God of the Operating Room

It's an old joke: a long line of people waits at the Pearly Gates as St. Peter slowly checks them in, taking an eternity. Little guy in a white coat shows up, carrying a leather bag, stethoscope around his neck. St. Peter waves him through. "What the hell was that?" someone asks. "Why does that doctor get cuts?" "Oh, that wasn't a doctor," Pete says. "It was God. He just likes to play doctor once in a while."

But it's no joke. Whereas I don't buy the "playing God" aphorism, I've had to make life-and-death decisions on occasion, and I don't like it. I mean "life and death" literally: this person lives. That one dies. Saving a life is nice, and part of the job; failing to save one is horrible, yet inevitable. But deciding in advance -- looking at a situation and concluding it best to let things go, or choosing to render help when the outcome might be regrettable -- is a responsibility beyond understanding. Maybe it also comes with the territory, but who has the roadmap?


Bowel infarction is a good example. Dead bowel happens for a lot of reasons. Untreated, of course, it's fatal. In operating, one may find -- depending on the cause and the anatomy -- a small segment of intestine the removal of which is not only life-saving but free of side effects; or you might find essentially the entire gastrointestinal tract dead and black. Removal in that case is possible, too, leaving the person entirely dependent upon permanent intravenous feedings. Or there might be enough small and large intestine remaining to handle oral intake with or without intractable diarrhea, with or without the need for complicated supplemental nutritional support.

And there you are, in the operating room at three in the morning, looking into a belly. No crystal ball, no outcome-prediction software; no moral counseling or ethics committee with two-cents worth of advice. What resources do you marshall; how do you decide whether to close up and deliver the bad news to the family, or to go ahead? Can you make a decision without interjecting your own moral values? Should you? Surely it's conceivable that two people might make different decisions; ergo, it's subjective. Who, then, has the right? Rarely, you may know enough about the patient to have an idea of what he/she would want. But how can you apply that when you're not sure what kind of life will result from going ahead? Wrongful death? Wrongful life?

These people don't come to see you in the office, don't participate in a leisurely give-and-take about their illness. They show up in the ER in pain, sick as hell, in no position -- much less able -- to philosophize. Nor do they come to you because they like what they've heard about you. Luck of the draw: they show up when you're the guy on call. Their lives are in your hands because of the most random of circumstances. But there's no avoiding it.

It doesn't take long to realize the power of influence you have. In fact, it's my impression that often people -- patients, their families -- WANT to be relieved of the responsibility. Grandma has been in a nursing home for a couple of years. Ninety years old, not always recognizing everybody, she suddenly is complaining of abdominal pain and is now in the ER with signs of some sort of abdominal catastrophe. "We need to get her to surgery right away," you can say. "Or she'll die." Clearly that stacks the deck toward going ahead, and, frankly, it's the easiest way out -- for the surgeon. I know many who always take that approach, and I think it's neither that they love to cut above all, nor that they want the money (what little they'll get from medicaid.) It's just that it avoids all the moral wrestling; with the people, with yourself. But it is, of course, just as subjective.

"It's obvious something serious is going on, something that would require an operation to fix. It may or may not be fixable; she may or may not be able recover from what we'll have to put her through. This could be too much for her no matter what we do; so I want you to know that it's possible to be sure she's entirely comfortable, to be sure she doesn't suffer in any way, and to let her go. You know her better than I; you know her life. I'm willing and comfortable with either approach. What do you think?" That's another way to handle it, one which I've done many times. And sometimes, either when such an approach doesn't lead to consensus, or when even before I've said such a thing I see a family in turmoil, I'll ask, "Would you like to know what I think?" That's where it gets hardest of all.

