Visual Rhetoric

During one of our group sessions, our mentor and medical school group leader opened up about her personal journey. “Every time I caught a glimpse of it in the mirror, I felt marked, almost branded,” she confided, her voice catching as she spoke directly to us. She explained that the black X drawn on her skin was a functional marker — overlying a tiny, rice-grain sized indicator used by her surgical team to precisely locate the tumor for an upcoming lumpectomy to treat her breast cancer. Even though she was sharing her own experience as a patient, she continued to teach and guide us through that raw, jarring moment — a collision between her clinical expertise and the vulnerability of being on the other side of care.

“I felt dirty,” she told us. “It felt like it was trying to define me. And I hated it.” Her words were a revelation to me that day. They cast a shadow over something I had always viewed as purely clinical: surgical markings. These marks are a routine and necessary step to guide surgeons where to incise, where to reapproximate tissues, and confirm the right body part to be operated on. Surgeon mentors in the past taught me to mark with abandon, as the utility in the OR was on their mind. But her story revealed something I had never considered — that the emotional weight of a mark depends entirely on its context. Hearing from her about the weight of the black ink struck me: How did I not think of this before? Black, a color so often associated with finality and mourning, seemed harsh and unforgiving against the backdrop of her vulnerability. The X, like a wrong answer on an exam, seemed less like a guide and more like a pronouncement — a symbol that marked her body as diseased, as if the cancer itself had inscribed its claim.

For a patient undergoing plastic surgery, markings might symbolize transformation or hope — a carefully laid blueprint for a new beginning. Yet for my mentor, that black X was not a harbinger of change but an unwelcome intrusion, a stark reminder of cancer’s grip on her life. It wasn’t a mark of healing or progress; it was an indictment, a scar before the incision that weighed heavily on her sense of self.

Just as we choose our words with thought and care in medicine to comfort and guide patients, perhaps we should extend that same deliberation to surgical markings. If language, when chosen mindfully, can shape a patient’s experience, then so too might a reimagined approach to these physical marks — transforming them from symbols of disease into signals of hope and healing.

Her story made me think about how we, as future clinicians, might approach these moments differently. The contrast between logically understanding the clinical necessity of the mark and the raw emotion of seeing the mark on her own body brought a new perspective to the patient-physician relationship. Could we frame these marks in a way that emphasizes healing rather than disease? Could we engage patients in conversations about what these symbols mean to them? Perhaps it begins with something as simple as explaining the purpose of the marks in a way that connects them to the larger story of recovery, reframing them as tools of precision and hope rather than reminders of illness. Could we offer patients a choice in the appearance of the markings — the color or shape — giving them a sense of agency in a process that so often feels out of their control? Even temporary marks, like the black X, might feel less alienating if they carried a softer hue or symbolized something empowering rather than stark finality. These small changes could profoundly impact the emotional experience of the patient. By engaging in these conversations, we can ensure that even routine aspects of care honor their humanity.

As I move forward in my medical training, I will carry her story with me. Every time I pick up a skin marker, I will think of her. It’s a reminder that every mark we leave, whether physical or emotional, becomes a part of our patients’ narratives. Our responsibility isn’t just to make those marks with care but to ensure that they signify hope, healing, and humanity.

All identifying information is shared with permission.

This article was originally published by Doximity as an Op-Med on April 21, 2025. It can be read at the following link: https://opmed.doximity.com/articles/her-surgical-mark-was-a-scar-before-the-incision

It sat on my shelf, creased just-so, the slim spine a reminder of what I thought medicine could be — a journey of discovery, resilience, and learning the skill of managing uncertainty. My professor gifted it to me, a nod of encouragement for my journey as both a medical student and a writer: Siddhartha Mukherjee’s The Laws of Medicine. One passage from the book has lingered in my mind, depicting a legendary surgeon, Dr. Castle, whose presence in the OR was nothing short of commanding. His mastery of surgery, so formidable “that he allowed the students to do most of the operating, knowing that he could anticipate their mistakes or correct them swiftly after,” left an indelible mark on those around him.  And then, as if to hint at his humanity outside the OR, Mukherjee snuck in a one-sentence mention of Castle’s weekend retreats to the sea, where he sailed on a vessel aptly named “The Knife.”

