Monday, February 12, 2007


I consider surgery -- yes, even surgery -- to be grounded in science. Positing an idea, subjecting it to testing and peer scrutiny, healthy skepticism, constant re-evaluation: all those things, we do. Doctors are heirs to those who invented transistors, calculated moon-shots, figured out DNA. Still, it's not as if we're pure as snow, scientifically. I'm not, anyway. My gut -- which has metaphorically and metabolically grown over my career -- still plays a role. Here's one example, and I'd bet other surgeons (and to the extent that the concept applies to other docs, they too) would agree with this: you can tell who's going to do well as soon as you meet them. I doubt it's testable. For that matter, it may not even be true. But I'm saying there's a vibe about some people, good or bad, that can fill a room -- signaling strength or portending problems, making me light on my feet or feeling doomed. Demi-doomed, anyway. Wish I'd been able to bottle the good stuff.

We're talking gut here, so I'm not sure I can elucidate. It's not about particulars, although surely there are some at play: eye contact, family interactions, general health. Attitude. Practicality. Not fear, per se: everyone's afraid. How and where the fear fits, how it's broadcasted. What questions are asked: about pain, side-effects vs. how soon can I get back to work. Humor. (Especially, appreciating mine!) And you know who's predictably among the best? Little old ladies. Let's hear it for little old ladies. Maybe it's because they've seen it all; perhaps it's because they are innately trusting. It's not, certainly, because they're worn out or don't understand. They just know they can handle it, is all, because they've already handled so much. Yeah, maybe that's it.

It's widely held, I'd say, that positive attitude improves outcomes; optimism helps to cure cancer. At least one study says otherwise. As squishy a thing to measure as is "attitude," I'm sure the study is subject to criticism. Still, the result doesn't surprise me. Stress maybe. Attitude? I'd question it. But I have no doubt (just don't ask me to prove it) that how you feel going into an operation has much to do with how you come out of it. Even little things, in my self-regarded opinion, make a difference. Here's one: in the recovery room, when patients are just struggling awake, most nurses ask them "are you in pain?" When I'm there, I ask "are you comfortable?"

If, as studies tell us, a more happy patient isn't necessarily a more cured patient, nevertheless you'll never convince me (until a study is done) that a happier patient isn't a quicker-recovered one. I'm a hand-holder, a sitter-on-the-bed, a patter-on-the-knee. I'm a cracker of jokes, a looker-for-the-lipstick-sign.* And my patients, mostly, got home happy from surgery, PDQ. For that, I do have data. And the ones that didn't? Well, I just knew it.

*Positive lipstick sign: when a lady makes the effort to put on lipstick after surgery, you know she's on the home stretch.


Anonymous said...

Cancer patient, here.

I thought the burden of wisdom in the "optimism" article you linked to is, of course, the "burden." I tend to avoid both civilians and health professionals who, intentionally or not, force me to act out the role of happy optimist. They wear me out. Even worse, too much of that just makes you want to take refuge in self-pity (No one understands me! They keep wanting me to be all optimistic! I will now show them what's what by being a real pessimist!)

I'm doing pretty well, given my disease and stage at diagnosis and all that. But I won't claim to be one of those people who gets the bad news and then suddenly transforms into everything they always wanted to be, because time is so short. I mostly try to be what I used to be, when I can. One of the things I used to be was the weilder of a pretty dry sense of humor, and I haven't given that up. I have no idea what relationship it has to the idea of "optimism."

All I know, Dr. Scwab, is that you could come sit on my bed and tell jokes any time. When I told my internal medicine doctor that she had more guts than I do--after a hemicolectomy, most people on earth have more guts than I do--she didn't laugh. Damn it. I thought it was funny.

Sid Schwab said...

And indeed it WAS funny! After all the intestinal resections I've done, I don't recall anyone saying that one.

It's true: people need to deal with these things in their own way, and, however well-intentioned, sometimes cheerleading from the sidelines is the wrong thing at the wrong time.

Anonymous said...

Have you ever had an ostomy patient mention that Nurse X was an asshole about something, and we all know I don't need an asshole I have no use for, I've already got one I have no use for?

To me, "cheerleading" was kind of like salads. Yes, salads are good for you. Yes, I like salads. No, you are not helping me by bringing me salads two weeks after surgery; I've explained to you a jillion times that I can't digest them at this point. When the day comes that I can eat salads again, I'll let you know. Until then, you can either share my oatmeal and applesauce with me, or wear my oatmeal and applesauce. At the moment, I don't care which.

Some friends and family learn to deal with that, some don't. You just have to avoid the ones who don't.