"We can take a look. I can see what's going on, and make a judgement: if I think it's a solvable problem with a reasonable chance of recovering, I'll do what I can. Or I'll come and talk to you before making that decision." "I think whatever is going on in there, it's too much for her, given her condition, and I think making her comfortable would be a kindness." I've said each of those, more or less, on many occasions. Some people think that if there's a one in a million chance of recovery, it should be taken: as a general rule; as a moral principle. I don't share that idea, but I can't say it's objectively wrong. If a patient in a one-in-a-million situation got me as their surgeon, they'd be more likely to die without an operation. If another surgeon, they'd likely die with one. Should that be a matter of chance? From one point of view, always going for the one-in-a-million chance seems the purest, cleanest, most honorable (life-affirming?) approach. From another, it looks like the ultimate moral cop-out, an abdication of responsibility. Can anyone say for sure?

It doesn't end, of course, with the decision for surgery. In the case of the dead bowel, you'll likely be confronted with operative uncertainty. In the example of the old lady, if virtually all her gut is dead, it's nearly automatic: take a look, and close up. ("Peek and shriek," is an oft-used phrase.) But what about a twenty-year old? It could happen, as a result of blood clots. Most likely you'd remove the bowel and do everything you could to get the person through the crisis, knowing they'd be facing a very abnormal existence. Having the whole gut gone is pretty rare. Having most of it gone, though, is not; enough that you could hook a foot or two of small intestine to a foot or two of colon. Again, it's not something I'd do with an elderly and sickly person; but I did it once with a young person. In both cases, it was entirely up to me, and I made the decisions -- necessarily, far less than fully-assured. And if not ninety, but yes twenty, then where's the line? Sixty-seven? Or what accompanying factors? Heart disease? How many vessels? More than that: what factors am I bringing to bear from within myself? Experience, knowledge of what I can (or can't) do, what decision I'd like made if it were me? Am I allowed those colorations? Given that there are no clear answers, it's not hard to understand how some surgeons would take the approach always to operate, and always to do what's technically possible, no matter the consequences.

A commenter in one of my recent pancreas posts described the misery of his life after a big operation, implying, I think, that he wishes the surgeon hadn't done it, hadn't saved his life. No one that I can recall has ever said that to me, not even the lady I left with severe short bowel syndrome. But I didn't end up seeing her for long after the operation, and I imagine her life was miserable in many ways. I'd not be surprised to learn that she's said it to someone, since. If it were to me, I'd feel really, really bad.

Family Matters

Don't get me wrong: I admire family practice docs. I recognize what a tough and undervalued job they have; and the ones I know do it well. It's just that it was not always the case, either in terms of my admiration or their job performance. There was a time, of course, when all doctors were generalists. We can long for those days, or not; they drove their Model Ts to the farmhouse, passed out potions, delivered a baby or two, cut off a dead toe, comforted the dying. I might like to have a Model T to drive on special occasions. But for regular use, I'm glad I have a nice radio, air conditioning, and traction control. Thanks, but no thanks. The concept applies generally.

Years ago, family docs expected to assist in surgery for the patients they referred. Internists, who early on made up the bulk of my referring docs, hadn't the slightest desire to do so; was it because they didn't care as much about their patients? Did their patients, for some reason, not need the comfort obtained from knowing ol' Doc'd be there? Self-selection by patients, or self-delusion by doctors? I have an opinion. Whatever the answer, I can say without equivocation that having the family doc assist in surgery was an enormous pain in the ass. It began with scheduling, and got inexorably worse. The doc could only be there at such a date and such a time, usually first thing in the morning. Since I had certain reserved times in the operating rooms, and since I usually had people scheduled well in advance, signing up the FP patients meant making lots of calls to rearrange my other patients, along with a bunch of calls to the doc's office to make sure he/she knew the final arrangements. Ordinarily, such calls weren't necessary, because I had my own assistant; highly skilled, totally familiar with how I liked to do things, there from start to finish. People who really understand surgery (or people who've read my book) know how excellent it is to have an experienced team working together in surgery. People who spent a few weeks rotating through surgery during training do not understand surgery. If they did, and if they really cared about their "whole patient," they'd INSIST that the surgeon to whom they sent their beloved patient use his best and most experienced team when cutting on them. They'd know without being told that the best team decidedly did NOT include them. But we're talking about knowing limits, and about knowing what you DON'T know...

