Passing the Instrument: On Teaching, Letting Go, and Beginning Again

She was forty-three, a schoolteacher, and she had been bleeding for two years. By the time she sat across from our fellow in the examination room, she had already answered the same questions on three different intake forms. She was fluent in the language of yes and no — the language medicine had trained her to speak. 

I sat quietly in the corner of the examination room as our fellow pulled her chair closer, set aside the tablet, and asked simply: Tell me what this has been like for you. 

What followed was twenty minutes I will never forget. The woman described the exhaustion of planning her wardrobe around her bleeding, the classroom lessons interrupted by cramps, the quiet grief of feeling her body had become unreliable. She described it in her own words, her own sequence, her own emotional logic. When she paused, our fellow leaned forward and said: Tell me more. And she did. At the end, our fellow summarized everything she had heard — carefully, without clinical distance — and asked: Is there anything else you want me to know, or any questions you have for me? The patient exhaled. She shook her head, not because there was nothing left, but because, for the first time, she felt that everything had already been received. 

She became, as we had always hoped, our fellows would learn to let patients become, the author of her own story. 

That story went into the operating room with us. It shaped every decision — the urgency, the approach, the conversation with her family afterward. It was not data extracted from a checklist. It was a human life, offered in trust, and received with care. 

In the operating room, we teach our fellows and residents something that appears in no textbook and on no surgical checklist: hold your patient’s hand as she goes to sleep. Under the glaring lights, surrounded by masked strangers and the cold choreography of preparation, we are the only people that patient truly knows. Too often, in those final moments before induction, surgeons are across the room — typing, texting, reviewing images, attending to everything except the person at the center of it all. We ask our trainees to be different. To stand at the patient’s side. To hold her hand until the anesthetic carries her somewhere quiet. It costs nothing. It takes thirty seconds. And it changes everything about what that patient carries into unconsciousness — and what she remembers when she awakens. 

She told us so herself. Weeks later, she sent a card — generous and handwritten — not to the institution, not to the department, but to the fellow who had finally listened, and who had held her hand as the lights of the operating room went dim. She wrote that she had not expected it. That in all her years of navigating the medical system, no one had ever done that. That it was the thing she remembered most. That card lives on my desk still. It is the best argument I know for everything we are trying to teach. 

Teaching a fellow to do that — to resist the seduction of the structured intake screen, to sit with a patient long enough for the real complaint to surface — is among the most difficult and most important things we know how to do. It cannot be demonstrated on a simulator. It cannot be assessed on a written examination. It is transmitted the way all deep knowledge is transmitted: through presence, through example, through the slow accrual of witnessed moments. 

And then, just as they have learned it, they leave. 

We did not arrive at this understanding on our own. We were taught to listen by those who came before us, who showed us that the history is the diagnosis, that the patient will tell you exactly what is wrong if you give her the silence and the safety to do so. We were taught to hold a resectoscope by hands steadier and more experienced than ours, in operating rooms where questions were welcomed and mistakes were instructive rather than punitive. We carry those teachers with us into every case, every teaching moment, every conversation at the scrub sink. We are all, in some sense, an accumulation of those who formed us. 

Which is why this season — late June, the season of departure — carries such particular weight. 

Fellows who arrived uncertain and became surgeons are now gone, carrying what we gave them into hospitals and clinics we may never see. We have watched residents master operative hysteroscopic resectoscopy — watched the precise moment when the mechanics of the resectoscope gave way to genuine fluency, when their hands stopped thinking and started knowing. The delight on their faces in those moments is something a teacher stores up, returns to, holds against harder days. And then we have watched them pack that mastery into their new environments, their new institutions, their own future residents waiting at their own scrub sinks. That is the chain. That is the whole point. 

But letting go is its own discipline, and it does not come naturally to those of us drawn to surgery — a field that selects for control, precision, and the conviction that outcomes can be shaped by will and technical mastery. There is a temptation to keep correcting, to stay at the elbow one rotation too long, to confuse our investment in a trainee with ownership of their development. The finest teachers learn — often by getting it wrong first — that the goal was never to produce a version of themselves, but to cultivate independent surgeons who will surpass them. 

We have not always managed this gracefully. There are fellows we held too tight and fellows we released before they were ready, and we have had to sit with the discomfort of both. Teaching is not a performance of expertise. It is a practice, and like all practices, it includes failure. The willingness to examine that failure honestly — to ask not only how a trainee performed, but how we taught — is what separates evaluation from mere documentation. 

What we know now, after years of this cycle, is that the teachers are changed by the taught. Our fellows have challenged our assumptions about work and rest, about hierarchy and transparency, about what resilience actually requires versus what we merely endured. They have arrived fluent in simulation platforms and robotic systems we are still learning, and they have been patient with our learning in the same way we tried to be patient with theirs. That reciprocity — quiet, rarely named — is one of the great gifts of academic medicine, and one of its best-kept secrets. 

The faces at the scrub sink have changed too, in ways that matter. The field of minimally invasive gynecologic surgery has been shaped profoundly by women surgeons — as teachers, innovators, and mentors — and there is something distinctly powerful about a discipline where the surgeon, the teacher, and the patient so often share an understanding that runs deeper than clinical. That shared experience does not replace rigorous training, but it enriches it in ways we are only beginning to fully name and honor. 

Today’s trainees are shaped by a world unlike the one that formed us. They trained through a pandemic. They carry with them a literacy in mental health, in sustainable practice, in the honest acknowledgment of limitation, that many of us had to acquire the hard way and too late. Teaching them requires that we remain curious about what they know that we don’t. It requires that we examine, with honesty, which aspects of our training culture produced excellence — and which merely produced survivors. 

The doctrine of great teaching has not changed in its bones: show, explain, guide, observe, release. But the texture of it must evolve. This means feedback that is specific, honest, and timely — not a bureaucratic compliance exercise, but an act of genuine respect for someone in the process of becoming. It means modeling equanimity under pressure, knowing that in the hardest moments, our trainees are watching not just our hands but our character. And it means graduating them into a landscape that is harder than the one we entered — shaped by burnout, systemic strain, and the gathering uncertainty of artificial intelligence and workforce shortages — with both the technical excellence and the moral clarity they will need to navigate it. 

There is a word in Japanese — shokunin — that describes a craftsperson devoted wholly to their art, not as a destination to be reached but as a daily practice, humble and lifelong. The teaching surgeon lives something like this. Not in the completion of training cycles, but in the sustained commitment to doing this difficult, human work as well as it can possibly be done — year after year, cohort after cohort, beginning after beginning. 

The silence of late June does not last long. It never does. 

New faces will appear at the scrub sink. New hands will hold laparoscopes and hysteroscopes with the particular tentativeness of those who are learning what their hands can do. Somewhere, in a clinic we will never see, a surgeon we trained is pulling her chair closer to a patient and setting aside her tablet. She is asking: Tell me what this has been like for you. When the patient pauses, she will say: Tell me more. And at the end, she will summarize everything she has heard, and ask if there is anything else the patient wants her to know. The patient — finally, gratefully — will exhale. And later, in the operating room, under lights that can feel merciless and cold, that surgeon will walk to the patient’s side, take her hand, and hold it until sleep comes. The patient will not expect it. She will remember it always. And the room will hold, for a moment, everything that medicine is supposed to be. 

We pass the instrument. And the work continues.