The operating room has a way of exposing the difference between knowing something, understanding it, and being able to use it when the usual options disappear.
In Tanzania, we performed open reduction and internal fixation of a proximal humerus fracture using a distal tibia locking plate.
It was not the implant we would ordinarily choose for a fracture through the surgical neck of the humerus. It was simply the plate available that best matched the shape and fixation demands of the fracture.
In the United States, an operation like this usually begins with a manufacturer-specific system. We can review a catalog of proximal humerus plates, choose among different lengths and configurations, and expect a tray containing screws designed to work with that particular plate. In Tanzania, we were sometimes handed an assortment of sterile implants and had to determine what fit, what was structurally sound, and what could be modified safely.
There was no fluoroscopy in the operating room. We reduced the fracture, positioned the plate, selected compatible screws from a limited supply, and completed the operation without the real-time imaging that normally confirms each step. We did not see the final radiograph until the patient had left the room.
The same process played out during a clavicle fracture. We cut down a pelvic reconstruction plate until it had eight holes, then bent it in the coronal plane to reproduce the contour of a clavicle plate we might have opened directly from a sterile package in the United States. If the screw we needed was 22 millimeters and the shortest available was 30, the solution could involve cutting the screw to length with a wire cutter. Every choice required attention not only to size but to whether the screw and plate were actually compatible, particularly when using locking fixation.
It felt less like selecting products and more like carpentry.
The experience clarified something that years of training had been teaching me more gradually: equipment can make an operation more efficient, reproducible, and safe, but it cannot replace an understanding of the problem. When the catalog disappears, the underlying principles have to remain.
The operating room destroys vague understanding
It is possible to feel knowledgeable in a classroom. Surgery is less accommodating.
You cannot bluff anatomy or speak confidently enough to make the correct tissue plane appear. A memorized list of indications does not choose an operation for you. When the anatomy is distorted, the imaging is imperfect, or the preferred implant is unavailable, what remains is the quality of your understanding.
That is why surgical questions often sound deceptively basic. What is preventing motion? Where is the center of rotation? Which structure is producing the deformity? What must be restored, and what can safely be accepted?
In Tanzania, those were not seminar questions. Without fluoroscopy, there was no image confirming each decision before we moved to the next one. We had to reason from the fracture, the anatomy in front of us, and the fixation we could achieve.
Those questions force a move from description to mechanism. Knowing that a certain plate is designed for the proximal humerus is useful. Understanding what the plate must accomplish—maintaining reduction, resisting deforming forces, protecting the biology of the fracture, and allowing eventual function—is more durable.
During residency at Northwell and hand fellowship at Michigan, I learned to distrust familiarity as a proxy for understanding. Having seen a procedure is not the same as being able to explain it. Being able to explain it is not the same as being able to adapt it when the conditions change.
Difficult things become manageable when they become specific
Early in training, an operation can look like one enormous, continuous act. The attending seems to move from incision to closure with a fluency that feels almost innate. From the other side of the table, it is easy to conclude that some people simply “have it.”
Eventually, the operation resolves into smaller decisions: positioning, exposure, identification, reduction, fixation, tension, closure, and rehabilitation. Each contains a different problem. Once the problems can be named, they can be practiced.
“Get better at surgery” is not an actionable goal. Improve instrument handling in a deep field. Anticipate the next three steps. Place the guidewire correctly on the first pass. Recognize when a tendon transfer has the appropriate tension. Know which part of the plan cannot be compromised and which part can change.
This is now how I approach difficult work outside the operating room. Large ambitions—becoming a better writer, building a company, learning to fly—are emotionally appealing but operationally weak. Progress begins when the ambition is translated into the next observable skill.
Expertise looks mysterious from a distance because we see the finished performance. Up close, it is usually a collection of specific abilities, acquired unevenly and assembled over time.
Repetition becomes useful when it contains feedback: form a plan, perform, identify the difference between what you expected and what occurred, and adjust the next attempt. Without that loop, experience can reinforce habit as easily as it builds skill.
Teaching became another test of the same process. As a chief resident and later as a fellow, I found that if I could not explain the problem, what we were trying to restore, and why the plan should work, then my own understanding was probably less complete than I thought.
Reliability and judgment matter more than flashes of brilliance
Surgical culture naturally admires technical brilliance. The longer I trained, the more I understood the value of a less glamorous trait: consistency.
One of the most useful standards I encountered was simple—be flat and reliable. Be prepared on ordinary days, not only when the case is interesting. Communicate before someone has to ask. Know the relevant details. Arrive with a plan. Follow through after the visible part of the work is over.
Patients do not need occasional access to the best version of their surgeon. They need a dependable one every time. Reviewing the imaging again, confirming the equipment, anticipating the postoperative problem, and returning the call are not the dramatic parts of surgery. They create the conditions in which technical ability can matter.
Consistency also supports judgment. Trainees often imagine that experts feel certain. They generally do not. They are better at identifying which uncertainties matter, which risks can be reduced, and when enough information exists to make a decision.
That was the real tension in Tanzania. We had to adapt, but adaptation could not become improvisation without discipline. A plate that could be made to fit was not automatically safe to use. A screw of the correct length was not useful if it was incompatible with the plate. Limited resources increased the importance of preparation and first-principles understanding; they did not lower the standard of thought.
The operation exists for the patient. The patient does not exist to validate the ingenuity of the operation.
What remained when the usual tools disappeared
After five years of orthopaedic residency and a year of hand fellowship, I do not think the central lesson of surgical training was endurance, although endurance was required. It was not confidence, although confidence grew. It was learning how to remain engaged when the answer was not immediately clear.
In Tanzania, we still needed the same things we would have needed in any operating room: a clear understanding of the injury, stable fixation, respect for biology, attention to detail, and a plan that made sense for the patient’s actual circumstances. The tools changed. The responsibility did not.
That distinction has stayed with me. When I approach a new field now—writing, technology, education, or anything else that initially feels opaque—I am less likely to interpret confusion as evidence that I do not belong. I try to identify the principles, break the problem into parts, seek useful feedback, and keep working.