There is a risk every surgeon understands but rarely states directly. Not complications, not litigation. The loss of the hands.
For a microsurgeon, the hands are not an instrument. They are everything. Losing that is not a career transition. It is a loss of function at the core of your professional identity.
In September 2023, I was diagnosed with Psoriatic Arthritis.
By 2024, I had stopped operating.
The decline surgeons rationalize.
None of it was expected. The speed least of all.
Psoriatic Arthritis is not supposed to present that way. You anticipate a slow build, something you can track and adjust to. Instead: rapid onset of stiffness, swelling in the PIP joints, and pain spreading quickly across multiple joints. The fatigue was its own thing, a bone-deep exhaustion, like every reserve had been emptied at once. There was no pattern to it. Some days were manageable. Others I could barely function, with no telling what I would wake up with.
The rheumatologic findings confirmed what I was already feeling. Active, severe psoriatic arthritis with synovitis.
It was not only the joints. I developed loss of sensation in my index fingertips. Fine control of suture placement was compromised. That matters when you are using 9-0 nylon to anastomose flap vessels to the internal mammary vessels. Sutures finer than a human hair. Anastomoses with no acceptable margin for tremor or imprecision.
On good days, I was still good enough. Likely as good as most surgeons.
That sentence contains the problem. The standard for this work is not most surgeons. The benchmark was my own standard on my best day, and I was no longer meeting it consistently. On the better days I could compensate, adjust, work around what the disease was doing to my hands. Compensation has a ceiling. I was getting closer to it than I wanted to admit.
When compensation ran out.
One night on call, I could not operate safely. The workarounds were gone.
I called a partner. They came in. The patient was treated appropriately. No external signal that anything was wrong.
The internal standard had been crossed.
Patient safety is binary. You are either operating at the level required, or you are not. There is no acceptable gray zone. I had always believed that, but I did not expect to be the one it applied to.
That was the end of my operative career.
What the system did while I was navigating all of this.
PRMA continued to deliver consistent outcomes, not because of any individual surgeon but because of the system.
Standardized pathways. Reproducible processes. Quality metrics that did not depend on my presence in the room to function. The infrastructure we had spent years building did exactly as it was designed to do.
The confirmation was not gratifying in the way I might have expected. It was clarifying. Losing a high-volume microsurgeon mid-career is a real blow to any practice. The system absorbed it and continued to deliver at the highest level, not because individuals do not matter, but because the system was built by and around surgical expertise from the beginning. That is the point of building it.
A surgeon influences one patient at a time. A system that delivers consistent care reaches every patient who enters it. That is not a consolation. It is the primary objective.
What becoming a patient taught me.
I also became a patient in the full sense. I navigated a diagnosis I did not ask for. I made decisions under uncertainty. I tried to understand options that were not always clearly explained. I felt the specific loneliness of being a physician who knows enough to be frightened but not enough to be certain.
The treatment history runs through Taltz, Remicade, Bimzelx, and Tremfya, each switched out after it failed to produce a meaningful response. I currently manage the disease with Rinvoq. Rinvoq carries a known thrombosis risk, and a history of DVTs and pulmonary emboli from 2010 puts me in a higher-risk group, so I take anticoagulation alongside it as a precaution.
Every belief I hold about access, shared decision-making, and patient navigation continues to be confirmed by my experience, not because I encountered a broken system but because I live the ordinary friction every patient encounters, felt from the other side. It is the same friction I built Breast Advocate® and Toliman Health™ to address: the gap between what patients are told and what they actually need to decide well.
The patient in front of me was me. That does not change what I built. It clarifies why I built it.
The north star has not moved.
The forced transition from operating surgeon to physician executive was not the plan, at least not this soon. It produced something the plan could not have: a leader who helped build the system, tested it under the hardest possible conditions, and lived the patient experience from the inside.
I now lead Clinical Operations at the Advanced Reconstructive Surgery Alliance (ARSA), working to extend a physician-led, outcomes-driven approach to reconstructive surgery across multiple markets. Quality metrics that travel across the network. Physician recruitment designed to identify future leaders. Specialty program expansion driven by outcomes evidence.
When I founded Toliman Health™, I named it after a star. Toliman is one of the closest stars to our own, bright enough to steer by. That was the idea: a fixed point a patient can navigate toward when the path through a diagnosis is anything but clear. I did not expect to need that bearing myself. The work has not changed direction since. The certainty behind it has.
Build for the moment you will not be in the room. Eventually, one way or another, you won’t be.
Related reading: The Wall I Kept Hitting: Why Every Venture Started the Same Way →