Chair of the Department of Surgery and heart surgeon Craig R. Smith, MD, has made his mark. Completing thousands of surgical procedures, teaching countless residents, guiding research and development, and providing leadership and transparency for NewYork-Presbyterian/Columbia University Irving Medical Center through a global pandemic are merely the broadest touchpoints—his professional contributions.
What we come to learn in Dr. Smith’s new memoir, Nobility in Small Things: A Surgeon’s Path, is what lies beneath the professional. It is a deep exploration of self and reflection on the people, places, and events that shape him. With this intimate and honest portrait, Dr. Smith takes us through the trials and tribulations of life, replete with the wisdom of experience and contemplation.
What does it mean to live a life of value, of service? In this expansive interview, Dr. Smith talks to the Content Director for the Department of Surgery, Lindsay Gandolfo, to discuss the many themes of his book and the nuance therein.
On Writing and Leadership
I’m curious; Why ‘nobility’ in the small things? You talk so much about courage, curiosity, confidence. What made you choose that descriptor?
That’s a good question. It's a phrase from one of my [Covid] updates where I mentioned a member of our faculty who held her cell phone over a dying patient so he could FaceTime with his family. And I thought that was such a noble gesture. I wrote “nobility in small things will get us through this.” But to use it as the title was actually suggested by one of the editors.
I was part of the team that disseminated your daily Covid Updates in the spring of 2020, but I also relied on them. I derived comfort from them. You have been a leader for a very long time, and it’s the only way I’ve known you. It was funny to read what your father-in-law said about you the first time you met: “He’ll never be a leader.” Did you think about that when you started writing the memos?
Yes. Many times. Though not specifically when I started writing the Updates. And he was right then. Because I didn't know what I was doing. I barely had the nerve to get through lunch with him, and I didn't think of myself as a leader.
In fact, I didn't really think of myself as a leader, even when I was an athlete in a typical leadership position, like playing quarterback. I think if I had thought of myself as a leader, I would've been a somewhat different athlete at the time when that was so important to me.
How do you think you would have been different?
I would have thrived as a quarterback. I had the skills, but I didn't think of myself as calling the shots. I was the guy who did those other things. Give me the ball, and I'll run with it. For a long time I didn't imagine myself as that other guy.
Is leadership something you feel you cultivated or grew into?
It was there when it was needed, I think. I didn't go into surgery or into medicine thinking I was going to be a chair someday. I was happy to think that I might be chief of cardiac surgery someday, almost as a practical necessity. And when it was time to become chair, I overcame my indifference, and I’ve found it very rewarding. I think I've been successful at it, but it's not because I said I set out with this leadership plan or some Red Book of Principles that I followed. I just did. If you're a person who thinks that leaders are born and not made, then I guess I was born, and it took a long time to express itself.
Do you believe that leaders are born and not made?
It's another one of those dichotomies we'll never resolve. Maybe it’s neither, or both. If my life had followed a different path, say I stayed with the phone company, would I have risen the executive ranks like my father-in-law to become an AT&T executive in Massachusetts or whatever? Would that mean I was a “made” leader? Who knows?
I enjoyed how you expressed your intense curiosity in the sciences and what felt like such a deep reverence for the mundane. Does that curiosity and reverence contribute to successful leadership?
I think it contributes to a successful worldview or to a happy person. Leadership is a funny thing. I mean, there's a great modern example going on right now in Ukraine with Zelensky. Talk about stepping up.
He probably agrees that projecting confidence is an important part of leadership, and as I say the book, some of the most important times to project confidence are when you don't have it. Nobody taught me to do that. It’s not one of those things anybody ever discusses.
What advice do you give to people stepping into leadership positions?
There are a bunch of practical things. Some seem contradictory, such as don't feel you have to solve all the problems the first day, and yet there will be a problem on the first day that you must solve. That's where instinct comes in, when it's both.
Don't be afraid to sit on things, but also don't be afraid to solve problems. Don't get too caught up in consequences, and don't look too many moves down the chessboard. Just do what you think you have to do. Trust your instincts. Tell people to trust their instincts. There are a lot of perils, but there are also a lot of pleasures in it that I didn't know existed.
Well, the one I often cite is something that makes it like surgery, not just this administrative paper-pushing thing, which is often how it's portrayed. How could it be something I enjoy, like surgery? Somebody makes an appointment, comes in, and sits down. You have no idea what they're really there to talk about. And you have no idea what will come out of their mouths until it comes out. And you have to react in the right way.
That's where "Do I act now or do I delay?" comes in. It’s an immediate tennis game in real-time. You can't prepare for that. You can't read books on that conversation. Sometimes people say amazing and surprising things. And some of their issues need an immediate reaction. Some of them need to be ignored.
A very writerly interpretation. Do you feel like you’re good at reading people?
