"I'm basically a nice guy--I don't yell, I don't throw things."

John Marshall is in the first year of a three-year plastic surgery fellowship in Texas, which follows five years of general surgery residency. He is a thirty-seven year old married man with two children.

There's a book called The House of God, which was written a long time ago. A character in the book kept saying that these postcards would come in the mail and they'd say: "If you want to go to medical school, fill this out and send it back." And: "If you want to go to residency, fill this out and send it back." My wife and I joke that that's what happened. But that is a joke, because I worked hard to get where I am.

Before and during nursing school I worked for two different ambulance companies, and I worked as a house orderly, and I worked for two different ERs as an on-call tech. I actually started from the very bottom, from central supply in Tucson. I was a cast room tech for a while. I was a deeder, which is the person who assists the pathologist with autopsies.

Six, maybe nine, weeks into nursing school I knew I wanted to go further, but I went ahead and finished. It was a two-year associate degree program. The first thing I did when I got out was start an ICU internship in Berkeley at Herrick Hospital, a ten week training program. From there I worked nights in the ICU-CCU. After about six months I transferred down to the ER because I would have more time to study.

This was a time when it was difficult to get into medical school. Being bull-headed, I pressed on, taking pre-med classes at the community college in Napa while my wife, who was an LVN, finished getting her R.N. Then I got accepted to do undergrad at UC Davis, so after finishing that one year in Berkeley I took a job at Sutter Memorial in Sacramento. My wife worked in the ICU there.While taking anywhere from fourteen to eighteen units at Davis, I was working nights in the ER.

There were many nights when I would work a night shift and go to school at eight in the morning, studying with these young kids fresh out of high school who were fast-burners. I'd take classes until three or four in the afternoon and then I'd come home and play with the baby and go to bed at eight or nine o'clock, and my wife would go to work because we were sometimes opposite days. Then she would call me at one o'clock and I'd wake up and I'd study from one o'clock in the morning until seven o'clock and then go to school the next day. By and large I'd have to work that next night. That went on for three years. Between the year in Berkeley and the time at UC Davis, it took me four years to get my bachelor's in physiology.

I was a pretty good nurse. It was certainly a way to make a good living and I liked doing what I was doing. I didn't have any illusions. I didn't know if I'd be getting into medical school, so I entertained nurse anesthesia, but never very seriously. I enjoyed the intensive things in the ICU, and the trauma patients in the ER.

One of the things that struck me when I first got into nursing school was I wanted to make some decisions for myself. I wanted to be able to decide when to change a dressing or when to give this kind of medicine. That's very frustrating for some nurses, and those nurses tend to migrate more towards specialties where they can do things on a more autonomous level, like the intensive care unit or in the ER, where they can work and act on their own.

I'm a big guy, about six foot five, and as a male nurse I never had trouble with the physicians. I never had a physician yell at me or berate me, even over the phone. If you watch how male nurses interact, by and large they don't take crap. A lot of female nurses don't either, but you're much less apt to see a male nurse break down and cry after a doctor's yelled at him. I certainly wouldn't argue that I was more nurturing than a lot of my female counterparts. In fact I would very easily say that wasn't the case.

My counselor at UC Davis, who is still a good friend, wrote my letters of recommendation and counseled me all the way through. I met her about six months into nursing school and she remembers thinking I was crazy, I'd never have a chance. I was much older at the time. But I got in at my first choice, Uniform Services University in Bethesda, Maryland.

I was raised military and was familiar with the military system. I'd enjoyed moving around. This was a beautiful campus and offered the chance for my wife to not have to work, although she did. There was a lot of appeal about the school. A number of my classmates were former military officers in other fields--pilots, medics. Also, I had been in touch with a good friendthrough the course of his training there and he spoke highly of it.

Another reason I chose the school was because I received a second lieutenant salary in the military. Plus I had all the health and other benefits that went along with the military, which included access to the commissaries and the exchanges. In undergrad school we'd had one child, and in my second year of medical school we had a second. We didn't have to scrimp during medical school. There are people who have stories about having to live on Rice-a-Roni. We never had to do that.

