The Test of Excellence

By Steve Paulus, DO

I remember my first clinical rotation at the start of my third year of Osteopathic medical school as if it were yesterday. I felt a cacophony of divergent emotions: fear mixed with excitement, anticipation blended with apprehension, and confidence juxtaposed with inexperience.

I chose a rural Family Practice rotation in a small town in central Wyoming, far from the flat farmlands of Iowa where I attended medical school. This remote town of 3000 people had the only hospital within a 100 mile radius. This hospital was a 20 bed county facility staffed by two DO family physicians, a DO general internist, and an MD general surgeon. Several sub-specialists would run additional clinics once or twice a month to treat medical conditions that fell outside of the skills of the local doctors. Complicated cases were shipped via air ambulance to Salt Lake City, the closest urban referral center.

I was given the tremendous opportunity to assist in the care of every patient admitted to hospital. I worked every day in the private offices of the family doctors, assisted in each surgery performed by the general surgeon and the itinerant surgical sub specialists, attended all births, and saw every case that came into the emergency room during the evenings.

As a student, it was exciting to see people with a wide variety of diseases and to be trusted by the attending physician (or teacher) to assist in the care of their patients. I was filled with questions and devoid of experience. I didn’t know the good from the bad or the proficient from the incompetent.

On my second day, I got the chance to assist the general surgeon in an emergency appendectomy. Dr. Jed Smith (known as J. D. to the other doctors) was a talkative, philosophic, and eager teacher. He looked like a cowboy and acted like a gunslinger. When he wasn’t wearing his green surgical scrubs, he was dressed in blue jeans, pointy cowboy boots, and a well worn Stetson hat. He had a loaded rifle on the gun rack in his pickup truck and spent his time away from the hospital riding horses and tending cattle at his ranch at the edge of town. While we waited in the doctor’s lounge for the patient to be prepped for surgery I asked him an innocent and profoundly simple question, “How can I tell a good surgeon from a bad surgeon?” His answer grabbed my attention and proved to be prophetic. He confidently replied, “They must pass the Test of Excellence . . . A good surgeon will make the operation look effortless. He will make it look so easy that you will believe that you could do it.”

Ironically, Dr. Smith labored and struggled throughout the entire operation. There were no surprises or complications with the appendectomy, but everything he did was arduous. I didn’t have much surgical experience, so I initially thought all surgeries must involve a lot of cursing, frustration, and irritation.

I subsequently assisted on nearly 25 surgeries with Dr. Smith and every case was the same. The room was filled with turmoil and aggravation. He was never able to fit his own definition of excellence. Even though I was inexperienced, I wasn’t naïve. I witnessed some unnecessary disasters, I felt disgusted. It was no surprise that many of his patients had post-operative complications.

Later in my third year, while at my primary teaching hospital in a major medical center, I had the great fortune to work with many truly gifted surgeons. These men and women made every operation look easy. With each operation they passed Dr. Smith’s “Test of Excellence” and I thus was convinced, in the moment, that I could perform any surgery.

Since that clinical rotation in 1983, I have used the “Test of Excellence” as a guiding principle in my life. Over the years, I have applied this template for quality to many diverse situations in my interactions with people. It doesn’t matter whether the individual is a physician, cook, auto mechanic, gardener, dancer, fisherman, etc. If that person makes what they do look so easy, where I think I could do it, then I know they have the brilliance and superiority of skill that makes them a gifted authority.

I believe that A. T. Still could pass the “Test of Excellence.” But not at every point of his life—he grew into excellence, it wasn’t freely given to him. If I could have just one moment with Dr. Still, I would choose to meet him at age 64: confident, defiant, deeply intuitive, inquisitive, and highly gifted. This was the Dr. Still ready to reform American Medicine. This was the Dr. Still filled with life experience, eager to educate those ready learn.