Sunday, February 04, 2007

It's Complicated: part three

The idea behind surgery is a really simple one: you come to me with a specific problem, I fix it, you go away happy. And when you come back, you're still happy. What's so wrong with that? If I wanted to be miserable, I'd have gone into primary care.

When a surgeon screws up, his/her role is clear: admit it, make it better, or as good as possible, and stick with it as long as it takes. (Comments on the first two posts in this series indicate that it's not so clear for some surgeons, and it's depressing to realize it.) But what about when you don't screw up, and the patient is still unhappy? As I indicated last time, in some ways that's the most difficult situation of all. Once again, it's complicated: there are bad outcomes or side-effects that result from well-thought-out and well-carried-out surgery; and there are, well, who knows exactly what they are...

As an example of the first sort: it's possible nowadays, with certain beautifully engineered staplers, to remove a rectal tumor and hook the colon right down to the anus, sparing the patient from a colostomy that would have been a certainty a couple of decades ago. When approaching such an operation, I would always tell the patient that there could be difficulty controlling the bowels, temporarily or, rarely, permanently. Converting to a colostomy later is an outside possibility. Likewise, it's not rare for a circular staple-line to scar down to a point where it could need dilating, which is usually a simple office procedure but occasionally requires an anesthetic. Those things are, in fact, pretty straightforward: if the problems occur, the patient might be uncomfortable for awhile (or in the case of poor bowel control, miserable.) But it's a known thing, and not reflective of operator error. And there are fixes. If I'd ever had to convert a hook-up to a colostomy later (I never did), I'd have felt bad for the patient, and no doubt would have encountered disappointment. I could handle it without feeling like a screwup, and likely without losing the patient's trust.

Somewhere in between this and the most miserable circumstance, is the patient who doesn't get better. Early in my practice days, I did a text-book perfect thyroid operation for a young man with Grave's disease (over-active thyroid.) Taking out most of his thyroid, successfully avoiding the mine-fields of damage to laryngeal nerves or parathyroid glands, leaving him the perfect (according to my training) amount of residual gland with which to live without the need for thyroid hormone replacement pills, I felt great about the whole thing. Six months later, it was as if he'd never had an operation: big neck again, and all the symptoms. For me it was like falling off a nice sailboat into icy water. (And it led me to decide that people are better off taking pills than having a relapse; so I began -- without any regret -- to remove essentially the whole gland for all my future patients. Hell with what I'd been taught.) Faced with re-operation -- more dangerous the second time around -- he opted for radiation, which he'd strenuously rejected as an option initially. Feeling bad is bad. I guess it's better than feeling guilty; but I didn't like seeing the look on his face. Knowing I did everything right doesn't change the sense of failure. To me, it's like a robbery: I feel great about it, I have every right to, and then suddenly it's all upside down. "Gee, I hope you know I did everything right" is what I want to say. But I don't.

Sometimes a proper operation makes things worse. Known side effects, like dumping syndrome: it's like playing great odds and still losing. These can be the times when the surgeon sends the wounded patient back to his primary care doc -- or with dumping, to the gastroenterologist -- creating ill will all around: surgeons just operate and leave the problems to someone else. It's where the stereotype was born, I'd say. In my practice at least, it's an unfair characterization: I'd do everything I could for as long as I could. But there comes a time when other expertise is likely to be better; when it does, it looks -- and feels -- bad.

And what of this: I operate, I fix the problem, make it gone. But the patient isn't happy: I can't sleep, he says; I get headaches all the time; my bowels are messed up. I'm sweating. Ever since the operation, I've been impotent, anorgasmic. My incision still hurts. It's a long and frustrating list, and it's likely eventually to lead to an unhappy parting of the ways. "Tie goes to the runner." "Benefit of the doubt." Such things need to be taken seriously; there are a number of known causes for various post-op symptoms. But after enough time, enough tests, enough maneuvers and investigations to have ruled out every imaginable cause, where do you go? What are you to think? Can you broach the subject of psychological cause without producing a pissed-off patient? Like post-partum depression, post-op depression is a known entity, and I've used anti-depressants sometimes, to good effect. But it's a touchy subject. And when that doesn't work, then what? It's tempting simply to say, look, I've done everything I can, you need to find a new doctor. Some do, I gather from this and other blogs. It really is the hardest of all: there's no pleasure or satisfaction, there's no explanation, there's no graceful exit, no fallback. It makes everyone miserable, the relationship is shot: in every way, it's the complete opposite of why you're doing this. It just sucks, that's all there is to it.

I also mentioned discussing the frustrations of cleaning up another surgeon's mess. Forget it. I'm already too depressed.


SeaSpray said...

Wow! Again, another moving post. Maybe I will respond to this later when I have more time. All that post-op stuff - is that why a surgeon might not want to commit - if the surgeon feels they can't invest in the follow-up time? In all probability post-op will go smoothly, but if it doesn't, then is that where the commitment is key? Do some physicians have more time to commit than others based on what insurance plans they participate in? They have a busy practice and so can't spend the time on a lengthy follow-up if necessary?

I never realized how involved everything is for you surgeons. I have always thought of you as just like going to see a PMD and it is only through these med blogs that I am realizing going to surgeons is different.

Sid Schwab said...

I should have responded to your "commit" question before. Commitment is part of the job of any doc, and, to my way of thinking, comes with the territory to the extent that it shouldn't even need discussion. I suppose the opposite is noteworthy, and from reading comments and other blogs it's more of a problem than I'd like to believe: doctors (maybe surgeons more than others) who seem not to have a commitment to their patients.