When we got into medical school it was like a vacation for me because that was my job. I didn't have another job to do. I was able to support two kids and be comfortable. My wife worked half to three-quarters time, so we were able to take little trips. Actually medical school was very enjoyable for us. We were comfortable with each other, married now for fifteen years.

I had to book it just as hard as my classmates. You focus on different things in nursing. Though you talk a little about the pathophysiology, you're looking at many other things. In the first two years my only advantage was when we had the physical exam class where we actually went into the hospital and interviewed patients and examined them. My first rotation was in pediatrics and I'd never liked pediatric nursing but I felt much more comfortable than my counterparts in drawing blood or starting IVs. Other than that just being a bit older and wiser than most of my classmates was my only advantage.

Certainly I knew surgery was what I'd be doing. I couldn't imagine doing anything else, from day one. Initially I thought I wanted to do orthopedics because I really liked working with healthy people. I'd had my fill of intensive care and high time requirements for taking care of patients. But shortly thereafter I decided on plastic surgery because I like to draw and I like to work with my hands.

There are a couple of ways to get into plastics, but I did it by going through general surgery, which was five years of surgery residency. Then there are an additional three years of plastic surgery fellowship. At each step along the way you have to apply, and you never know if you're going to be accepted. So you apply to get into internship and from internship you apply to be accepted into residency. After residency you apply to be accepted into fellowships.

For training I chose the hospital on Travis Air Force Base because my family and my wife's family were in that area. Which turned out to be a good thing, because my mother developed leukemia during my residency. So I was able to be there, as opposed to being far away. Actually, she was a patient in the hospital where I worked, which made it hard, but it also made it better.

When my mother was first diagnosed with leukemia, my wife was away, because her brother had just died. I had to take emergency leave and stay home with my two kids. My mom lived in the next town and she'd had a cough. So I went over to visit, and she told me she'd coughed up a little blood. I said, "I want you to go see this doctor." I thought she had pneumonia. He saw her and he in turn consulted a classmate of mine from medical school who was an internal medicine doctor at the time, a very bright guy. That guy called me about two hours later and said my mom had leukemia.

But my mom told me later that when he came into the room, where she was alone, and told her, he had a smile on his face. She said it was like somebody who had a new toy or had just discovered something. My mom hated him from that day. I'll never forget that. When I walk to someone's bed to tell them a diagnosis, whether it be benign or cancerous, I remember how people hinge on your pauses, your exclamation points, anything. It's just amazing, how much power you have. I make a very strong effort to be heard.

I still harbor a lot of guilt about how it all went. There would be days when I finished my day at eight o'clock, which had started at four or four-thirty if I hadn't been in the hospital all night, when I'd be ready to go home and I'd realize that I hadn't seen her for a while. So I'd go up and spend time with her. It was hard.

The internship year is very demanding because of all the time that you spend in the hospital. There are so many things you don't know and you're constantly being questioned. Number one, you're trying to take care of your patients and stay up on all the things about their care. Number two, you're trying to read about all the operations you're doing or taking part in. Number three, and something very important to me, was trying to stay a father and a husband. I did not want to get out of residency and have my kids not know who I was. And I think I was fairly successful. Plenty of divorces occur in the course of a residency. I'm very fortunate. I happen to have married the right person.

In my internship there were four people who wanted to have that one residency spot. I would never do anything to try and make someone else look bad. There are times where I actually held my tongue when somebody else was being questioned, where I knew a given answer and they didn't. There were plenty of people who would just spit out the answer and make somebody else look bad.

My philosophy, which was passed on to me from friends and it made common sense, was to work hard and keep your nose clean, and it would pay off. In my case it did. There are other times when it doesn't work out that well. You end up going off to general medical officer assignments in Korea. If you get bumped out of a pyramid and you don't find another place that needs someone, you're out of luck.

Right now I'm finishing the sixth month of my plastic surgery fellowship. You can do plastic surgery in two or three year fellowships, but this one, which is a military fellowship, is three years. Six months during the second year are spent in Louisville, Kentucky, doing strictly hand surgery. I start that in July and for the first four weeks I think my wife and children are going to come with me and live there. My wife works part-time as a same-day-surgery recovery room nurse. My son is eight and my daughter is ten. They'll have to come back to start school, so that will be a difficult period.