SeaSpray said...

Dr. Schwab - I am not at all certain that I should be entering such a long comment here. Obviously, your post spoke to exactly where I am at. If I mention God - I do not mean to offend anyone - it is simply my belief system. I will probably copy and paste this comment to use for one of my own posts in some way. If this is too long - then please delete it.

Dr. Schwab - you ARE speaking to me! It really does seem as though you are writing just for me lately.

You know how sometimes you hear that a pastor will have given a sermon that speaks to many people in the congregation, so much so, that individuals are affected so profoundly that they think the message was just for them? Well, your posts of late have been having a profound affect on me as well, addressing concerns that I have had but because I had lost sight of who I am, my belief systems, etc, I lost my focus, sense of purpose and opened myself up to fear and negativity.

THAT is so opposite from who I really am and how I HAVE lived my life, whether for myself or helping others. I have ALWAYS been the person that sees the good through the bad and the bottle half full and THAT attitude does carry one a long way, through even the most difficult of times.

Maybe, I just got worn out from the seemingly unending roller coaster ride of the med issues this year and their effects into other areas of my life and therefore allowed that bottle to be turned upside down. Also, as I commented in one of your recent posts - I put God aside this year. I never stopped believing - I just didn't apply my faith knowledge to my circumstances, which surely would've affected my attitude, possibly affecting outcomes....ripple effect and all that. :)

Certainly, my med issues pale in comparison to the really serious diagnoses, but I think it was the frustrating ups and downs over a long period of time and then by the time fall rolled around there were other stressors that I normally would've handled well, but instead they just piled on and so by Christmas I was totally overwhelmed.

I was not in a good frame of mind to be contemplating surgery or any other serious issue. I don't think I have ever felt such a sense of powerlessness or fear and anxiety and was in a horrible emotional place to be. Also, I was thinking with my emotions by that point and not my head!

My doctors, family and friends could not have been more supportive. I have been blessed with really good people in my life. This girl does know a blessing when she sees one! :)

I am ashamed to say that I became totally self absorbed, looking inward, navel gazing if you will - when I should've been looking outward to see who I could be helping.

I have always considered myself to be a very empathetic and compassionate person, but boy oh boy, when I do get back to working around patients again - they will certainly get that and more from me! I want to be a blessing and NOT a hindrance. :)

I am happy to say that while it has been a 2 month process( at times - I crumbled like a little girl),that I AM rallying back to my stronger and optimistic self again. Thank God!

I would be lying if I said that I didn't have concerns about surgery - but then I don't think I would be normal either if I didn't give some thought to it. I just REFUSE to dwell on the negative and am believing for a good outcome!

I believe your instincts about positive attitudes are right on the mark and certainly you have seen the outcomes over the years.

You are right about little old ladies. I have seen them come into the ED and not want to interrupt anyone - even when they are having cardiac problems! Fortunately, because of triage requirements - they don't get past us.

I agree with the study in that I do think it is important to validate the patient's concerns because they DO need to be understood, heard and maybe reassured that what they are feeling is normal. At the same time, I also think it is possible to hold on to optimism for them when at that moment they feel they can't.

There is a scripture in Proverbs (NIV) 17:22 that says:"A cheerful heart is a good medicine, but a crushed spirit dries up the bones."

Also, didn't Norman Cousins cure himself by watching a lot of funny movies?

I have always appreciated the wonderful senses of humor that medical people have, especially the OR staff. I would much rather be on their side of things, helping the patient but have been grateful for having some good laughs before going under! I actually wrote that in a thank you note this past summer in which I said something similar.

You are so right about the lipstick sign! When I had sepsis - I was so drained, weak, etc. - that I was unable to do any of that. I remember how good it felt to finally be able to shower, dress and become a painted woman! The day I was discharged, I saw the surprise on the nurse's face when she saw that I had changed from sepsis girl to a normal looking one!

Oh, by the way Dr.Schwab - "hand holder, sitter-on-the-bed,patter-on-the-hand and cracker of jokes" - I think I would've put my lipstick on just for you. Do you like pink? ;)

Seriously, this post has been inspirational and speaks to what I also believe is a concrete reaffirmation to my spirit of who I really am, to embrace that and move forward with courage if needed, yet with joyful anticipation of a good outcome, remembering that ultimately God IS in control. (I can not believe that I let myself lose sight of that!) Also, looking forward to all the laughs along the way! :)

Thank you Dr. Schwab.

P.S. All things do ultimately work out for good. When we overcome our tough times, we are than more equipped to someday help someone else through their difficult moments.

The Angry Medic said...

