Behind the Mask

By Peter Stoler

THE MAKING OF A SURGEON by William A. Nolen, M.D. 269 pages. Random House. $6.95.

Even the cockiest intern can lose his nerve the first time he cuts open a live human being. "It went horribly," admits Dr. William Nolen, recalling his own baptism, a routine appendectomy, at Manhattan's Bellevue Hospital 17 years ago. "My knot-tying proficiency had melted away. My fingers, greasy with fat, simply would not perform. My ties slipped off the vessels, the sutures snapped in my fingers; at one point I even managed to tie the end of my rubber glove into the wound."

Fortunately, both doctor and patient survived. At 42, Nolen is now chief of surgery at Meeker County Hospital in Litchfield, Minn. But The Making of a Surgeon is no tale of easy triumph --or comfort to people headed for the hospital. The point of this impressively honest memoir is that surgeons learn by doing, and patients often suffer in the process. As Nolen tells it, trial and error is still the only way to develop the skill and gall that a first-rate surgeon requires.

Ring of Truth. Peeling off the surgical mask, Nolen reveals the semi-deity behind it as a bundle of human wiles and failings. In passages that entertain as well as shock, he tells how he and his colleagues frightened patients' families into giving blood--not to save their loved ones, but to fill the bank for others. He explains why so few patients were recorded as having died on the operating table: to avoid paper work, the doctors quietly sewed up the corpses and let them "die" after surgery.

Nolen makes no secret of his contempt for surgeons who perform unnecessary operations because insurance companies pay more for major surgery than they do for diagnostic procedures. And he frankly describes a surgeon's key motive: impatience. "The guy that goes into surgery," he writes, is the fellow who doesn't want to sit around waiting for results. He "wants the quick cure of the scalpel, not the slow cure of a pill." Even the scalpel can be too slow. "For God's sake, will you cut?" asked the surgeon who supervised No-len's first timid incision. "At the rate you're going, we won't be into the abdomen for another four hours."

What gives Nolen's book an unmistakable ring of truth is his unsparing criticism of himself. He offers no excuses as he tells how he lost his temper with a patient who refused to let him cut into a vein for a transfusion; he assumes full responsibility for an operation that resulted in the death of another. Nor does he hide his pride in his growing proficiency. "A surgeon needs conceit," he says. "He needs it to sustain him in trying moments when he's battered by the doubts and uncertainties that are part of the practice of medicine." Nolen, who earned every bit of it, is plainly grateful for his conceit. His patients should be, too.

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