Plastic surgery is a wonderful specialty because there are so many different things you do. People think the plastic surgeon is someone who does strictly nose jobs and face lifts and breasts. That couldn't be further from the truth. Plastic surgeons are trained as hand surgeons, they're trained as microvascular surgeons. We do a lot of grafting and skin flaps and muscle flaps to cover up defects that wouldn't heal on their own. It can be very challenging and also very rewarding.

When I finish I'll be a military plastic surgeon. I could go anywhere in the continental United States, and it's even remotely possible that I could be over in Europe, but I don't envision any hard spot. Hardship would be if we had to go to Elmandorf, Alaska. But my practice would be partially cosmetics and probably the majority reconstruction.

My obligation is for seven years after residency, so I don't even see the light of day until 2003. It doesn't bother me. I don't have to worry about going out and hiring an office staff and renting an office and developing affiliations with civilian hospitals.


I was and still am a family advocate. As a nurse I took time with families and I felt good about doing that because most of the patients in the ICU were intubated. I very much enjoy talking with families and patients, but I like being able to walk out of a room and not have to clean the patient up and make sure they eat, and that they get weighed. These are things I did and I did well as a nurse and a nurse's aide, but there are other things that I have to do now. I enjoy making sure the patients are well educated in what they're having done and talking to families before and after surgery.

There are plenty of physicians, particularly surgeons, who want things done their way, and after a period of time that becomes known. But there are times when nurses need to think on their feet, and make a decision. When get a phone call or a page at home, and it's a nuisance page, I'll step away and say, "Boy, if she'd just used her head she could have answered that question herself." I'll get this glare from my wife across the room. But I stick to my guns. There's a degree of autonomy that nurses need to practice. I did when I was a nurse and I think they should do it here as well.

I never had trouble with nurses and I never made it an issue to say that I'd been a nurse, but once people found out, I was treated differently. I'm basically a nice guy. I don't yell. I don't throw things. I have always gotten along well with folks. At the same time when a mistake was made and it was made because of somebody not knowing what they were doing, my temper would get up and I'd let it be known. But I'm not really one to raise my voice.

If you're a ward nurse you're theoretically at fifteen or thirty bedsides. You're dealing with not only patients' suffering, but with the families' suffering. You're dealing with whatever you've got going on at home. There's just a tremendous amount that falls on your shoulders. I experienced that when I was working nights as an ICU nurse, but I had a goal to look forward to. Out of the ten people who started my ICU training class with me, about four of them stayed in the position. The others went off to easier jobs. It was so intense. It's hard to go home and just leave it at work.

The physician is often shielded from that. I did a lot of hand-holding and dealt a lot with families of people who were dying. The physician comes in and says "Hi. Is there anything I can do for you?" and then turns around and walks away. They can go on to something that's maybe a bit more uplifting. Maybe the next room has a patient who's doing well.

There are some nurses, thank God, who like doing ward nursing and like taking care of patients, and my hat's off to them. I try to show appreciation when I see somebody going above and beyond for a ward patient.


As a plastic surgeon I probably won't ever come across issues about dying. I will never make the decision to let somebody go because I won't have anybody under my direct care who's that ill. But when I was a general surgeon there were times when enough was enough. People needed to be let go, and I didn't have trouble talking with families about that, or patients, when they were able to understand. It has a lot to do with my personality, but also subconsciously it has to do with having seen a lot of dying, spending those eight and ten and twelve hour shifts with people who were just so miserable, that there was no existence there. There were times in general surgery where if I was consulted on something, I'd say, "Look. What are you doing?" Because they'd lost sight.

All this would not have happened if it were not for hard work, and it would not have happened without my wife. There's just no way. She was understanding in terms of the time commitments and continues to be. She's a great wife, a great mother, and she just makes my job a whole lot easier. Had I errantly married the wrong woman, I could have been had.