Whoa, Dr Schwab, looks like you caught a few patients with this one.

I agree with the optimism thing. This study, along with the one that said prayer was no help for recovery, is bollocks in my book. I may not know much yet, but one thing I have been taught (yes, taught, quite literally) by the patients I have seen is that optimism is invaluable in treating patients, no matter how minor (or major, in this case) the illness.

I applaud you for being a hand-holder and (as some doctors would put it) a coddler. I've seen surgeons who are the exact opposite (but you know all about that :P) and I'm gonna be exactly like that when I finally get out of med school.

SeaSpray said...

Good for you Angry Medic and good for your patients! :)

Sid Schwab said...

AM: I have no doubt about the attitude/recovery connection. Recovery referring to getting over the effects of surgery. Long-term outcome, ie "cure," may be a different matter. But as I've tried to say in several posts, I've always felt strongly that the way a surgeon relates to his/her patient is highly important; and it's clear it's an overlooked issue by many.

In reference to your comment on an earlier post: it reminds me of a time when I was operating on a fairly ill trauma patient. It happend that several of the team were decent singers (I did some musicals in high school and college -- had someone heard me and said, kid, I can make you a star, I might have dropped medical dreams in a flash) and we were doing a four-part rendition of the Hallelueah (how the hell do you spell that?) Chorus. Sounded damn good, too. (Some ORs are not unlike showers, acoustically). It occurred to me that at some level the poor patient might be hearing it and figuring he'd died....

SeaSpray said...

Ha!Ha! At least he heard angels! :)

Anonymous said...

Dear Cancer patient, I understand you can not always be optimist. Long term disease wears on you in every possible way. I get that. And yeah, I know that sometimes, people say to look at the bright side and all you want to do is say "oh shut up, at least you can eat" (or whatever the case may be)If iot makes you feel any better, I have had most of my guts removed too..the good thing is, all of my friends who are older are getting sick and stuff, I have nothing left to get sick or to! I'm just saying, I kow you mourn the life you once had and I know it sucks and it's hard to embrace what you currently have. I kow the future can look daunting, at best. You aren't alone though. Hang in there.

SeaSpray said...

I just reread what I wrote earlier and wondered why I did so much self disclosure about myself. So, then I reread your post again and it just speaks volumes to me about a positive attitude prior to surgery.

I had already determined that I would have an attitude adjustment regarding certain things and your post reinforced that decision.

I am printing your post and my comments to review if necessary as a reminder to stay focused on a positive attitude and the good that is going to come from all of this.

Regarding a patient asking about pain/side effects vs how soon they can get back to work - I do think it is important to be knowledgeable in what to expect, so that they know that something is normal and no need for alarm or so that if something is wrong they can alert the staff and not just assume that something potentially emergent is the status quo.

(I know the point you were making is about attitude.)

Someone once alerted me to the fact that when you have a spinal, you can't feel yourself breathe and it had scared this particular person to the point that she said she started to panic. That information helped me because, sure enough - I couldn't feel my self breathe and I knew that I was - but it was still a bit unnerving, yet I remained calm.

Anonymous - I love it when people have a dry sense of humor and your joke about the guts is hilarious! "Damn it. I thought it was funny." Also hilarious! :)

P.S. When I do get back into the working world, people in the blogging world will probably say "SeaSpray Who?", but for now - I apparently have a lot of free time. :)

Greg P said...

Medicine is a strange business indeed.
I had an ALS patient who became a good friend, and we'd have a good time whenever he showed up.
One day I received a call from an ER in town saying that he had tried to kill himself by running his power wheelchair into the Ohio River.
A few weeks later, there he was in clinic! What was this going to be like?
He was jubilant, telling me about the adventure he had, and I found myself sitting there in the room with him, laughing as he told his story about the "GD Good Samaritan" who rescued him.
He expressed no regrets. I think he felt that he gave it his best shot, it didn't work out, so he accepted his fate.

Anonymous said...

I know that this is probably not what you are referring to when you wrote about attitude but your post made me think of my experiences with utilizing the gut-o-meter, but in reverse. That is, as a patient, I can sometimes determine within the first couple of minutes if the physician or surgeon is a genuine and sincere caregiver or if he / she is just doing a job.

Like you, I cannot describe what cues I pick up on at a conscious level, but there are many overt mannerisms as well as subtle actions that make an impression. What I can describe which leads to a positive rapport are those that you listed when you interact with the patient: that is, optimism grounded in realism (with a pinch of fatalism); good humour - the dryer the better (my surgeons favorite expression was "this is going to hurt you more than me") and respectful interaction with his / her co-workers (respect, decency and truth goes without saying).