On the top of the same bookshelf sat a model of the 1992 America³ sailing yacht, its mast just barely avoided scraping the ceiling. It, unlike the book, was indeed a mere trinket; ornamental as a means to suggest refinement of taste. Years later, I thought back to these bookshelf items while watching the sailboats on the lake from the seventh-floor conference room of my medical school. From that vantage point, I observed the sailors, occasionally glimpsing moments of struggle as they grappled with the lines, trying to tame the luffing sail. It felt like a serendipitous sign.

The imagery of Dr. Castle, both in the OR and his leisure time on the water, fascinated me. This was the archetypal surgeon: skilled, composed, and confident in every facet of his life. It wasn’t long before the seed planted by the story of Dr. Castle took root in my mind. I found myself drawn to the sailing club on the lake, perhaps yearning to give reason to the model yacht holding such a prominent position in my room, or perhaps conflating my desire to be the man written on the pages with the need to be a sailor. Either way, and on a whim, I made the decision to sign up for sailing classes during the summer of medical school.

As I stepped onto the deck of a sailboat for the first time, a sense of apprehension quickly enveloped me; my sense of stability rocked with each small wave. The terminology was entirely foreign – “it’s time to raise the halyard,” “don’t forget to tighten the boom vang,” or “we’re not ready to gybe yet” – but beneath the surface lay an undeniable allure: a promise of childlike adventure, a chance to learn something new without the responsibility to be good at it yet. A fitting promise, as our adult class followed a summer camp of nine- and ten-year olds learning the same things earlier in the day.

In the weeks that followed, I immersed myself in the world of sailing, learning the ropes — quite literally — and embracing the process of learning with a childlike curiosity that I hadn’t felt in years. Sailing was entirely new to me, and with that unfamiliarity came a refreshing sense of freedom. There was no pressure to be an expert or even to be competent — just the joy of discovery. Much like the children in the camp immediately before us, I allowed myself to stumble, make mistakes, and, more importantly, ask questions without inhibition.

When I took that spirit of learning back to medical training, that same sense of awe and wonder became readily apparent in my studies. I found a renewed motivation to push through the challenges and rigors of medical school. As adults, we often shy away from admitting what we don’t know, fearing judgment or embarrassment. This is especially true in medical school. But in this new setting, surrounded by knots, sails, and terminology that made little sense to me at first, I let go. I was no longer concerned with how I appeared to my peers. I tapped into the openness of my inner nine-year-old, who wasn’t afraid to ask why the boom vang needed tightening, what would happen if the sail wasn’t properly trimmed, or, for the 12th time, what the clew was.

In doing so, I rediscovered the beauty of learning like a kid — not burdened by the self-consciousness of adulthood, but driven by an insatiable curiosity. Every mistake was a lesson, every failure an opportunity to understand something new. Like the children who spent their summer mornings mastering the art of tacking and gybing, I approached each challenge with a willingness to fail, eager to see what the next lesson would teach me. In the seriousness of medicine, it’s a lesson that I often neglected.

Learning in this way also brought an unexpected joy. I found myself laughing at my missteps (and almost falling in the water at least once), celebrating small victories like tying a proper knot or gybing without losing control of the boat. With each outing, my skills grew, but more importantly, so did my sense of wonder and appreciation for the learning process itself. That summer of sailing, it turns out, was not just about mastering technique — it was about recapturing the fearless, inquisitive spirit of youth. Bringing that same fearless curiosity back to medical school, I’m reminded that the path to becoming a doctor isn’t just about getting things right; it’s about embracing each challenge as an opportunity to learn and grow, with the wonder and excitement of a child.

