new technology, the fundamental surgical skills are disappearing.

In the last ten years, I’ve noticed a steep decline in the newer generations of surgeon, and worse still, unlike someone who learns through their hands, they never progress to mastery, leading to much worse outcomes for their patients.  Because of this, I’ve often been called in to fix a mess a robotic surgeon created that neither they nor their colleagues felt comfortable handling (in some cases needing to be granted emergency hospital privileges since the specialized surgery was not something I’d been “trained” in like them).

I distinctly happen one case where this happened with a urologist who had no understanding of how he caused the complication and acted as if touching the tissues, respecting how they moved, and closing the muscle layers so they could hold the bowels into their correct compartment were novel concepts which he had never learned.

The part that really shocked is that rather than improve, those who suffered from these inadequacies seemed to spend most of their energies on redefining success rather than overcoming weaknesses. Sometime later, these same group of surgeons who expressed incompetence at the most fundamental levels of taking care of their own patients, became leaders of the medical safety committees in our hospital.  Rather than recognize the holes in their training/knowledge/skills and take initiative to learn/train how to care for the needs of their patients, they became administrative leaders.  As such, they subsequently chose to redefine “competence” or "good patient care" into something that has nothing to do with patient outcomes or surgical ability.

I’ve seen this so many times. Hence, many like myself are now faced with the dilemma I faced: to have the privilege of helping people through surgery, which is something I loved and felt called to do, I had to compromise bits of excellence at regular intervals to work in these systems and tolerate 'bad care' being labeled as 'good care'.  

This is a difficulty of living a life and a medical practice of trying to be in touch with The Spirit or The Way. One needs to be working in a place with minimal (maybe no) cognitive and moral dissonance to have excellent outcomes and to be connected.  When we work in an extremely flawed system and a fallen world, there is always an inherent tension to be connected to Truth.  But now the gap of reality has become staggering in healthcare.  It is extremely difficult to stay in standard health care and remain without overwhelming cognitive and moral dissonance.  In truth, it isn't welcome anymore.  Few are called and able.  I could not anymore, and I chose to live without the dissonance and transition to a different facet of healing.  For those who can stay and stay true, I have a fierce admiration.

Note: a few of the more egregious examples of poorly performed surgery Dr. Miller witnessed are detailed here. Sadly, many of the points he describes holds true for many disciplines besides just surgery.

Conclusion

In my eyes, one of the greatest tragedies of Dr. Miller’s story (which also holds true for many other pioneering physicians who questioned the COVID-19 policies like Paul Marik or Pierre Kory) is that they are the doctors patients would most want to see in the hospitals—yet, the existing system pushes them out for putting patients before profits.

In a recent article, I discussed the dangers of spinal surgery—a procedure which frequently leaves patients much worse off and often doesn’t address the root cause of back pain. In that field, ethical spinal surgeons exist, but like the COVID dissidents, when they speak out against unjustified or poorly done spinal surgeries being performed by their unscrupulous colleagues, they are pushed aside by their profit focused institutions. In short I argue that were surgery were to return to its roots and prioritize connecting with the patient, many of these issues would stop happening.

Note: as I show here (and many readers have since corroborated), chronic spinal pain can often be treated with DMSO. However in many other cases (as discussed here), a regenerative or lifestyle therapy is needed to eliminate the route cause of spinal pain.

Fortunately, the COVID-19 response was so egregious that it has woken the public up to this problem and a profound shift has occurred, best shown by a recent JAMA study of 443,455 participants, which found compared to 2019, where 71.5% of Americans trusted physicians and hospitals, now only 40.1% do. This is a critical loss for an industry which depends upon the public’s trust to function. To regain it, the medical profession must return to its roots and chose approaches that bring doctors closer to their patients rather than profitable medical technologies that further disconnect them.

Author’s note: This is an abridged version of a longer article on the subject which discusses the above points in more detail, shares cases that illustrate what can do wrong without a traditional training in surgery, and pointers for identifying the ideal surgeon to work with. That article and its additional references can be read here. Additionally, an article about how DMSO can help the practice of surgery, wound healing and chronic pain can be read here, and an article on the risks and alternatives to spinal surgery can be read here.

An updated index of all the articles published in the Forgotten Side of Medicine (including the DMSO ones) can be viewed here. Additionally, to learn how other readers have benefitted from this publication and the community it has created, their feedback can be viewed here.