So after rearranging my list several times, and making calls and followup calls to the doc's office, invariably that doc would show up late. Regular readers of this blog know how I feel about lateness. (For a short operation, their lateness sometimes allowed me the pleasure of finishing before they showed up.) If they made it into the OR in time for the incision, they'd arm themselves with the cautery pencil and start buzzing the tiny skin bleeders as soon as my knife moved on. Drove me crazy: those things stop bleeding; cooking them probably adds to scarring, and I'd have to stand there while they got off on their workmanship. They also loved to tie knots. Slowly. Deliberately. Feeling surgical.

None of this is particularly critical: I'd get the operation done just fine, if a little less quickly, and with a little less of the pleasure one gets from an operation done rhythmically and artfully. If being annoying assistants in the OR was the only problem, I might not be writing this.

It's puzzling. How much familiarity with a thing is necessary to know how unfamiliar one is? Where's the dividing line between understanding and kidding oneself? What's the responsibility of a training program to make the delineation clear? What I do know is that seven years elapsed between getting my MD and finishing my surgical training; and that during that time I'd gone from knowing nothing to knowing a hell of a lot. And a lot of what I knew was that I didn't know everything. For example, when I first went into practice my partner asked me if I wanted to do vascular surgery. I told him I didn't think I'd had enough experience in it. (I trained right at the time of transition: earlier, all vascular surgery was done by general surgeons. In my time, vascular fellowships were appearing, and at my institution, which included one of the premier vascular departments in the country, general surgery residents were doing fewer vascular cases, as fellow were doing more.) My partner offered to observe and mentor me until I was more confident. To me, that seemed like a deception to a patient: I've always believed if I were to operate on people, I should be able truthfully to tell them I thought I could do it as well as anyone. I knew how to do those operations; yet I would not have and did not feel right passing myself off as a vascular surgeon. I knew enough to know that ability to sew a graft was only a small part of vascular surgery. And were a complication to occur, I don't know how I'd live with myself. So how is it that family practice docs were coming to town, right out of training, and asking to do (click warning: gross, NC 17) hernia repairs, C-sections, and tubal ligations? Tracheostomies! What did it say about them, and about their training? Since, as I eventually learned, these are good people, I think it says their training sucked. They learned from teachers with an inflated sense of the primacy of primary care, and a deflated sense of what's involved in surgery. They were told that the more they did themselves for their patients the better it is, and to the extent that they referred to specialists, they were letting their patients down -- subjecting them to narrowly focused monomaniacs who didn't care. Whereas my training was characterized by the constant reminder of how little I knew, by the public out-hanging of every error big or small, theirs must have been the opposite: the paltry time you spent on a surgical rotation, doing OB, is enough to have given you everything you need to know. (Again: this was a while back, when the holy grail, the salvation of American healthcare, was the gatekeeper.) A few examples may serve to explain why I felt that way: (most of these refer to incidents in my community but not in my clinic, I hasten to add.)

A) Fresh out of training, a young FP asks for tubal ligation privileges, and is denied by the OB department. She goes to the hospital board, threatening suit. Over the resignation of the OB chairman, she's given privileges. At the independent surgery center, which grants privileges based on the hospital's, she does her first procedure, assisted by her slightly more experienced partner. Pathology report from the right tube: "normal appendix." A general surgeon handles the subsequent admission for sepsis, from which the patient recovers without sequellae.

B) I'm referred a patient with a hernia, repaired by his young family doc. The doc assists as I repair it, finding the original operation was one I thought universally abandoned because of its well-known high recurrence rate. I didn't hide my surprise. "Well, that's what Joe taught me," he said. Joe was his senior partner, an older guy grandfathered into pretty broad surgical privileges, having learned most of what he knew from HIS senior partner, long since retired. Joe usually managed to get general surgeons, to whom he referred those cases he didn't do, whorishly to help on his own operations. I wasn't on his list.

C) Another young study of Joe hacks into the femoral artery during a hernia repair. (Trust me, that's pretty damn hard to do.) He does have the sense to hold a finger on it while awaiting the arrival of a surgeon.

