Thursday, December 21, 2006

The Gambler

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?....


Anonymous said...

I think the reason some patients feel that surgeons are overly aggressive about wanting to do surgeries is because of the patterns of interactions. In my family situation I have had 2 significant encounters with surgeons. (son-uro and husband-spine) Unfortunately there were complications both times. My husband had a back surgery that in retrospect he wishes he did not have. However, as soon as the post surgical problems became evident his relationship was OVER with the surgeon. He was shipped off to pain management and back to the GP. Regardless of the need for that practice, I believe he felt abandoned or written off. I would think it might be difficult to realistically gauge the costs/benefits of a surgery when you don't follow the patient beyond initial recovery. My son had a pediatric medical/surgical specialist and even tho his surgery recovery was problematic, we had continuity of care with him and he is still being treated by him. One thing I have noticed in my dealings with surgeons is the following. First you are evaluated (which is kindof a big deal for you because you have questions and concerns and it is all new to you) and you get the sense that this is kindof a tedious "same old-same old" for the surgeon. However, if you have ever had the displeasure of having a rare or unusual case.....The surgeon comes in with a spring in his step and a glint of excitement in his eye! In short .... you never really want to "impress" a surgeon. It is like you made someone's day with your bad news. Anyhoo---it is kindof a creepy phenomenon when you are the patient! And I am not being critical---I really like the surgeon---I will just never forget him telling me the bad news that he was so excited to have the ability to fix!

Anonymous said...

misha: It's odd, but you can't really lump "surgeons" into a pile. Different specialties tend to have different personalities and most definitely different approaches to medical (i.e. nonsurgical) management. Ortho (presumably who did the spine op) is NOTORIOUS for turfing any and all med management to IM or whomever else, and indeed are often the butt of jokes for it. (How do you hide $1 from an orthopod? Put it in a book). Uro is on the exact opposite of the spectrum: medical management is a huge part of their job description and they go into it knowing they'll be surg/med hybrids.

That being said, I have seen some surgeons who just don't want to face their failures. In no other job are your mistakes as important or in your face as in the case of a surgery with bad outcome. I have also seen surgeons who like to operate so much it blurs their decisionmaking (this is primarily an issue in back surgeries, which lurk in a mysterious cloud of "Do they or don't they work"). But they are the small minority and, like media reports on sensational crimes when the crime rate is actually dropping, often give a misleading picture.

Bongi said...

i have recently started reading dr schwab's book (i can strongly recommend it by the way). in one of the earlier chapters the good doctor describes a disaster involving a young man bleeding to death through his neck. it was not at all his fault but in the book he describes how he considered not continuing with his studies because of that. that would have been disasterous for the many people he has helped through the years. sometimes things happen we can't help and usually we are distraught over them. but, also without sounding too callous, we work in the realm where we get to see these things close up where most people will only read about them. sometimes you just need to move on. this does not mean you as the surgeon don't care, but simply that a surgeon is not god and tome of these things can't be helped. it is a difficult and complex thing, but thank god that schwab didn't give up then. otherwise what blog would we be reading now?

Anonymous said...

In regard to Analmou' comment on the pancreas. I think it's very hard when you live in chronic pain, can't eat anything except carbs, no fat, etc, to keep your eye on the target. For me, my daughter's father is dead. So It is my obligation to stay alive for her as long as possible. She doesn't live with me as I am too sick to care for her. Has my pancreas disease cost me everything? Yes, I have been stripped of EVERYTHING, after my whipple, I was without a job, without a place to live and still very sick. My faith in God is all that kept me going. I knew he didn't bring me this far just to let me die. I think you have to realize that docs are human beings. They care more than you think they do. There many times I wish I was dead. I focus on the good things, just being about to sit on the beach, to feel the sun's warmth, is a gift. And when things are their bleakest, I think to myself, well, I can breathe on my one and that's more than some people. I have it good. I do think docs think about life quality. They also think about saving your life. I am SOO glad my docs never gave up on me. I have had not so good docs as well. I have had docs blow off major panc attacks, give me a hanful of diluadid and send me home, only to return with kidnet failure. I have had docs say there was nothing wrong with me, only because they cdid not have the expertise. I have had docs say they have done all they could. Finally, my surgeon, the best surgeon, I found to help me is in MN. I think you can never stop looking for the right doc for you. I think you can accept to refuse your situation. MUCH of the responsibility lies within the patient, it's your body, by God!! You know if you want your pancreas out, you can do an ICT. Dr David ER Sutherland is the best. Drop him an email about your case, and see what he says. If he can't help you, he'll say so. Take Care

Anonymous said...

