Dr. Everett Lindqvist in Operating Room 3 at Codornices Medical Center in Berkeley, Calif., on Wednesday, with the Halsted robotic system, rear, which he dismissed from a gallbladder removal in progress the day before and which has remained against the wall since. Credit: Miriam Castellanos/The New York Time5
Dr. Everett Lindqvist in Operating Room 3 at Codornices Medical Center in Berkeley, Calif., on Wednesday, with the Halsted robotic system, rear, which he dismissed from a gallbladder removal in progress the day before and which has remained against the wall since. Credit: Miriam Castellanos/The New York Time5

BERKELEY, Calif. — Operating Room 3 at Codornices Medical Center is, at 7:10 on a Tuesday morning, a quiet place. The lights have a particular quality, white and unarguable. The instruments are laid out on blue cloth in an order that has not changed since the 1950s and that no one in the room could fully justify. A radio plays, softly, a station the circulating nurse selected years ago and that the surgeon has never asked her to change, because, he says, he does not hear it. And in the corner, under a clear plastic drape, on a cart the size of a refrigerator, four jointed white arms wait with the patience of a thing that has never been asked to wait before.

The arms belong to the Halsted, a robotic surgical system manufactured by Meridian Surgical Technologies, and from 7:40 that morning until 8:27 they were inside Gerald Pappas.

Mr. Pappas, 61, a retired train scheduler for the Bay Area Rapid Transit system who lives in Berkeley, had come in for a laparoscopic cholecystectomy, the removal of the gallbladder, a procedure that Dr. Everett Lindqvist has performed more than two thousand times and that the Halsted, according to its manufacturer, has performed more than four hundred thousand. Forty-seven minutes into the operation, with the gallbladder partly freed from the liver and the Halsted’s guidance software displaying what it had identified, with 94 percent confidence, as the cystic duct, Dr. Lindqvist lifted his face from the console viewer, stood up, and said, according to four people in the room, “Thank you. That will be all.”

The robot was undocked, its arms withdrawn and folded, and wheeled to the wall. Dr. Lindqvist scrubbed in. He then informed the room that he would be finishing the procedure using what he called “pure artisanal thinking,” by which he meant, he explained later, that he would not consult the Halsted, the Halsted’s decision-support software, the hospital’s clinical guideline terminal, the laminated surgical safety checklist taped to the anesthesia cart, or anyone else, and that he would arrive at each remaining decision himself, in real time, by thinking about it.

“I wanted to know what I actually thought about this gallbladder,” Dr. Lindqvist, 56, said on Thursday, in the kitchen of his home in the Berkeley hills, where he was feeding a sourdough starter that is older than his residency. “Not what the machine thought. Not what the guideline thought. Not what I would have thought in 2009. What I thought, in that room, with that duct. A robot removes a gallbladder. I wanted to encounter one.”

It is, by any measure, a gallbladder. It is a small, pear-shaped organ that stores bile, and it is removed, in this country, roughly 1.2 million times a year, more often than any other abdominal organ, usually in under an hour, and increasingly with the assistance of machines like the Halsted, which the hospital leases for $2.4 million a year and which Meridian describes, in its literature, as “a second pair of hands that does not get tired, does not get distracted and does not have an afternoon.” Dr. Lindqvist’s position is that this is precisely the problem. The remaining portion of Mr. Pappas’s procedure, which the Halsted would have completed, by the manufacturer’s estimate, in about 25 minutes, took him one hour and 52 minutes.

He narrated it. This, the people who were in the room agree, was the part that stayed with them. “He would say, ‘Now, what is this,’” said Renata Volkov, a circulating nurse who has worked with Dr. Lindqvist for eleven years and who turned the guideline terminal to face the wall at his request. “And then he would tell us what it was. And then he would say why he thought so. And then he would say what someone might say if they disagreed, and why they would be wrong. We knew what it was. It was the cystic duct. The robot had said it was the cystic duct. But he wanted to get there himself, and he did, and it took about nine minutes, and the whole time he had this look.” She paused. “Like a man reading a menu in a language he used to speak.”

