Friday, March 21, 2008

A Horrible Feeling

Probably I shouldn't write when I feel this way. I'm stunned by the death of a really good person, whom I've known for a long time. Our kids were friends. We spent lots of time on lots of sidelines of lots of athletic fields, watching our kids and talking about whatever parents talk about. Let's call her Mary. And the thing is, she died after an operation of a sort that I did all the time and which, had I still been in practice, I likely would have done for her. Which is, among other things, why I feel so bad.

I've always felt guilty about bailing out a few years younger than I'd intended. I tell myself -- because it's true -- that in my foreshortened practice I did more surgery by far, and saw more patients by the thousands, than most surgeons do in many more years. That's, of course, one of the reasons I burned out. But the guilt has until now been sort of generic. Today, in a bizarre and (I know) entirely unrealistic way, my guilt is personal. I feel like I let Mary down by not being there.

There's no reason for me to think mistakes were made; in fact, they most probably weren't. But I find it nearly impossible not to think that had I done the operation, and had I done it the way I always did, Mary would have done fine. I never had such a thing happen to my patients, and I've done many more than the surgeon who did hers. Of course, bad outcomes can happen no matter what; and had it ocurred if I operated, I'd be feeling immeasurably worse.

One of the corollaries to being able to dramatic good as a surgeon is the potential to do devastating harm. I've had operations turn out badly even when done well. It's an awful thing. But this is the first time I've felt like this: a sick feeling at the loss of a friend, compounded by a hard-to-suppress sense that had I had the (what is the word? Character?) to stay in practice longer, it wouldn't have happened.
I wish I'd been there. Perhaps it's not so much guilt as helplessness in the face of tragedy.

The tragedy is not mine. It's Mary's wonderful family's. But as her husband told me the sad saga, in my mind I was shaking my head and screaming in exasperation. Maybe it's just an example of a false sense of indispensability in the way I used to believe it. But, for whatever reasons good or bad, I feel deeply sorry right now, for Mary and her family, and in some perverse way, for myself. It's painful and embarrassing to admit it.


rlbates said...

Dr Sid, I wish I had some "sweet words" to give you as a "balm" to your sorrow. So sorry for the loss of your friend, for her family, and for you sorrow.

Take care.

tenchi said...

Dr. Schwab,

I am a 3rd year medical student and I want to be a general surgeon. Looking ahead toward the life that you yourself are transitioning away from, I cannot begin to understand the things you know and have seen in your life in surgery.

Despite all that, and with no disrespect meant, I have to take issue with your suggestion that there is even the slightest chance you could have prevented this truly unfortunate loss.

It is a blessing and a curse that surgeons take so much personal responsibility for these outcomes, when no matter how immaculate your technique was, bad things happen.

I am sorry for your loss, and whether your hands are gloved in the operating room or typing at the computer, helping to influence the next generations of surgeons, what you do continues to have great meaning.

Thank you,
Michael Sigman
Washington, DC

Anonymous said...

I'm sorry for your loss. Certainly, no one would hold you accountable for her death in the least. I don't know if this is any consolation, but (as I'm sure you know) it would have considered unethical of you to perform surgery on a friend. I hope you can soon come to terms with the truth that this was not your fault in any way.

Anonymous said...

Dr Schwab,

I am sorry for your loss of your friend and wish you the very best in this difficult time.

Would very much like to echo the thoughts of michael. . . .

I am a medical student outside the US, in a city you may never visit and in a hospital you will likely never see. If you were still a practicing surgeon, our paths would have never crossed. Yet, your blog has touched the lives of many in my class and inspire us to be better and more human doctors. Please don't underestimate the contribution this blog makes to the care of the patients of your readers all around the world.

Take care.

SeaSpray said...

I am so sorry for the loss of your friend and the feelings you have surrounding it all. She must've been a special lady for you to be affected so greatly.

You shouldn't knock yourself for retiring early. You did what you needed to do at the time. You also accomplished so much while you were in full time practice.

I think it is natural for you to go over the surgery in your mind thinking of all the things you would've done and wondering if there was a difference, could it have had a better outcome.