I’ve had brain surgery (I’m your commentator who had the ventriculostomy), two hip surgeries, hand surgery, eye surgery, exploratory surgery and gall bladder removal surgery, and I think by now I’m knowledgeable enough about being on the receiving end of surgery to offer your commentator who concerned you three vital suggestions: laugh a lot - about anything (it has a wonderful effect on your health and recovery); be proactive by helping others in some way that is very important to you; and learn everything about the type of surgery you had, learn about any procedure even somewhat like yours, which is why I’m reading this blog now. A simple truth is that by being proactive in this way, you will overcome at least the psychological repercussions of your surgery. My first surgery, for my hip, occurred when I was a kid after a drunk driver crashed into our car. My pediatric surgeon said that he would make my hip stronger than before it had been broken (his words impacted me so much that they effected the outcome of every surgery I’ve had since). As a kid, I thought he secretly ran a torture chamber because of how I screamed when he adjusted my traction, but now I walk without a limp and my hip is so strong that it withstood a second major car accident and I’ve had six babies the natural way. I also remember the vibration, how much I felt like I was falling, and the incredible pressure of the drill during my ventriculostomy ten years later, but I’ve learned that sometimes trauma patients have just been through such a trauma that anesthesia doesn’t completely take. I know that, and I have the attitude that no matter what pain I have it will always result in good. These experiences, to me, are gifts, otherwise I would not have been so inspired by my trauma surgeon (who is still my muse). My hand surgery was my last surgery, and it was the most therapeutic thing I could ever imagine doing. I wanted to be awake and aware for it, and I was able to feel the pressure on my hand, so much so that at times I wanted to tell this surgeon to be careful:), but to soak in that experience seemed like a burden had been lifted off my shoulders (even though I hadn’t really realized how intensely my past surgeries had effected me). I’m grateful to have found this blog, Dr. Schwab, because you go into detail about surgery from a surgeon’s point of view, which furthers my quest for knowledge and understanding, and its just so much fun to learn! I’m trying to learn as much about the brain as I can, especially the areas of my brain that were injured, though I find only sparse explanations of a ventriculostomy (and I saw it on ER once), so if you should want, maybe in a later post, I would be much obliged if you were to delve into the brain!

Anonymous said...

It's easy to say 'laugh a lot' when you've had good recoveries from your surgeries. It's a different story when there is no recovery, when you the patient are no better off after surgery than you were before.

What's also difficult to deal with is not only your own disappointment, but that of your family and friends, who had high hopes that you would get better. Particularly since having surgery is so dramatic, that it means being in the hospital, and that you'll likely need help at home after an operation.

I feel very sympathetic with the two posters who've had pancreatic surgeries; their situations are far more serious than my own unsuccessful ankle surgery. My impression is that the risks and complications of their surgeries, as well as the success rates, were not adequately explained to them. I also get the impression that they weren't given much information about what their lives would be like after their operations, even if the operations did successfully correct whatever was wrong. I don't have the impression that they feel their surgeons had poor surgical skills.

I do enjoy reading this blog, and I've certainly learned a lot about the working life of a general surgeon.

Anonymous said...

In response to lrl...My whipple was live saving, that is all. My surgeon is Dr David ER Sutherland. He is one of the world's leading transplant surgeons. He is the leader is and the pioneer of the ICT. He is the best of the best. I first went to him for transplant. After we talked me and looked at the ercp films, and given I had 2 pancreases, not all of my duct work, no connecting duct work, and SOD and gastroparis, the whipple was the obviouse choice. We looked at my whipple as "part one" . When you reach that level medicine, the dynamics change. I also want to remind you that they call it "the PRACTICE" of medicine because it is just that you truly one never knows how you will respond or what's really in there once your gut's open. That has happened to be more times than not, we had to go to plan B and sometimes there was no plan. We just had to the best we could. There are no promises or guarentees. and yes, you CAN still laugh. I used to paint my toe nails shades of blue. One on my nurses actually thought something was wrong with her eyesite! LOL on time I got a pancreas , a stuffed one from Eli Lilli, and strapped it to my belly with a note, say "not this one" one once saying, ' no stents please". You can laugh. Even when it's not one time, one of my nurses thought I was a phengren adict, so I refused it just to shut her pie hole and I barfed blood. It was funny...Everything is a choice and it's how you make it. My surgery was successful, I alive. The bottom line is, once you r pancreas goes bad, there is no good senerio. None. You can get a stent, and it helps, but it also causes more damage and brings on an acute attack, which can kill you, there are about 6 surgies they can do, but like, for me, I need drainage in a really bad way, sludge had to be pumped out of me on a regular basis, so, whipple was the best choice for me. I knew what a stent did and to have someone CUT my pancreas??? Was I insane?? It's a business decision and you have to lok at that way, you can not get persoanlly involved when medicine is at that level. You have to look at the facts only. The pancreas is an evil evil thing...if you really want to understand it, read my blog and then you will see. Take Care and you are right about could i have put them threw so much, years of my disease..and tell them I am not much better off?? They are tired. How could I tell them? For me, I said, you know, we knew this could happen, we knew that going in, it's the nature of the beast and this is why I chose the best transplant surgeon


Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...