Jo Buyske firmly believed in chaos theory when she entered the male-dominated field of surgery.
The theory was posited by her supervisor in medical school. Surgery, he said, was a natural specialty for women, especially those who wanted a family, because surgeons were masters at managing chaos. A woman unflappable enough to be a surgeon could easily cope with motherhood.
"At the time, it made perfect sense to me," Buyske, 47, said.
What about now that she's chief of surgery at Philadelphia's Penn Presbyterian Medical Center, married to a surgeon, and the mother of fraternal twins - two sets, no less?
"I think I was lucky, and a little bit stupid," she said with a laugh.
Now an authority on the holes in chaos theory, Buyske (pronounced BY-skee) is poised to tackle the big issues facing her profession, including what many see as the biggest: making training and practice more family-friendly at a time when growing numbers of women are entering the field. She has just been named the first female associate executive director - the number-two job - at the American Board of Surgery.
Little known to the public, the 70-year-old, Philadelphia-based organization ensures the quality of the nation's 38,000 general surgeons, plus thousands of subspecialists in hand, pediatric, critical-care and vascular surgery.
The board tests them and certifies that they have a defined level of training and knowledge - standards the board helps to set. Certification is voluntary, but top institutions require it. About 20 percent of surgeons who seek it fall short.
Buyske, chosen after a national search by the board's three executive staff members, will be in charge of continuing development and oversight of the written and oral certification exams. Her subtler role: breath of fresh air.
"She's so organized and has such leadership skills and enthusiasm," said Julie Freischlag, the first female head of surgery at the medical school and hospital of Johns Hopkins University in Baltimore.
Women are still rare in the upper echelons of academic surgery. Buyske says that "it's me and a bunch of white guys" at many gatherings.
But at lower levels, women's ranks are growing, feeding the pipeline.
About 5,500, or 14 percent, of general surgeons are women, a tenfold increase since 1975. Among surgeons-in-training, called residents, 28 percent are female.
At the entry level - the first year of the grueling, five-year residency - 43 percent are women. That has been rising about 2 percent a year since 2003, coinciding with mandated restrictions on residents' work hours.
"I think we'll see parity in a few years," said Frank Lewis, executive director of the American Board of Surgery, and Buyske's new boss.
Buyske is a respected teacher, researcher and administrator, as well as an expert in gastrointestinal surgery. She is a pioneer of new minimally invasive techniques that are transforming the bloody cut-the-patient-open approach.
She is also credited with putting Presbyterian's former minor-league surgery department on par with those at the city's other big teaching hospitals. (She was apprehensive about one big-league recruitment - her husband, thoracic surgeon Joseph Friedberg - but it's worked out well.)
She also understands how to build bridges and consensus, said Jeffrey Ponsky, chair of surgery at Case Western Reserve University School of Medicine.
"There's a blurring of the lines between many specialties," he said. "For example, surgeons and gastroenterologists do many of the same procedures. There can be turf wars based on economic issues. We need people with balanced approaches, like Jo, to make sure the right thing is done, and to integrate training between the specialties."
Which is not to suggest Buyske is all gravitas.
Tall and tomboy-thin (she runs before dawn), with a few gray steaks in her dark, chin-length hair, she has an impish side.
Behind her, on an office shelf, was an award from the Society of American Gastrointestinal Endoscopic Surgeons (of which she is vice president) for a review of surgical complications - done as a "Rocky Horror Picture Show" takeoff.
It's easy to believe her claim that in college, she majored in English and minored in partying.
Her father, a biochemist - and a fraternal twin - persuaded her to stop "wasting her time." He offered to pay for an extra year of college if she would take premed courses.
"That's when I kind of got a grip," Buyske said.
Buyske got into the prestigious Columbia University College of Physicians and Surgeons, where her final "rotation" - sort of a medical career sampler - was in surgery.
"It was a life-altering event," she said. "I liked taking care of surgery patients. And I loved the boldness of the surgeons. I thought, `If I'm going to work really hard, these are the people I want to work with.' "
"Hard is an understatement. All specialties now limit residents to 80-hour workweeks. Before 2003, however, the five-year surgical residency was infamously hellish.
Buyske alternated aptly named "gray" and "black" weeks at Massachusetts General Hospital in Boston. A gray workweek was 125 hours; black was 145 hours. Do the math: She had 3.2 "free" hours per black day.
"That's what it takes," she said. "Or what we "thought it takes."
Residents were taught that nothing came before taking care of patients. Never mind that young MDs often got stuck doing nursing tasks and waiting around for senior surgeons.
This took a greater lifestyle toll on women than men. Male residents typically left all home-front responsibilities to their wives. Women typically postponed - or sacrificed - marriage and children.
"Those of us who survived look pretty good," said Hopkins' Freischlag, who had her son at age 40. "But there were a lot of casualties along the way - drinking, suicides. The cost of that kind of training was not good."
Barbara Lee Bass, chair of surgery at Methodist Hospital in Houston echoed that sentiment: "We got where we got because no one was going to stop us. But the new generation of surgeons are not like us. That's where Jo comes in. She's found a balance. She's a great role model."
One fallacy behind the patients-come-first mantra, Buyske eventually realized, was that top surgeons - namely, men - wound up jetting around the world to give talks and receive honors.
"Does it really matter whether the reason you can't see your patient every day after surgery is because you are ... giving a keynote address or because you are ... at a child's soccer game?" Buyske wrote in 2005 in the journal Archives of Surgery.
One antidote, she concluded, has begun to change surgery's macho ethos: "Work is shared. We take care of our patients as a team."
Still, quelling chaos is tough. Buyske said she and Friedberg "hemorrhage" money for domestic help. They live in the city to be close to work. (OK, they live in a spectacular converted factory)
They also expect the twins - 13-year-olds Emilia and David, and 9-year-olds Gabriel and Dashiell - to understand their priorities.
"If they say, `Can you come on my school field trip tomorrow?' I say, `No. If you wanted me there, you should have told me way in advance.'"
Buyske is sometimes surprised by how much her kids "do understand. Once, when Friedberg had been at the hospital for several days straight, Gabe griped, "I need a chest wound to see Daddy." To Buyske, that was hilarious.
Not to Emilia.
"Emmy said, `Don't you dare tell Daddy. You'll make him feel bad. What he does is very important,'" Buyske recalled.
Buyske was initially torn about accepting her new post because it requires putting aside that defining part of her profession - doing surgery.
Friedberg finally said: "You sound like a lawyer fretting about whether you'll miss trying cases when you're sitting on the Supreme Court."
As the family sat on its rooftop deck, Buyske pointed to the Suburban Station building, where she'll move in January.
"I'm proud of her," David said, echoed by me-toos.