You didn't let Mary down because she wasn't your case to do and she wasn't expecting it. It does sound like you were a good friend to her and you are supportive of her husband.

And Dr S...You may not be in the operating room as much, but you are still helping people. You are a person who makes a difference in the lives of so many.

Good thoughts and prayers being sent to you and your friend's family.

broca's area said...

chill man dont be so hard on your self!....appreciate your self conscious!!!!:)

Anonymous said...

I agree with your commenter's views. You are where your meant to be, I feel. You may have been spared from being on her doctor's end of this outcome. (Where the outcome, possibly, could not have ended differently no matter who performed the surgery) We can't know. I'm sorry for the grief you feel. It is so hard to lose someone we love.

Anonymous said...

Why did the patient die? Inappropriate pre-operative assessment, limited intra-operative technique, post-operative complications, advanced disease?

egomosperficio said...

my condolences to you and mary's family.

Sid Schwab said...

I appreciate the comments. I didn't really post to fish for them; I just said what I was feeling.

For the record, I don't believe it's considered unethical to operate on one's friends; or even family. Stupid, sometimes. But it's not an ethics issue, per se. I have, in fact, operated on friends, partners, family thereof. I haven't -- except for minor procedures -- operated on immediate family. For some things, I'd have been tempted... but I'm pretty sure I'd not have done it.

Anonymous said...

I'm so sorry. And if Mary's family knows how very hard her loss has been for you as well as them, it would give them a chance to offer you comfort, which would comfort them--they know, as do we all, that Mary's death was not in any way your fault. It's the grieving together that helps the healing to begin to find a way in.

Anonymous said...

Really? They told us at my school that it's considered unethical to treat close friends or family members because you can't be as objective and you will almost certainly give them a different level of care.

Don't think I'm judging you for doing it though--I'm sure as heck going to deliver my best friend's baby!

Sid Schwab said...

tracy: maybe it's splitting hairs. I don't think it's about ethics; it's about wisdom. It's quite true that there's temptation to give a different sort of care, which is why it's generally unwise. It's only the specific word "ethical" with which I disagree. Unethical means something different to me: doing unnecessary surgery; improper billing; taking kickbacks; things like that.

SeaSpray said...

Dr Schwab...I am curious...and maybe this could actually be a post.

What would be the contraindications for operating on a friend/family member or anyone that you may have lost your objectivity and is the surgeon himself the most reliable indicator as to whether or not they should operate?

Do you think for most surgeons...a host of personal feelings might come up before the scheduled surgery as they anticipated it and would need to cancel or is surgical training so ingrained in surgeons that they can and do rise above any feelings?

I know of a surgeon who worked on the guy who assaulted his wife.

This is a silly example by comparison and obviously I don't have surgical training, but one night my husband's grandmother was being brought up to the ER with the paramedics. My shift was ending and so I asked the ADN if I could be in the cardiac room with her. I have been around hundreds of seriously ill/injured pts and carried on as usual. But as time went by and i knew she would be there any second, I started getting strong mixed feelings and told her that I changed my mind and went out to the waiting room.

Sid Schwab said...

I actually started writing a post about the subject today. I'll see where it goes...

rlbates said...

Seaspray, I was glad when my mom's surgeon let me scrub in on her colon resection (perferated diverticuli). I just assisted, but had much better peace of mind than if I had had to be in the waiting room. My mom told me she was glad I was there. So it helped both of us.

make mine trauma said...

Sid, I know that you realize that your guilt is unfounded. You wish you could have done more, but it was not to be. As all of those involved in surgery have seen, there have been amazing recoveries from operations that patients should not have survived, and unbelievable, untimely deaths from "routine" operations.
The universe has a plan that we don't always understand. You cannot change the past but you can be there for the family in the present.

Anonymous said...

Dr. Schwab,
I'm so very sorry for your extended loss.

Anonymous said...

I am also sorry for you loss.

Being a surgeon I'm certain you will be able to understand what went wrong. Although that will probably only magnify the pain- because you will understand how it might have been avoided.

