Pale, colorless skin transected by a web of blotchy purple lines. The patient on the operating table looked like he was already dead. The monitor displaying his vital signs didn’t look much better.

“I can’t give him any anesthesia,” the anesthesiologist said, matter of factly. “Just a little muscle relaxant.”

“I understand,” I replied. With his hold on life so tenuous, even a little anesthesia would be enough to make his heart stop. “I’ll get you some surgical stimulation in a minute.”

The nurse slashed brown sterile soap onto the abdomen. The surgical tech and I flapped a blue drape over the patient like stage magicians.

“Knife,” I called.

Normally we would engage in a whole list of surgical niceties before starting an operation. Things like counting all the instruments, confirming the patient’s identity and the procedure we were performing . . . giving anesthesia. But this patient did not have the time for niceties.

Taking the scalpel, I made a confident cut down the abdomen’s center from just below the sternum to just above the pelvic bone.

Confident?

“Confident” might be a word that needs some explanation in this situation. The patient in question had suffered a ruptured abdominal aortic aneurysm. The main artery from his heart to his lower body (the aorta) had developed a balloon-like dilation. And just like any balloon, when it gets too large, it will burst.

When this aneurysm burst, each heartbeat pumped vital blood directly into the abdominal cavity. The patient was bleeding to death. This is a severe injury, and 80% of people who suffer it will die. I was fully aware of this fact and had been straightforward about it with his wife before the surgery.

“Will he survive?” she asked in a small voice, afraid she already knew the answer.

“The odds are against him,” I said. “I promise, I’ll do my best.”

She gave me a withering look, clearly disappointed by my answer, and by extension discontented with me. But she signed the consent for the surgery.

So how is it that I could use the word “confident” when I was facing an operation with such a high risk of mortality?

What is confidence?

If you define confidence as the ability to determine the situation’s outcome, then I should not have felt confident at all. But that is not how a surgeon defines confidence. Surgeons see confidence as the ability to control their response to the situation. I was confident in my ability to handle myself. Even in the face of such dismal odds, a surgeon can maintain his confidence because he knows that he can take control of himself in the situation. I knew I could bring all my skills to bear and give this man his only shot at continuing to breathe come sunrise.

How to Look at Challenging Situations

A surgeon looks at a situation like this in three parts: the event that happened, the surgeon’s response, and the outcome. Only one of these is entirely within the surgeon’s control.

Event + Response = Outcome

Event

The event is something that is outside of our control. In this case, it is the ruptured aorta. But it’s many other things as well. It includes the patient’s other medical problems, the time between the rupture and arriving in the Emergency Room, and the ER’s handling of the patient before I got the call. These factors all play a role in the ultimate outcome, and they are outside of my control. Since I can’t control any of those things, there is nothing to be gained by wasting energy wishing they were different.

Response

The second part is my response. My reaction is the one piece of the equation that is in my control. In this case, I have the skills and experience to deal with this disaster. I needed to keep my cool and work on the problem. All I could do was keep thinking, keep working, and try to stay one step ahead of the dilemma. My response to the event is 100% in my control. So that is where I focus my effort.

Outcome

The last part is the outcome. The outcome is dependent on a lot of factors outside of my control, and also my response. Could I ensure a successful outcome for this surgery based solely on my actions? No. But failing to respond well would certainly doom this man.

The surgeon’s confidence does not come from knowing he/she can control the event’s outcome; it comes from knowing he or she can control his or her response.

To be Confident, Redefine Success

Confidence comes from defining success in terms you control. In this operation, I could bring all my skills and focus to bear. I could call on my experience with cases like this in the past. I could play a good game, even with the odds of victory stacked against me.

Another way to think about this is in a sports analogy. Imagine a basketball player who goes out and plays her best game. She sets a new personal scoring record as well as collecting rebounds and assisting her teammates. It is her individual best game ever.

But what if the team loses? Does that negate all that she accomplished? It shouldn’t. She took control of how she played. She prepared for the contest and worked hard. She managed what was within her power. But there are nine other players on the court. Our player can’t control how well prepared those other nine players are or how hard they worked. She can only be responsible for her own play. If she did that well — which she did — then she should chalk this one up as a personal victory regardless of the final score.

My confidence came from knowing I could play my game well. So that is what I did. I worked quickly and efficiently to open the abdomen and move the intestines out of the way. I communicated with my assistant about what I needed him to do and what I would do next. Then I identified the aorta and followed the ballooned segment up to its neck, where it narrowed to a normal caliber. I opened the tissue over this neck, being careful not to injure the renal vein or the inferior mesenteric vein. One more problem would be one too many for this man to survive.

Meanwhile, Back at the Operation

Once I had a healthy segment of the artery isolated, I placed a vascular clamp across it and occluded the vessel between the heart and the hole in the artery. Time was of the essence, and I had done all this as quickly as possible.

“Clamped,” I called out in a loud, clear voice to inform everyone in the room.

I looked up at the monitor. The patient wasn’t any better, but they weren’t any worse. I had bought the anesthesia doctor the opportunity to transfuse the patient and catch up, but I had done so at the price of cutting off blood flow to the lower half of the patient’s body.

I felt a glimmer of hope.

While anesthesia worked to stabilize the patient, my assistant and I switched gears from working as quickly as possible to set ourselves up to do a more careful repair. We suctioned blood out of the abdomen to circulate through a machine that would wash it and transfuse the patient with his own blood. We set up retractors to hold the abdominal organs out of the way so I could work on the aorta in the space behind the abdominal cavity.

I replaced the damaged segment of the artery with an artificial graft and restored blood flow to the rest of the body. As I reopened the vessel, the anesthesiologist and I watched the monitor to see how the patient would respond. It certainly wasn’t great, but it was better.

My assistant and I removed all the instruments, closed the abdomen, and transferred the patient to the ICU.

“He’s not out of the woods, yet,” I told his wife in the waiting room. “But I’m feeling optimistic.”

A Surgeon’s Confidence

Surgeons draw their confidence, not from knowing they can control the situation’s outcome but from knowing they can maintain themselves in difficult circumstances. That is what surgeons train and practice to do, govern themselves. To play well even when it’s the fourth quarter and the score is against us.

Confidence does come from victories and racking up wins. But true, deep confidence comes from not achieving your goal and still knowing that you did well. It comes from measuring your personal performance, not looking at the final score. It requires humility — the kind of humility that comes from a realistic assessment of your abilities and limitations. Then you can measure your response against how well you could have done and know if you succeeded or not.

Real confidence comes from knowing you handled yourself as well as you could, regardless of the outcome. Trust me on this, I know. I tell this story because it was a success, but not all of my cases have ended well. I have had my share of surgeries with tragic outcomes. But knowing that I did the best I could is the consolation that makes it possible for me to go back to the operating room and do it all again.

True Confidence Come From Controlling Yourself

Confidence is moving from the need to control the outcome to focusing on managing yourself. In any challenge, there are three parts. The event is outside your control. Your response to that event is within your control. And the outcome is determined in part by your response. Even if you respond well, that does not guarantee success. But to react poorly will ensure failure.

Focus on your response. If you conduct yourself to the best of your ability, you can build confidence even in the face of defeat. Because real confidence comes from knowing you can control yourself in the situation and not from knowing you can control the outcome.

“I golf three or four times a week,” this patient told me more than a year after his surgery. “Ya, I pretty much do whatever I want.”

“I’m so glad to hear that.”

“I just can’t thank you enough,” he said as he shook my hand in both of his.

His wife still had that disappointed look on her face. I don’t think she has forgiven me for not telling her what she wanted to hear before the surgery.