D) Called to see a man hospitalized with a bowel obstruction, I find a FP had admitted and cared for him without consult for several days. The dead bowel I removed wasn't enough to leave him nutritionally affected, and he did fine after several more days. Consultation on admission would, I'm certain, have led to a quick operation with no dead bowel, and many days fewer in the hospital.

E) I run into one of my old mentors at a meeting; he's a trauma guru, and a strong advocate for surgeons managing ICU patients. In training, I did manage those patients, with their ventilators, cardiotonic drugs, their multi-organ failures. In practice, I thankfully dealt with such critically ill people far less frequently. Intensivists, I tell Don, are much better at it than I'd become. "Don't give up your role," he says, strenuously. "You don't understand what it's like in the real world," I tell him. "I'm not as good at it anymore." He glowers.

F) While I'm serving on the board of my ever-expanding clinic, in the midst of the gate-keeper frenzy, a family doc presents a form he's planning to send along with his patients to every specialist, requiring specific enumeration of reasons for every test, every procedure proposed. He'll not authorize anything without its return and personal review. After some possibly ill-chosen words, I resign from the board.

G) Having saved a woman who'd showed up in the ER with a perforated stomach due to cancer, requiring emergency gastrectomy (and washing her belly with distilled water to kill any cancer cells that were spread by the perforation), I ordered tests after she recovered which showed a solitary metastasis in the left lobe of her liver. Liver resectionally, the left lobe is more or less a piece of cake; but I hadn't been doing elective liver surgery because it just didn't come up much. Despite her strong desire to stick with me, and despite knowing how to do the operation, I referred the patient to a more experienced liver-surgeon (who fucked it up royally, I must say.)

It wasn't fair: taking young docs right out of too-brief training and immediately telling them they must be in charge of everything. Even if they knew at some level they weren't ready, they really weren't in a position to say no. And I think, because of their training, many didn't think they weren't ready. Until they found out, the hard way. At the time, I could fathom neither the training that sent them into the world so misinformed, nor the system that demanded it of them; nor especially the fact that many seemed not to have the warning mechanisms built in to have kept them above water.

Other realities settled in: for one thing, as reimbursement for surgery steadily declined, and as the assisting fees did likewise, it became clear to most family docs that it simply wasn't cost-effective for them to be out of their offices. I guess their patients' need for knowing ol' doc was there disappeared at just the right time. Meanwhile, pre-paid healthcare, with its extraordinary pressure on primary docs and its placing them in direct conflict with their patients, came to be seen as a false profit. (Good one!) So family docs began, perhaps first of necessity, but eventually as a matter of reality-testing, to realize they could with impunity leave specialty care to specialists. Most are even giving up OB, if sadly.

I can't say if I was right about what they were told then in training, or if it's different now. I can say that most family practice doctors now have practices mainly in their offices, and that I think it's a good thing. I don't think their surgical patients are any worse off for their doctors' absence from the OR. And whereas I think it's true that the referring docs with whom I worked -- if for no other reason than being in a contained group with frequent interaction -- eventually came to trust me with their patients without having to throw up roadblocks, it's also the case that I came to understand what an important and difficult job family docs have. They're the central clearing house, the entryway, the providers of continuity; and they still have pressure to do as much as possible themselves. They need all the love they can get.

Postscript: It's not as if I think surgeons don't make errors. I have. They do. But I can honestly say I've never made one because I over-reached; never because I failed to recognize when I was in over my head. Such errors ought, in my mind, never occur. Inculcating the sense of limits, giving doctors and nurses the intuition and knowledge to know what they don't know, and when they don't know it, is the single most important mission of training, as I see it. Nor am I absolutely certain it can be taught. I think it can, and I know for sure doctors (and nurses) who don't have those mechanisms ought not be in the business. Maybe there's a way to pre-test for it... And based on experience, I can say it's surgical training that comes at all close to the mark, with the medical specialties not far behind. For a while there, family practice was decidedly (bringing) up the rear. I'm guessing not all readers will agree.