Of course we probably all think we're good at reading people. I think, in general, I'm good at it. I've had some striking failures.
I have to ask, with your leadership duties and operating, how do you find time to write?
Well, for this project, the truth is that there is more time than you might think, before and after what we call the “critical parts,” the parts that are mine and mine alone to do. In a full operating day, with two or more cases, I might have several hours to work on other things.
And in COVID, I suddenly had no operating to do, so I just sat down and wrote every day.
How often did you write before the pandemic?
Editorials, and plenty of other stuff directly related to surgery, all the time. But not a memoir. Except for the Clinton journal [In 2004, Dr. Smith completed a quadruple bypass on former U.S. President Bill Clinton], which was just a daily diary kind of thing. What became the final chapter of the book I just sat down and wrote out of the blue when I saw that scene in 2019, just as it's described. And I don't know what it was exactly, but something about that brief scene made me decide to write about it. Later I thought, "Should I do something with it?" I never did.
Until now. Did you enjoy the process of writing this book more than other writing you’ve done?
I guess I did. It was not entirely fun. The Covid writing was very different. I mean, that was like a religious experience, like being beamed up. It just had to be done, I fell into it and had plenty of time.
I always knew I could write. And usually enjoyed it. I just never thought I'd do it seriously.
Risk, Confidence, and Surgery as a Performing Art
You speak a lot about your propensity for risk as a child and young adult. You open the book with it. Do you feel that inherent openness to risk is an attribute of your confidence?
I think it probably is. It’s combining physical confidence, which I've always had, with being an incurable optimist. I did sober up, though, I must say. Since I was about 20 or 25, I have been much less of a risk-taker.
Well, you were scaling the smokestacks and water towers of Philadelphia in the middle of the night.
[In Dr. Smith’s late teens, he and his best friend Chris would seek out ‘urban peaks’ late at night for the thrill of the climb. Some radio towers were 1,100 feet tall.]
That was crazy reckless. I wondered if I should even write about that. I’m not sure I want my children and my grandchildren to know about it.
Do you think there’s an element of risk that is required to have confidence?
Yeah, probably so. Confidence is an interesting notion. I talk about this to the new interns every year. I tell them about the “six C’s” [compassion, concentration, collegiality, composure, curiosity, creativity]. But I point out that one of them is not confidence, because confidence is only measurable as a ratio of confidence to competence. When that ratio is too much greater than one, those people are dangerous. And when it's way below one all the time, then people don't live up to their potential. So, a surgeon should always be sine-waving around one, and something that everybody has to go through is losing confidence. That’s what my daughters called ‘Dad’s Law’ because they got tired of hearing it: Dad’s Law states that nobody has confidence who hasn’t lost it and regained it.
You write much about having, losing, and regaining confidence in the book, but you rarely speak of fear. Do you feel like fear was an operator for you?
I’d say I’ve never been particularly fearful. Although, when I was a child, I had a very active imagination, and the simplest horror movie would make me sleepless for days. Then, I reached a point in adulthood where they were easily watchable, but seemed so ridiculous that I couldn’t take them seriously. But I doubt that’s the kind of fear you’re asking about.
As a child, I could certainly relate. Do you think that streak of recklessness—combining physical confidence and optimism—makes you a better surgeon?
I have to be careful how I put this, but yes, I would say it does. You don't want to make it sound like you enjoy risking other people's lives, but of course, you're risking your own self-worth and everything else. You can't do things like that without some risk-taking ability.
And it was much more obvious in the first generation of heart surgeons, those who were 10-20 years ahead of me. They would do 10 operations and have eight of them die. Today one or two in a hundred might die.
That risk-taking has also led you to experience some severe and intense injuries. You share several in the book—a fall in the coal bunker that left you in the hospital for 10 days, an ankle fracture from practicing the long jump in high school that easily could have taken you away from sports altogether. Do you think these injuries and recovery helped you cultivate some fortitude?
[In a summer between college semesters, Dr. Smith worked in a coke plant, where coal is carbonized through baking, and he would sometimes make choices that violated safety rules. One of these led to a bad fall that ended his time in the plant.]
Injuries made me grow up. Particularly the ankle fracture, which was probably the worst of the bunch. It was a very maturing experience for a little high school freshman to be that debilitated for that period of time. It probably would've been much simpler today. I assume there would be easier ways to maintain reduction of a fracture without suspending my leg in the air, in bed for 10 days, completely immobilized.
After that injury, you could not run at all. As a young athlete, that had to be incomprehensible—and then to have the full recovery you did.
I was pretty beat. It took a year out of my athletic life. I came back remarkably well. Everybody was rather surprised to see me show up for summer football practice my junior year.
Early on in the book, when recounting your coke plant injury, you spoke with reverence for your caregivers, calling it the healing arts. Through personal tragedy and difficult professional experiences, you maintain you have never lost faith in the hospital. I was struck by that. Is the art form part of what fuels your faith?