To some of us uninitiated folks trying to get information, let alone understanding in such a situation, is like the Kafka book "The Trial".

I must say, that is an apt painting.

My best wishes to you, my friend I have never met, on this day.

SeaSpray said...

That's wonderful RLBates! I would feel better too if someone that cared about me was doing the surgery too.

I never thought of this before now...but I can imagine that it might actually be much more difficult for a surgeon to have to wait in the waiting room than a lay person because you all KNOW what can go wrong and I am thinking you would rather feel like you have control in the OR than feel powerless in the waiting room.

Anonymous said...

If my husband, parent or child were a doctor, especially a surgeon, I would be greatly relieved if they were in the OR with me. Even if just to observe.

Anonymous said...

I'm sorry for your loss, and grateful at the same time, to read the tribute you pay your firend in the telling of this.

The inability to have control over events such as these is so difficult - I'm reminded of that old graduate school saw that one must be able to tolerate ambiguity.

In this case the ambiguity is in not knowing if your skill would have led to a different outcome. I hope that in time you will be able to tolerate this specific ambiguity and take comfort in the remembrances of your friend and the richness she brought to the world.

mscriver said...

The best therapist I had would give you short shrift for your horrible feeling, labeling it grandiose and narcissistic. No matter where you draw the line and quit, there will be someone you could have saved just beyond it. When you are dead yourself, there will be people dying that you could have saved. This situation is not as though she had cried out for you specifically to come help her and you refused, is it? Or is it?

Given the blunt and freezing reality of that, it is a terrible burden to feel that something vital went undone because of a decision you made. We all have limits. No one hits them exactly. What if this person had an additional complication that you didn't know about -- maybe no one knew about -- and you insisted on operating, but lost her? Would that be less terrible?

But I ache for your grief.

Prairie Mary

gay CME guy said...


I've been somewhat 'blogosphere' absent of late, and am behind on reading my favorites, including you. I have no doubt that part of has made you such a good surgeon has been your personal, personable, humanistic approach with your patients, whether they were family friends or strangers. Although we've never met, I make this assessment from reading your blog and your book. There have been many times reading you, that I've thought to myself, "God, I wish you'd have done any of my 4 surgeries!". I have no panacea, nor words of wisdom to alleviate your grief and sense of guilt. To tell you "don't feel that way!", only serves to discount and diminish. I don't believe any of you readers have this intention.
The one thing that be said for certain about Mary's death, is that it just sucks s#it--for her; for her family and friends she leaves behind.
I hope you are able to find comfort by whatever means you can. As attested by myriad responses to many of your posts, your writings have had a positive impact on many people whom you will never meet face to face. Please know that.

Anonymous said...

I am sorry for your loss.

One of my parents' best friends was in a terrible car accident. She sustained an isolated pelvic fracture and landed in a Level I trauma center. She was alert and awake on admission. My parents wanted me to accept her to my institution, also a level I trauma center, albeit an hour away. I said she is at a competent center and she should be fine. She died an hour and a half later due to a poor resusitative effort on the part of the trauma team.

This was nearly 7 years ago... and I still think about it often.

Not Important said...

Dr. Schwab,

Just like rlbates, I am at a loss for words, but I am sorry for your loss.

Anonymous said...

Sid, I am sorry for your loss. I try to keep up with your blog, but find that I miss some entries - like this one. I am glad I scrolled all the way down to the bottom of the page and started reading bottom-to-top. I would have hated to have missed this entry. My, how powerful your words were. I am not a surgeon, but am a professional in a field that I love. I have a love-hate relationship when friends and family ask me to work for them on a project. Part of me believes that no one can do what I do better than I do, but at the same time I know that they will be too careful to express any concerns they might have post-job, and every time I see them I will wonder how they feel about the job I do. Not to mention my fee! Do I charge them market rate? If I charge them less, will they think of this as a favor? If I don't charge them at all, how does that make my profession appear in their eyes? I know I am being a bit uncomopassionate here, but it is what goes through my mind when situations arios - though none involve life-and-death like what you go through.


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