This article was originally published by Doximity as an Op-Med on January 21, 2025. It can be read at the following link: https://opmed.doximity.com/articles/learning-the-ropes-of-medicine-literally

This article was reprinted in the Spring 2025 issue of Worcester Medicine. It can be read at the following link: https://issuu.com/wdms/docs/worcestermedicine-spring2025_

Years ago, as a medical student in Boston, I watched a senior surgeon operate on a woman. The surgeon, call him Dr. Castle, was a legend among the surgical residents. About six feet tall, with an imposing, formal manner that made the trainees quake in their clogs, he spoke in a slow, nasal tone that carried the distinct drawl of the South. There was something tensile in his build—more steel wire than iron girder—as if his physique had been built to illustrate the difference between stamina and strength. He began rounds at five every morning, then moved down to the operating theaters in the basement by six fifteen, and worked through the day into the early evening. He spent the weekends sailing near Scituate in a one-mast sloop that he had nicknamed The Knife.

The residents worshiped Castle, not only for the precision of his technique, but also the of the quality of his teaching. Other surgeons may have been kinder, gentler instructors, but the key to castles teaching method was supreme self-confidence. He was so technically adept at surgery—so masterful at his craft—that he allowed the students to do most of the operating, knowing that he could anticipate their mistakes or correct them swiftly after. If a resident nicked an artery during an operation, a lesser surgeon might step in nervously to seal the bleeding vessel. Castle would step back and fold his arms, look quizzically at the resident, and wait for him or her to react. If the stitch came too late, Castle’s hand would reach out, with the speed and precision of a falcon’s talon, to pinch off the bleeding vessel, and he would stitch it himself, shaking his head, as if mumbling to himself, “Too little, too late.” I have never seen senior residents in surgery, grown men and women, with six or eight years of operating experience, so deflated by the swaying of a human head.

Siddhartha Mukherjee, “The Laws of Medicine”

The afternoon air had a palpable starchiness to it, cool and damp but still thick. As I arrived at the airport around 3 p.m., a bright haze lingered in the sky. Only a few other people were present as my brother and I walked towards the hangar: a flight instructor and her student debriefing from their lesson, another pilot shuffling around his plane filling the fuel tanks, and 5 or 6 other planes sitting parked, scattered along the ramp. Inside the hangar, the afternoon light streamed in through the gaps of the corrugated metal construction. The rusty wheels groaned in protest as the large hangar door raised, their grating screech reminiscent of nails on a chalkboard. With the door open to the beautiful vista outside, I set my bag on the floor and pulled out the checklist. Stained blue from the occasional drips of aviation fuel, this small piece of paper was my Bible.

My training as a pilot means that I’ve become an ardent supporter of checklists, and I hope, an effective user of them. As a medical student, I’ve had the privilege of observing many different surgical teams, and while my experience in the OR is still growing, my background as a pilot has given me a unique perspective on the value of checklists. I’ve noticed that in medicine, some of my colleagues seem to suffer from checklist fatigue – a very real challenge that I believe stems from a misunderstanding of what checklists are truly meant to accomplish. The purpose of my checklist as a pilot is to: (1) help correctly configure the aircraft, consistently; (2) mitigate human factors by assuming humans are imperfect; and (3) prompt the pilot to brief the tasks that do require adaptability and judgment.

These days, I walk around the plane scanning the leading edge of the wing with my eyes and running my hand over the rivets and screws that hold it together, often without ever glancing at the physical paper. I’ve gotten so used to the flow of my pre-flight checks that I don’t need anything to remind myself what to do. However, it was hammered into me as a student pilot that mental flows like this should always be backed up with the physical checklist — just in case. It’s become a habit now, that after the exterior pre-flight, I pause and read each item in my checklist out loud. Crucially, as I read each item aloud, I actively recall inspecting it.

For example, one of the lines reads: “Tires / Brakes / Struts.” It’s easy to simply read it off rotely, without fully being aware that you’ve checked each separate item. I’m certainly guilty of this too. Now, as a more experienced pilot, I realize that doing so is a disservice to myself, my passengers, the people on the ground without any control of the matter, and all those who place their trust in us as pilots.