It's popular to talk about the importance of science in surgery, and in medicine in general. And it should all have a scientific basis, but surgery is really a performing art. That's how I think of it. It has many of the same characteristics as a performing art. Not everybody can do it. It takes more than the science to be able to actually do the thing.
Surgery as an art itself, acting on the fly—
It's a kind of performance art I can do, for sure, but it doesn’t universalize. It's embarrassing that I simply cannot play piano for people, at least not in my adult life, even though I play pretty well.
Knowing the Bach pieces you were mastering, I know you play more than well.
But not well enough. Yet, I can perform in the operating room. I can improvise, deal with setbacks, analogously miss a note and just keep going. But with piano, I just can’t. I thought I should fix that someday, but I haven’t succeeded.
We relate a lot from our piano pasts. I could also easily coast through recitals, even compete, but in my late teens, I hit a performance anxiety wall, I could not play for people. It was all fumble and fluster no matter how perfectly I knew the piece, even memorized. You had your last public performance in college.
In medical school, actually. It’s maddening. For a long time, when I was trying to perform I thought I was getting caught in a gap between sight-reading and memory. So I thought, well, I’m just going to sight-read my ass off. I wasn't a very good sight reader, but I compulsively sight-read and deliberately didn’t memorize. That carried me through my organ phase. I never memorized anything on the organ.
Then, about 15 years ago, back on the piano, I decided I should try the opposite approach and start memorizing things and I've been on this memorization campaign ever since. Now I believe I can't really play anything well if I don't have it memorized. But even so, it hasn't made me a performer. Yet, as you know, sometimes you'll sit there practicing or playing, thinking about something else, and the notes are just rolling out like a player piano.
In the operating room is where I must perform, and I've never had the performance problems in the OR that I have with the piano. I've learned to do public speaking and all that stuff. I don't think I'm great at it, but I can do it.
Do you think your comfort has anything to do with how varied and long your study and experience in the sciences has been?
With surgery, I knew I was good at it. I could always do the technical stuff well. I've never had the slightest doubt to speak of. There were times, as I mentioned in the book, that I had another kind of paranoia.
In college, the trainer who taped up my knees every day for lacrosse, and had been a high-level college player himself, said one day "You throw and catch just fine, but you don't know what to do with the ball." And he was exactly right.
My fear in surgery was that I could cut and sew and tie knots and all that like a star, but I didn't know what I was doing. I didn't know what was here, what was there, what to do next. And that's the performance.
Do you feel like that criticism from the trainer helped you cultivate a way to learn?
I don't think in any conscious way. I remember thinking how exactly right he was. There were times in learning surgery when that's definitely been true. An appendix is supposed to be an easy operation. They're not so easy. Finding the damn thing and getting lost in the belly, that's where the “memorizing the music” concept breaks down.
That's the performance, it's not the hand movements. There are surgeons who are brilliant, and their hands move just fine. They cut and sew, but their hands don't tell them what to do next and how to react when something unexpected happens.
That reminds me of when you said something to the effect of “give someone a repetitive action with a measurable outcome, and eventually the herd will separate in skill, ability.”
I’ve wondered if that will come across as too much focus on talent. That readers will ask, “How do you fix the systemic problems in the world if people truly separate in situations like that?” Well, at least some of it is personal.
Personal Responsibility and The Mission
I’d like to discuss a division of sorts that you present in the book: personal responsibility vs. systemic injustice. Do you see it as a dichotomy?
No. Although I think it’s posed as one. Like all of life, it's one of those continuums, and both play a role. I mentioned the notion of personal responsibility to one of our surgery education residents several years ago. Very bright, interested in various education topics, and part of that was the six competencies of residency.
20 years ago, ACGME decided there should be six competencies that all residents are supposed to acquire. [Professionalism, Patient Care and Procedural Skills, Medical Knowledge, Practice-Based Learning and Improvement, Interpersonal and Communication Skills, and Systems-Based Practice]
I asked her, “I’m curious where in the six competencies does personal responsibility sit?” She looked at me like I had three heads, like she couldn’t believe I didn’t know you never say those words.
You said two things at very different points of reflection on your life that come to mind. The first is “insight trails impact,” and the second is something you were told in an annual HR training session: “impact has nothing to do with intent.” You can feel the continuum of systemic and personal responsibility in those statements. How do you feel the two statements work together?
I’ve thought a lot about that. It really did strike me, as something I’d never thought about, when that lawyer said in a lecture that “impact has nothing to do with intent.” And she said, "If you take nothing else home, that's what you have to remember about harassment." I've never forgotten it, and I've thought a lot about it, because it really is a complicated notion. It’s cause and effect, it’s free will. It’s many things.
