What Makes a Good Surgeon? What I Learned Watching Hardy Hendren

Perhaps the greatest compliment that an attending surgeon can bestow on a resident in training, is to comment, “He/she has good hands.” However, what defines good hands? What parameters are used to make that judgment? As an academic urologist, I had the opportunity to observe urology and general surgery residents in the operating room over several decades.

However, I found objective criteria to define dexterity to remain elusive. Potter Stewart, the Supreme Court justice, once said of pornography, “I can’t define it, but I know it when I see it.” Can the same be said of surgical skill?

As I pondered the question further, I thought back to one of my teachers, Hardy Hendren. Yes, there was a certain personal aura surrounding Hardy, but he was regarded as an outstanding surgeon by all of us who trained with him. What qualities contributed to Hardy’s skill?

The first was his preparation. He always reviewed the radiographic studies before the case and he knew his anatomy cold. The presidential advisor, James Baker, had a favorite saying, “Poor preparation predicts poor performance.” The so-called 5 Ps. The same can be said of Hardy.

The other quality that Hardy possessed was that he always had a plan B. One of the first cases that I scrubbed on with Hardy was a bilateral ureteral reimplant in a young boy. Hardy began by starting a Cohen cross-trigonal approach, but he met some difficulty in creating the planned ureteral tunnel. Without any hesitation, as if it were part of the planned procedure, he converted to the extra-vesical Leadbetter-Politano approach. His experience always permitted him to have a plan B.

Another of Hardy’s qualities was that he was innovative. He had designed several instruments throughout his career and was a major proponent of urinary undiversions. One may argue that a surgeon who hasn’t developed a new surgical instrument or technique cannot truly be considered outstanding. Good surgery goes beyond mimicry, an outstanding surgeon is looking to improve himself/herself as well as the field.

Hardy’s next quality was his composure. He was clearly the one in charge during his cases, but he was never a bully or ill-mannered. I never heard him curse. I never saw him toss an instrument or throw a resident out of the operating room, as some others did. He was always the consummate gentleman and he engendered a sense of calmness and camaraderie in the operating theater.

This brings me to Hardy’s next quality-his sense of teamwork. As residents, we never wanted to disappoint Hardy or let him down. We were all part of his team. Most importantly, there was Dottie, his career-long scrub nurse. She anticipated his every move and knew what instrument or suture to give him without being asked.

Integrity. Hardy was a man of the utmost integrity. If he encountered a complication, he confronted it honestly. He reported his surgical results accurately. To me, he embodied the words of Alan Simpson, the former Wyoming senator, “With integrity, nothing else matters, without integrity, nothing else matters.”

Stamina and concentration. Some competitors referred to him as “Hardly Human Hendren” because of his marathon reconstruction cases, some of which would last 15 h or more. I viewed his stamina and ability to concentrate as a requirement to become an outstanding surgeon. Qualities to be emulated, not criticized.

Confidence. Hardy was a confident man and a confident surgeon. I did not consider him cocky. His results spoke for themselves. Another one of my mentors, Judah Folkman, had a favorite quote that he felt defined the surgical personality, “Often wrong, never in doubt.” Nobody benefits from a timid surgeon. These observations lead me to my own conclusion that being an outstanding surgeon has nothing to do with being macho. In fact, in an era of having trained and observed multiple female urologists, in my opinion, there is no difference in the surgical ability of the two genders. In fact, if anything, I would give the edge to female residents, who are often more meticulous than their male counterparts.

Despite his busy surgical schedule, Hardy had a uncanny memory for events in the lives of many of his patients and regularly received correspondence from them that continued for years throughout his career.

From a technical standpoint, he had one idiosyncrasy. He often would hold a Metzenbaum scissors in a pronation rather than a supination position. He claimed that this gave him more control of the scissor tips.

With the benefit of hindsight as well as training with Hardy, I have come to the following conclusion. There are very few virtuoso surgeons. The bandwidth of dexterous skill among surgeons is pretty narrow. Technical skill is important, but so is knowledge of anatomy, creativity and relationships with staff and patients. The surgeon should strive to have good hands, but, just as importantly, a good head and a good heart. Good hands, head and heart, that is the true triple threat surgeon.

Kevin R. Loughlin,MD, MBA

Professor Emeritus, Harvard Medical School

Associate Editor

Boston, MA, USA