I had a patient who came to me with problems after an operation by a fancy surgeon at a fancy place: she said he walked into the room past her, looked at the xray, said "well, my operation isn't the problem," and walked out. That's not commitment.

C. said...

You mention post-op depression in your post. I have had two major surgeries, the most recent on 12/1/06 and suffered depression and anxiety after both. Why don't surgeons address this issue pre-op?

After bringing up the subject with a physican I was told surgeons don't like to bring it up so as to not "create" the problem. How do you approach the issue of post-op depression?

Sid Schwab said...

C -

I think post-op depression pretty uncommon; but surgeons need to be aware of it and consider it. I didn't routinely mention it, but it wasn't because I was worried about "creating" it. Nor was it a conscious choice not to mention it: it's just so uncommon that I guess it wasn't on my list. But I did look for it in particular situations. Also, it's multifactoral, I'd say. It's much rarer -- at least in my experience -- in routine surgery, even routine big surgery. On the occasions I saw it -- which were few -- it was in people who'd been very sick for very long. Which is not to say that's the only setting. When I've thought it was an issue, I'd bring it up directly, comparing it to post partum depression and saying that it's a real entitity that can be treated. Had medication not worked -- and it seemed to in the couple of people for whom I prescribed it -- I supposed I'd have considered a psych referral (after discussing it with their primary doc, of course.)

Bo... said...

So many of my patients are greatly relieved when I tell them about post-op depression. Knowing there is such a thing reassures them that they're not "going crazy". This has been a wonderful series of posts--very fascinating and enlightening about the "other side of the fence". I wish a lot of my patients could read it...

C. said...

My first surgery (bilateral mamoplasty) was fairly extensive and my surgeon did a fair about of pre-op advisement which I found very use full and mitigated what could have been worse.

The Cholestectomy that was done 12/01/06 and was much less planned as it was an emergency admission. He may have, but i dont remembering hearing anything about the propensity towrds anxiety and depression post op. I was partially prepared, but the anxiety is far worse and it is 2 months out.

Greg P said...

As good as any of us can be, I think we all have blind spots. Things we don't see, don't perceive. And like blind spots, we don't see that we have them, because our minds fill in the blank space so you don't see that hole in your thinking, your experience, your expertise.
What wisdom comes from practicing medicine for years is first the acceptance of that blind spot, and finding ways to know where the edges of it are so when it's not in the patient's best interest to stay with us, we help them find better help somewhere else.

SeaSpray said...

I think it's admirable when physicians recognize their limitations and acknowledge that it is in the patient's best interest to get help from another physician. However, if there has been a good Dr/Pt relationship, then there is a chance that patient is going to be resistant at first. Especially, when it is a relationship of mutual trust and respect and the doctor has really helped the patient.

Speaking from my own experience it can be downright scary to make the switch. I have said it before in these posts, but I have been blessed with an excellent and compassionate doctor.

I have been through a lot physically this past year (certainly not as bad as some but just tediously drawn out wrought with uncertainty) lost both jobs because of it, financially strained (yet I have felt unable to commit to a new job because of health concerns that may or may not have been justified) along with some serious concerns about loved ones, etc. etc. and such is life.

Hind sight being 20-20, I now see the cumulative effect this has had on me,taking it's toll and causing anxiety and intermittent depression. I was NEVER like this before!

The LAST thing I want now is to switch to another doctor.

Yet, if I trust my doctor as implicitly as I say I do then why is it so difficult to trust him in this and make the switch? Comfort zones and all that, I suppose. But it would seem that IS exactly what I have to do to move forward and get some resolution to all of this.

Having said all that, I do understand why I need to go to someone with possibly more expertise and at the very least a fresh opinion. However, my anxiety level has gone up even more since I found out that I probably do have to have the surgery I have been avoiding. So, basically if I avoid this new doctor than I can avoid hearing him confirm that I need the surgery.

I will be seeing the new guy for a consult tomorrow night.

I think it is of utmost importance that while the doctor encourages the patient to move on that he be patient and reassuring with the patient whenever possible. Mine has been, but it still isn't easy for me.

While you doctors see so many, many patients - each patient only sees you. They trust you. They are used to just you.

So much time and energy gets invested both ways between doctor and patient.

If it is life and death - then it's a no brainer - go where your life can be saved!

But when it doesn't feel emergent, it is easy to stay in a holding pattern, which is exactly where my life is at right now - on hold. Which is what he has told me - that I am keeping my life on hold if I don't do the surgery.

Dr Schwab - this post really spoke to me, on many levels.

Anonymous said...

Something I didn’t say in my comment on your last post (thank you for your kind comment about my comment) is that while I received frighteningly bad medical care when I had my first baby and for her almost surgery, I think it may have had a good deal to do with the fact that my brain injury had been less than two years earlier and I still “looked” brain injured. It hurts to say that I think they treated me poorly because they assumed I didn’t know what was going on or that I would forget it. One of the misconceptions of brain injury (at least mine). It hurts to say that they treated me like I wasn’t a real or complete person. This is why I can so clearly see how wonderful my trauma surgeon was, and more recently my family doctor (in spite of this bad experience, I feel so blessed). A few years ago I had the opposite happen, still resulting in poor care due to the misconceptions of brain injury - I went to an eye doctor because I still could not focus my vision, but after I told him about my brain injury he simply shrugged and said, “You look fine.” I was so upset when the Terry Shaivo controversy happened because (admittedly not knowing much about medical care at that point and what is most humane) I felt like they were treating her less than humanely. I think that even in some areas of the medical world, there might be prejudice against the handicapped.


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