Getting a little further into systemic hospital dynamics, you spoke of a corporate hospital ideology of “making bad choices vanish.” Do you think Morbidity and Mortality (M&M) conferences that surgeons routinely have to review bad outcomes is a tool that could be expanded to the corporate side of things?
Most people would probably say yes. In fact hospitals have a similar process they call “root cause analysis” of bad events, and hospital systems are frequent root causes. In M&M we also look at systems, it's just not all we look at. And what is a “system”? There are a billion systems.
Coming up in the heyday of this, do you think young physicians may feel that they are also a mechanism in this system where their personal responsibility is superseded? Do you feel that shift?
That's one of the topics that I've given a lot of thought to lately. I've definitely seen that. I hate to give up on it as irrevocably generational. Many of us seem to feel the same gap, and it seems to be a lot farther down the age chain than you might think. I think the question of personal responsibility is probably a more widespread issue across everybody. And in our profession, it shouldn’t be drifting away.
Do you think the perception of personal responsibility may be affected by the litigious culture in the United States?
I mean, maybe. It's certainly a longstanding trope for doctors to complain that litigious environments make them practice a more paranoid kind of medicine. I'm not sure that's the same as a shift away from accepting personal responsibility. Legal responsibility is just one type, and it's not even the most painful type in some ways. It's a point I try to make in the chapter about accountability. Whether you get held legally accountable or not, still, you live with your failures.
How does this shift play from the patient’s perspective? We all are patients, too, at one time or another.
As my wife reminds me all the time! She's much more passionate on this point than I am. There's a patient in front of you. And you’re going to be that patient someday.
I really enjoyed meditating on the questions of that chapter: What is responsibility vs. accountability? How do you quantify accountability? The way you tie wellness into it. What is wellness?
Right. Are wellness and burnout two sides of one coin? Is there nothing between them? But I'm trying to think what is wellness?
Maybe it’s something like an ocean liner you would call the USS Wellness, where you're all on board going to one destination, and you're going to get to that destination. You have a goal, and you're going to get there. It doesn't matter whether you're in steerage or the first-class cabins; you'll get to the goal.
It's very different than saying you're going to take a Caribbean cruise that starts and ends in Miami. Then whether you're in first class or not will make a big difference to your experience. What I fear is being lost in medicine is the sense that there's a real goal worth pursuing. It’s as if you've given up on getting to London no matter how you have to get there. You're kind of cruising around the Caribbean, asking what was the goal? Why did I do this? Why did I go into medicine? People will do anything, they will run through walls for a goal they think is worth achieving.
In the wider cultural sense, wellness can often feel like a cover for comfort. How do you see the effects of peak wellness play out in the medical profession?
Yeah, you might be onto something. There's some discomfort bubbling up, even in the most orthodox wellness communities. I heard it the other day in one of the chair’s meetings, “Is wellness the right word?” I'm starting to wonder about this. But in one of these meetings, someone said, "Oh, I have the perfect word for it—climate!" And I thought, well, I get what you're saying, but…
“Climate” brings me back to the M&M conferences. You review cases, including errors, poor outcomes, and death. In the book, you reflect on how conflict can arise and blame doled out between colleagues. But at their function, they are a learning tool that should provide support for each other too. To that end, the classification titles of review have changed, but the process is the same?
It's not always been practiced in the most mutually supportive way, but the goal of it is supposed to be improvement, and that's why we do it. We don't do it to air dirty laundry or to suffer. We do it to improve. We can eliminate the language of personal responsibility and the word “error,” but I'm not sure it's changed.
They still have me, the old Neanderthal, up there running the meeting. So, when I talk about the “opportunities for improvement,” there are four categories we score ourselves on at the end of every case. Asking the question, “Was there an opportunity to improve our judgment here?” And the answer is yes. So, there was an error in judgment. Maybe that language matters.
Speaking of language, with each chapter, you start with a quote. Do you collect quotes? How did you choose them?
I do now. That started in 2010 or so because I realized I had to give this huge lecture, the pinnacle of my professional life, the presidential address [for the American Association for Thoracic Surgery]. And I had three years to sweat it out before I had to give it.
So I started thinking, "What am I going to say?" I've always paid attention to things that I read, but I started keeping a list of things that have impressed me or made me think. And now it's massive. That's where I got some of the quotes, but not all.
Do you scribble them down by hand, or keep them in your phone?
I used to keep them in the Notes part of Apple, but I had a crisis with backup, and now they are in OneNote. Some of my own thoughts were also added to the same list, like “impact and intent.” The day after that lecture I wrote down the first couple of lines of what eventually became a short quatrain in the book “On the road back from impact to intent…”
It turns out that a collection of quotes like mine has a name. It’s called a “commonplace.” People have actually published their commonplaces.
Really? I didn’t know that. Maybe that’s next.
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