Thursday, December 21, 2006
An anonymous commenter on one of my pancreas posts said "I think ... surgeons tend to see things from a "look to the past" view as opposed to "look at the future" when it comes to individual patients..... I don't expect a surgeon to be God....but I do wish he could be God-like and consider the past, present AND future." He had undergone extensive surgery after which he was evidently left with severe side effects, and a miserable quality of life. As I understand it, he seems to be saying he wishes his surgeon had given some thought to what he was about to do to the man, and -- I infer -- not done it. The implication -- well, the clear-cut statement -- is that this person believes surgeons do what they do with no thought at all about the consequences. If you can cut, do it; the more, the better. Period. Nothing could be further from the truth.
Bottom of the ninth, game seven of the World Series. The pitcher has struck out the first two batters, looks like he's in the zone. Up comes Casey, who's already gotten a homer and a double, and who has a .480 record against Lefty. Manager brings in Righty O'Doul, who strikes out Casey. The crowd goes wild, carries Righty and the manager off the field. Great manager: brilliant moves, knows the game, damn genius.
Casey hits an arching 450-footer into the stands, dead center field, the Cephalopods lose. Beer cups rain down, sports-writers foam at their laptops, the manager loses his job. Bad manager? Didn't think about the consequences of his move, didn't have cold sweats over it then, and after? Trivial analogy?
In my book, (yeah, time for another plug!) I said that what we do is a sophisticated game of odds-playing. We have had lengthy training; we keep current on the latest developments; we have our experience on which to draw. My commenter knows we aren't gods, but wishes we'd be god-like in looking at the future. And exactly makes my point. Obviously, we can't. We can guess, hopefully in the most educated and well-grounded ways. We can bring to bear every bit of our knowledge and use all of our experience; listen to our "gut," even reflect it all against our sense of right and wrong. Some doctors undoubtedly pray over tough (or easy?) decisions. And inevitably, we will have some lousy outcomes, some patients injured as a direct consequence of our decision making. If I know with 99% certainty (rarely is any outcome that sure) that if I do A, B will occur, and if I do A a hundred times, the odds are I'll have one very unhappy (or dead) patient. I will have been right every time. Tell that to the one patient.
If my commenter were my patient, I'd feel horrible. I feel bad for him as it is. In fact, it's entirely possible that his surgeon screwed up, made a bad decision, or did exactly what my reader infers: figured there was an operation that could be done, and did it, because that's what he does. But I doubt it. We're an eclectic bunch, us surgeons, but most of the ones I know are thoughtful and careful -- exactly because we know that what we do is imprecise and unpredictable at best. We understand what improves the odds: meticulous technique, careful planning, knowing as much as possible about all the options, thorough knowledge of what's going on with our patients. To use "anonymous"'s words, we look to the past for our knowledge, to the present to assess what's going on, and to the future to make the best choice possible for the situation at hand. That we're not always right -- or more likely, that we made a careful and thoughtful decision the outcome of which was lousy -- doesn't mean that the process was flawed in the way my reader implies.
Perfect surgeons (if there were such a thing, and there isn't) will have imperfect outcomes. And I wouldn't deny for a minute that there are some bad docs out there. The nature of surgery is that bad surgeons can do especially bad things. I'm not making excuses. I am, I think, stating the case as it is: yet no matter how happy the ninety-nine are, it doesn't change a thing for the one who came up on the short end of the odds. And here's the part I'm not sure I can say without sounding callous: I have an obligation to do everything I can to get as close to perfection as possible, including thinking long and hard about the possible outcomes of every choice I make. But if I were to dwell too much on the admittedly deeply disturbing and regrettable folks like my anonymous commenter, I couldn't do what I (used to) do. And lots of people would be the worse for it. Assuming I am in fact fulfilling my obligations to try to be the best surgeon I can be (and assuming my best measures up), at some point I have to accept there will be failures, and to hope that on some level, patients will, too. Or else I'd jump off a bridge. There were times when I came close.
That's a couple of downer posts in a row, on more or less the same subject. Got a good one coming up. Y'all come on back, hear?....