Ms. Volkov said the surgical checklist was not used. Dr. Lindqvist described it, in the room, as “someone else’s thinking.” The anesthesiologist, she said, read it silently to herself.

Dr. Lindqvist is one of at least four surgeons in the East Bay who identify with what practitioners call artisanal thinking, or hand-reasoning, a loose movement with no formal organization, a newsletter and, as of September, a tote bag. The movement’s premise, as he describes it, is that cognition has undergone the same industrialization as bread, coffee and furniture; that the outputs are faster and more consistent; and that something has been lost that cannot be named by the people who no longer have it. He uses the phrase “single-origin.” He uses the phrase “small-batch.” He does not use the phrase “slow surgery,” which he regards as a pejorative coined by the hospital’s finance office. In a city that taught the rest of the country to wait for its food, the idea has been received, he says, “better than you would think.”

Dr. Franklin Krause, the director of the Institute for Occupational Cognitive Health in Baltimore, which studies the effects of sustained cognitive labor on surgeons, air traffic controllers and software engineers, said the institute has been tracking what it calls “unassisted reasoning events” in operating rooms since 2022, and that the count has grown every year. The institute’s 2025 paper on the subject, in its own Journal of Occupational Cognitive Science, found that surgeons who reasoned without external support for more than 40 consecutive minutes exhibited a 31 percent increase in audible self-narration and a measurable decline in the willingness to be handed things.

“Thinking is a tool,” Dr. Krause said. “It is the oldest tool we have, and like every tool it was eventually improved upon by a committee. Checklists, guidelines, decision support, the robot. These are not the enemies of thought. They are what thought built, so that it could rest. Dr. Lindqvist has chosen to use the original. We do not recommend it. We recognize it.” He added that the institute had been warning about this for years, and that no one had been in a position to listen, because they were operating.

Meridian Surgical Technologies, which has not previously had one of its systems dismissed from a procedure in progress, said the Halsted had performed as designed. “The system did not malfunction,” said Marcus Enright, a vice president at the company who oversees its robotics accounts in the western United States. “It was dismissed. Those are different incident codes.” Mr. Enright noted that the Halsted had remained in the room, powered on and sterile, for the duration. “It was available. It was, in a sense, on call,” he said. He confirmed that the hospital would be billed for the full session, on the ground that “availability is the product.” Asked whether the company regarded the dismissal as a repudiation, he said that Meridian did not take positions on surgeons’ feelings, and that the system did not have any. The Institute for Machine Welfare Research at Harvard, asked whether the Halsted could be said to have experienced its dismissal, said it had no position but had opened a file.

Mr. Pappas, who was under general anesthesia for the duration and learned of the change in approach the following morning, said he had not been consulted and was not sure what he would have said. “They told me the gallbladder was removed by hand,” he said, from an armchair at his home, where he is recovering. “And I asked, as opposed to what? And there was a long pause, and then the resident said, ‘The robot,’ and then there was another long pause, and I think that’s when I understood that there had been a robot.” His incision, he said, is somewhat longer than the one he was shown in the brochure. Dr. Lindqvist, at the follow-up, told him it had character. “I didn’t know they could have that,” Mr. Pappas said. “I’ve been looking at it.”

The hospital has convened a peer review, as it is required to do when a procedure departs from its planned course. Dr. Howard Aldana, the chief medical officer, said in a statement that the review would be “thorough,” that the committee had met twice, and that it had not yet reached the portion of the record in which the robot is dismissed. The committee’s own guidelines, he noted, call for it to proceed deliberately, and the committee had elected, after some discussion, to follow them. A member of the city’s Commission on Commissions has requested a copy of the record. The hospital has not determined whether the commission is entitled to it, and has referred the question to a subcommittee.

Dr. Lindqvist is not waiting. He has scheduled his next three procedures without the Halsted and has begun, he said, “thinking during the consult, too,” a practice he described as harder than it sounds and his patients have described as longer than it used to be. On Thursday afternoon, as the light came in low over the bay, he picked up his phone to check the time, looked at it for a moment, and set it face down on the counter. He had removed his watch before Tuesday’s operation, he said, because it was a smart one. He was not sure what it would have said. He had not wanted to find out.