“First, I’m going to knock you out, shave your belly, and scrub it cleaner than it’s ever been before. Then I’m going to cut you open with the sharpest knife I’ve got. After a bit of digging, I’m going to burn your guts apart with a hot iron. Then before I let you go, I’m going to pull it all back together with string, so my hard work doesn’t fall out when you try to stand up—which you won’t actually be able to do for a couple days. I promise you’ll mostly feel better later, and you probably won’t die.”

Faced with this sales pitch, or as we call it in the industry, “informed consent,” many people might think a bit harder before embracing the surgical route for treatment. Of course, that isn’t exactly how attending surgeons say it (I’ve been told I still have a bit of polishing to do when it comes to my bedside manner). Frankly, as a third-year medical student in the infancy of a would-be surgical career, this is what many of the operations seem like up close, though. I’ve been in the operating room for perhaps a dozen operations; some have been emergent, meaning they need to happen as soon as possible or risk serious consequences, and some have been carefully planned out and prepared for months. Regardless of the context, the reality is that surgery is brutal. This was something I wasn’t completely prepared for in my first weeks in the O.R., and that reality has prompted me, more than anything else, to deeply consider the consequences of the treatments we administer.

I still retain a sense of awe and anxiety when I walk into the operating room, or “operating theater,” to give a nod to the old masters. I think the latter appellation is often more fitting, because when everything goes smoothly, an operation can be carried out with the efficiency and precision of a well-rehearsed performance. The student enters back-stage, hands soaking wet, awkwardly pushing the door open with their shoulder or butt cheek, depending on how ambitious they’re feeling that morning. The scrub tech and nurse have a costume waiting: sterile gloves that never go on quite right, and a gown that is often just a little too big or too small. That awkwardness is only highlighted when the surgeon arrives, executing their entry with efficiency and intentionality only gained by years of training. With the surgeon comes an air of expectation that everything will go according to plan, nothing out of place. Ideally everyone knows their role and responsibilities (yes, even the student), and performs them without prompting. Then we commence with the cutting, burning, stabbing, sewing, and stapling. Throughout all of this, the audience, our patient, slumbers quietly, hopefully enjoying the dreams promised by the anesthesiologist. The production eventually comes together to achieve a risk-controlled injury, one which the surgeon has judged to be less harmful than the underlying pathology to be treated.

And that’s it, that’s what I thought surgery was.

Despite the implications of the somewhat cavalier consenting process we began with, the brutality comes after the theater and after our patient wakes up with a few extra holes, and minus a few other things. If all goes well, there will be a short post-operative period and they will be out of the hospital and back home safely. But there are a few villains in the story: the sometimes unanticipated, but always dreaded, “complications,” let alone the operation itself. Recovery may involve months of rehabilitation, and despite our best efforts, patients’ lives can be severely altered forever. They may be in intractable pain or be unable to perform the simple tasks they used to enjoy — enjoyable tasks like eating solid food, putting on their clothes in the morning, or wiping their own butt. For students, textbooks do little to prepare us to confront this reality.

In my head, I know that it’s best to leave an infected wound open to allow for proper healing and resolution of the infection. I know the stages of wound-healing, the dosages for antibiotics, and the types of bacteria to be worried about. But walking into a patient’s room, pulling the sheet off their abdomen, and discovering a basketball-sized hole where their bellybutton should be, can be a little disconcerting (even when you were the one who left it that way). I’ve witnessed poor outcomes and difficult treatments for seriously ill family members before; but it feels different being part of the cause of someone’s pain, regardless of how we rationalize it. I may be playing my part as the naïve medical student, but there’s a distinct sense of guilt seeing a patient the day after surgery and changing the bandage on a cut that I made. And sometimes a surgical incision will come apart or get so infected that we have to take a patient back to operating room, cut out more of their wasted flesh, wash them out, and put in a few more drain holes just to manage the aftermath of our efforts. I’ve experienced something like this once so far, and the sense of ownership over that patient’s pain was inescapable. I don’t know if the guilt fades with time, or you just get used to it, but it has changed how I think about medicine.

Surgery continues to fascinate me, but I’m also learning to be wary of it, and to respect the cost. For the first time I’m seeing the gray area, the fuzzing of lines between treatment and illness, medicine and disease. These dichotomies aren’t exclusive to the surgical world: Doctors and patients in many specialties are constantly making choices between one bad thing and another, possibly less-bad thing. It’s nothing like our board exams; evaluating questions on a computer screen, choosing a treatment course, and moving on to the next one without another thought. The human cost is a real thing, and something physicians parlay every day. Like most third-year students, I think about this as I consider my future in medicine and contemplate what I’m willing to come face-to-face with every day. Surgery has simply been the most jarring because of the acuity with which problems are addressed and the dramatic way in which they’re dealt with. It’s not a slow poisoning of an invasive tumor, but a deliberate, bloody excision, often taking healthy tissue along with the diseased. The means may be elaborate and couched in pageantry, but the cost to the patient goes far beyond the curtain call of the operating theater.