My worst experiences were with physicians and surgeons that I had great feelings of trepidation within the first few minutes of the visit. However, how much of that is self-fulfilling prophecy?

My best surgeon had the driest wit and the funniest shtick that I have ever encountered...(think Robin Williams meets Jon Lovitz)...the worst surgeon I have encountered never once cracked a smile (think Spock on his most "I am NOT 50% human" days).

The waiting room is also another big place to gather vibes for intuiting physician "attitude". You would be surprised on how the interactions between surgeon - office staff - allied personnel can make or break a doctor / patient relationship.

I do have some philosophical alarms that are ringing in response to doc's assessment of patient attitudes, but I am sure that this will be completely off topic (but I can be encouraged to elaborate!)

Anonymous said...

you choose a surgeon by their ability. When it's all said and done, it doesn' matter how nice they are, what sense of humor is, or if you hate the surgeon's guts, all that really matters are the pieces you are left with. How well the surgeon did their job is all that matters in the end. It's a business decision.

Bongi said...

the more i read your blog the more i realise all our cute south african surgical sayings anre actually international. the lipstick sign i truly believed was made up by a surgeon at one military hospital in pretoria. now i see it was not. small world.

SeaSpray said...

Greg p - Your patient was blessed to have you for his physician & friend, helping him through that awful disease.

Black humor is great for diffusing the emotional challenges. His joke about the Good Samaritan is a riot! I think it is terrific that you didn't judge or lecture him but met him where he was at.

I have a dear friend that is now having an Art Buchwald experience because she is in end stage renal failure, among other things and has outlived her allotted hospice time and will be transitioning into 24/7 nursing home care. If people heard some of the dark humor, they would think I was a terrible person. Sometimes, I will get on such a roll with the jokes that she will start coughing from laughing so hard and I have to remember that she is on oxygen. We have shared tears as well.

Anonymous - Ha! Ha! "This is going to hurt you more than me" - hysterical! I had a doctor that I was a little afraid of after the first couple of momentary encounters, but he ended up being one of the most compassionate and excellent doctors that I have ever had.

I think Kathleen is right in that in the end, we want the surgeon who is most able to do the best job for us, but it's wonderful when a patient can have compassion with the excellence. Also, my doctors don't have to be funny - that's just an added bonus through a challenging time. Excellence,compassion and good listener - that's everything.

Dr. Schwab - I have decided that this is my second favorite post - next to your infamous "Taking Trust." :)

Sid Schwab said...

Bunch 'a great comments here: Greg, what a fantastic story. I'd have wanted to know that guy. Anonymous: thanks for pointing out that "vibe" works both ways. We probably all have little aphorisms we like to use. One of mine was about to say "here comes that infamous mosquito bite. 'Bout a four-foot mosquito."
Kathleen: the concept of "choosing a surgeon" is a good topic for a future post. Hmmm...

I love reading this stuff!

Anonymous said...

The Lipstick Sign is priceless. I'm linking to this story on my blog, and I'm going to write an entire post just about my grandmother and her beauty regimen. Thank you so much.

Eric, AKA The Pragmatic Caregiver said...

There's a Seattle hand-and-wrist surgeon who is semi-notorious for trying to lure unsuspecting reconstruction patients (like me) into high-fives at their first followup. Everyone's a comedian.

My mom's first medical oncologist on this go-round had an exceptionally quick, dry sense of humor. At some level, when facing pretty grim odds, it's actually a comfort to be able to laugh about it.

Bad oncology joke: what's the difference between Shea Stadium and recurrent cancer?

At Shea Stadium, the Mets don't always win.

Anonymous said...

Actually I respectfully disagree with Kathleen about the bottom line being that choosing surgeons is just a business decision (or at least don't agree completley). And I think that is the point that Dr Schwab is making with this post - that it is the intangibles that dictate how successful the operation will or will not be. And that the intangibles are not quantifiable or even detectable by any known method. I truly believe that you can have the most technically talented surgeon in the world with a textbook succesful operation at the worlds highest rated hospital and still have a fatal or significantly disabling outcome after even the most "simple" of surgeries. Analysing the factors that came into play would reveal no recognizable or anticipated cause. Now whether this can be attributed to that "attitude" of the patient or physician that we are discussing here I have no idea...but I do know that when it comes to choosing who will take care of me, applying the rules of business will never come into play.

I want to be a patient taken care of by a doctor; not a customer or client who "hires" a health provider working under the market system. There are very significant philosophical, moral and legal distinctions between shopping for goods and services and being cared for by a member of the professional health organization.

Anonymous said...