On that cool afternoon day, as I read that line, I thought to myself:

• “Did I press hard on the tire to feel its pressure and rebound?” I remembered pushing down on the tire and looking at the treads and seeing that, while the front tire was well-worn, it would suffice for a few more months before needing replacement.
• “Did I move the wheel ever so slightly to see the gap between the brake pads and the rotor?” I remembered looking at the pads and the rotor, not seeing any grooves from contaminants that might have gotten lodged in between.
• “Did I look at the struts to see that there was plenty of space for suspension travel?” I remembered seeing the characteristic wear of the strut sliding up and down, absorbing all of the previous landings. It was clearly not bottoming out its range of motion.

This mental exercise took altogether less than a second. It’s a backup that gives me a chance to correct a deficiency while still on the ground. It’s a reminder that the checklist is not the physical piece of paper, but instead it is the act of actively recalling that each item was inspected or set correctly. I fully believe that this attitude contributes greatly to my safety in the air.

The same applies for medicine. Checklists must be specific; to each procedure, or at least specific to the specialty. Checklists must be sparse, only including the most critical elements that cannot be missed. Checklists should prompt the team to dig deeper where required, such as for particular procedures that need certain post-operative considerations or pose a greater risk of a sharps mishap. Checklists must encourage the team to brief the complexities where judgment is necessary. And perhaps most importantly, teams should be trained to use checklists effectively, starting with the pilot-in-command: the surgeon.

My hope is that when you come across a bad checklist, you can take charge to customize the checklist to work for you. Perhaps you can remove unnecessary items, or adjust the verbiage to say “Imaging available / As needed” instead of a yes/no checkbox, or create different checklists that include imaging only in procedures that actually require it. The success of my flights has reinforced my attitude toward checklists: I see them as tools for ensuring consistency, safety, and clarity, not as burdens or boxes to check. This mindset allows me to embrace their purpose and see beyond their limitations. With a well-designed checklist, and the right mindset, you’re not just following a procedure; you’re enhancing your ability to provide the best care possible in all situations.

While checklists are invaluable for ensuring consistency and covering critical elements, they are only part of the equation. Equally important is the role of briefings, which complement checklists by allowing space for the nuances and complexities that require professional judgment. I want to emphasize an important distinction in terminology. A “briefing” is different from a “checklist.” A checklist might prompt you to do a briefing, but the briefing enables you to consider the specifics of the particular scenario. It allows you to bring in that clinical judgment that can be lacking in surgical checklists. For example, as I’m sitting at the threshold of the runway, my pre-departure briefing prompts me to consider what obstacles will be ahead, what radio frequencies I will use to communicate to air traffic control, and what heading we will need to fly to get on course toward the destination. I think through the specifics that aren’t accounted for in a checklist.

This approach isn’t limited to the cockpit. Whether managing a flight or diagnosing a patient, the discipline of checking everything thoroughly – and questioning anything that seems off – is crucial. In both fields, safety and success depend on recognizing that the checklist is an essential tool, but not a substitute for critical thinking, human judgment, or intuition.

The checklist is more than just a series of rote tasks; it’s a physical manifestation of a core philosophy in aviation: humans are not infallible. Aviation embraces a systematic approach that acknowledges our human limitations and proactively builds in safeguards to reduce errors. Whether it’s a checklist, a pre-departure briefing, or simply reading things aloud, these are simple tools that help me fly safely. This philosophy recognizes that no matter how experienced we are, we all have blind spots and moments of complacency. By transferring this mindset to medicine, where the stakes are equally high, we can create systems that support clinical judgment, prevent oversights, and ultimately improve patient outcomes. Embracing the aviation approach in medicine means accepting that even experts need checklists, and that doing so is a strength, not a weakness.

This article was originally published by Doximity as an Op-Med on November 4, 2024. It can be read at the following link: https://opmed.doximity.com/articles/pilots-love-checklists-so-why-don-t-surgeons