Thursday, March 27, 2008
Cutting It Close
Shortly after I set up practice, my mom mentioned a little skin growth she wanted removed. Since she was part of paying for my college and med school (yes, I was one of the lucky ones!) I figured it was the least I could do. The lesion was a simple non-worrisome thing; removal was strictly cosmetic. But its orientation was such that I had to choose between a smaller excision, not in proper skin lines, versus a bigger one that might be less visible. For some reason, which I still can't understand thirty years later, I made the former choice, and it wasn't a very respectable scar. It did, however, lead me to pay much more attention to orientation; and to the realization that it had been under-emphasized in training. Little things like that are little things like that, when you are trying to learn how to remove half a liver.
But that's not my point. A recent post of mine, and comments thereon, led to thinking about operating on people to whom one is close. It's a close call. On several occasions I've operated on partners, or their family. I've operated on friends (it helps that I have few really close friends), and on people who came to me on the recommendation of friends. In-laws have been under my knife, if a small one. It's an interesting subject, a complicated one. To some extent, it depends on one's ability to compartmentalize. Or, more properly, to focus.
I've not considered it a matter of ethics; to me, it's about judgment. One of my commenters said she was taught in med school that caring for family is considered unethical; perhaps it's a semantic disagreement that we have. To me, "unethical" means submitting false charges, operating with no indications to collect the fee, taking kickbacks for using particular products (a matter of current investigation, evidently.) Were I to operate on someone close, the question is whether I could rise above emotion and make care decisions exactly in the way I would for a "normal" patient.
There's a strange implication here, when you think about it. I like getting to know my patients. Not only, as I've written, do I believe in the importance of establishing trust and confidence and a positive attitude, I just enjoy the relationship for its own sake. It could be said -- it is said, in fact -- that it's a mistake to have anything but a cold and distant relationship with one's patients. But if it's okay to reject that, if it's acceptable -- laudable, even, according to various patient advocates -- for doctors to establish and to have a connected relationship with their patients, then doesn't it follow that the idea of "professional distance" is a flawed one? Doesn't it imply I'd make better decisions when caring for a patient I don't like than for one I do? If not, then at best the idea of caring for a relative or close friend differs from caring for "regulars" only in degree; and a smaller degree, at that, than convention would suggest. Ethics, per se, are not the issue. Attitude is.
Perhaps I'm missing something, but I sort of reject the idea that I care less about my unrelated patients than I would about friends or family. Maybe I'm deluding myself in believing it, but when I enter the operating room I get into a zone of intensity and focus on the problem at hand that nearly obliterates everything else. Totally concerned about addressing the requirements of what I find, while I operate the personhood of my patient is no more and no less than that of the last one, or the next: I'm obliged to do my best. Period.
Of course, I'm not unaware of the temptation to think wishfully, to opt for a path less discomforting for a loved one; it's a possibility, to be sure, especially, perhaps, in after-care. Included in my "memorable patient" series is the story of operating, with only a couple of years of practice under my belt, on my partner. When I had to re-operate on him -- a decision which was harder in many ways than one to delay -- I deliberately chose as an assistant a surgeon out of my clinic, and told him ahead of time I wanted him to speak his mind. Not only was he among those that had suggested waiting, he also made a recommendation during the operation that I ended up rejecting. Later, he commended both of my decisions, and said he'd been wrong, twice. I was able, I'd argue, to think clearly about the needs of my patient irrespective of who he was.
It's not my aim to suggest that doctors ought to start caring for their loved ones; nor am I implying (I don't think so!) that I have mystical powers of concentration absent in others. But it wouldn't be the first time conventional wisdom was found wanting; at the least, it's not crazy-stupid to wonder about it. It's not impossible to focus. Like the paranoid who actually does have enemies, some doctors who think they could provide better care than their colleagues, even to loved ones, might actually be right in some instances. When he was a baby, it looked like my son might have had a hernia. I really liked the way I fixed pedi-hernias; no one in the area did it as simply or with as tiny an incision, sez me. (Most of the pediatricians I knew sent all of their hernia patients to me, because they thought so, too.) Had my son turned up with one -- he didn't -- I'd have been sorely tempted to do it myself, believing it would be in his best interest. My wife told me several times that if she had breast cancer, she'd want me to do the surgery. And having seen my work and that of others, I'd have considered it; probably I wouldn't have done it, but I'm not sure. Happily, I never needed to make the decision. Nor am I unaware of the egotistical implications of the pre-penultimate sentence of this paragraph.
Greater than the risk of providing improper care, as I see it, would be the burden to bear if something went wrong. In that, there would be a difference. It's hard enough to forgive oneself for error or poor outcome under any circumstances. It might be more than I could take, in someone close. Which, of course, argues strongly against taking it on, if for reasons somewhat different that those generally offered.
Maybe there's a happy medium. Plastic surgeon and rabid blogger Ramona Bates responded to my original post with one of her own, and she gave examples of what a surgeon can do to help in meaningful ways, while avoiding the potential pitfalls. When my dad needed surgery of the sort that I did, I had him come to town and hooked him up with a hand-picked team. I stuck my head in the room a couple of times and transmitted the information to my wife and mom. Same when my son had an orthopedic procedure. I was unobtrusive in the OR, helpful to my family, and felt useful in a surgical sort of way. Dayenu. As they say.