Dr. Schwab,
Wonderful post! Incidentally, a few people from my church and I are going to the ICU of the hospital in town tomorrow because we read an article that said Valentine’s Day is the loneliest holiday to be a patient in a hospital, so we’ve been doing this for several years. We’re taking gifts that the nurses can give to their patients and cookies for the doctors and nurses. In a way I do this for my trauma surgeon in my endless gratitude.

Anonymous said...

Dear Dr. Schwab, This is my favorite post by far, including reading the comments. Choosing a physician may start as a "business" decision, ie insurance coverage, but surely not the most important factor. To me, the relationship must fit, which includes compassion, respect and trust (along with a killer sense of humor) on both sides of the relationship. I had not heard of the "lipstick" sign before, but I live it each day since my MI and intervention procedures. And I never understood why until now... I've not left my house for any reason without the lipstick and looking my best, including all those trips to rehab, because I am so thankful to be alive. Must be why I always dress up to see my doc. So glad you are a hand-holder, sitter on the bed type of doc. My doc sits beside me, and I get/give hugs from him too. It makes such a difference in the healing process.

Randall Sexton said...

Very good post. You need to join me in training as a shaman, lol!

One poster thinks that mechanical skill is what makes a surgeon. I'd like to see a study on patient outcomes with surgeons of equal skill, but one an a**hole and the other like you.

Anonymous said...

In my case, the "lipstick sign" is meaningless, since I never used to wear lipstick. For me, it's the "limerick sign."

There once was a patient named Maggie
Whose spirits, you know, were quite saggy.
"Well, I don't give a shit,"
Maggie said in a snit,
"Since it now takes two hands and a baggie."

Maggie's nurse was a saint, name of Joanie,
Who did not hold with being a phony.
She said "In your fretting
You're clearly forgetting
That where there is shit, there's a pony."

"Pony! Ha!" Maggie barked with a scowl.
"Go ahead, lay it on with a trowel.
Just because you've got guts
Doesn't mean that I'm nuts
To be mad that they've cut up my bowel."

Joanie said, "Dear, that anger will bind you
And misery surely will find you.
Now your farts, so we learn
Blow ahead, not astern,
So I'll always be right there behind you."

Now, you might think our Joanie is naughty,
And Maggie, you think, comes off dotty.
But spare me your views
Till you've walked in my shoes
And sat for a while on my potty.

Lynn Price said...

“you choose a surgeon by their ability. When it's all said and done, it doesn' matter how nice they are, what sense of humor is, or if you hate the surgeon's guts, all that really matters are the pieces you are left with. How well the surgeon did their job is all that matters in the end. It's a business decision.”

Respectfully, I disagree with this. I write medical fiction (with a definite twist), and in all my research of docs and patients, there was a dominant correlation between attitude – doc’s and patient’s – and the patient’s pain med intake and overall speed in the healing process.

There is so much we don’t know about the human spirit and its ability to affect physiological change. Sure, these notions get laughed out of the zip code because you can’t put the elements that influence a human spirit, let alone the human spirit itself, under a microscope and say, “Ah hah, there it is – right between the liver and ribcage.” I interviewed plenty of docs who share your views, and, yes, they had success with their surgeries. However, I interviewed plenty who didn’t discount the idea of successful healing through non-medical treatment; prayer, meditation, laughter, touch. I’ve talked to far too many patients who don’t believe for a single minute that their surgery was strictly a business decision where their only criterion for choosing a surgeon was that of talent. Their choices were also based on an intimate act of faith and how well their surgeon empathized with them and their own beliefs.

Anonymous said...

To Lynn, I have to make surgical decisions like business decisions because no one in their right mind would do the crap surgeons propose. You reach the end of the road, no options...It's live or die and the surgeries used to save you cause more damage and lead to bigger surgeries where you have to start going to the Mayo...and can help you, but it's a trade evil for another..I'll tell you what, God for bid you ever get really sick and need highly specialized care when only a few docs will even touch you. Then, God forbid you have a major life saving surgery and still, you are not cured, then you are told, you never will be. You will always have battles. All the while, more organs get cut, removed and the only end in sight is when you run out of organs to remove...Maybe then we can talk about how it truly is a business decision. I had my choice of 3 surgeons in the US, one spoke almost no English and wanted me to blindly trust him. One got sick and left JH, One did the surgery "a few times" and wanted me to come down for an exploratory first, thus the 3rd one, one of the leading xplant surgeons in the world...what do I care if he is a nice guy or not, he was my only choice. Lucky for me, he is super nice, I'm just saying, you don't always have the luxery of choosing. That's the reality.


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...