Got Your Back

Where I trained, it was a very top-down place. At all levels, you were expected to inform the person next up the ladder before embarking on nearly anything. Which, as far as I'm concerned, is how it should be. Learn your limits: nothing is more important in being a safe surgeon. Ask for help, get advice, know the need. There were no mistakes as unforgivable as those of not following the chain of command.

In "Cutting Remarks," I told the story of a fellow resident who performed an emergency tracheostomy in the Emergency Room. That it turned out to have been unnecessary was not what got him in trouble. It was that when the nurse asked if she should call the Trauma Team, he said no, he could handle it, which he did, in terms of technique. But for his failure to communicate, he was called into the Chief's office and told this: "A cat has nine lives. A surgery resident has two. You've just used one. Now get out of my office."

That Chief was F. William Blaisdell, or, as we referred to him, the Blazer. A leader in the formalizing of trauma care, Blazer ran the Department of Surgery at San Francisco General Hospital while I was there, and he was one of my two most influential teachers. Some of his demands were a little annoying: no facial hair, no scrub clothes out of the operating room, wear a necktie at all times. But it was about respect. Respect for our patients, most of whom were derelicts and drunks and down on their luck. No matter. We handed every one of them a personal business card that Blazer had seen to for us, including the number of the surgery department and of the paging system.

What Blazer expected of his Chief Residents, of which, eventually, I became one, was not that we be right all the time. His expectation was that every decision we made was well thought-out, that it took full account of the situation, of all the possibilities, that the proper data had been collected and evaluated. Short-cuts, sloppiness were indefensible offenses. When I called him in the middle of the night to describe a patient and tell him of my plan, he might or might not choose to come in to assist. (I appreciated his confidence in me when he stayed away, but I always liked having him there. It'd be soon enough, I figured, that I'd be on my own. Now was the time to pick as many pearls of wisdom as I could.)

And here's the thing: if he felt you'd properly reasoned he'd never second-guess or fail to support your decision, even if it didn't work out. He'd talk it over, dissect it; teach back from the problems. But he'd stand up for you. Unlike some of the other staff.

Like most training programs, we had a weekly conference in which every imperfect outcome was discussed. "M and M" is the most common designation, for Morbidity and Mortality; ours was "D and C," for Death and Complications. The conference took up several hours of every Saturday morning, delaying the beginning of the infrequent weekend off, if such it was. But it was the best conference we had, probably the source of the most learning outside the OR. Chief Residents of each service presented the cases, but the grilling might be directed at anyone, even the loftiest of professors.

When I was on Blazer's service, the one thing I could count on, though, was that he'd be there for me. If there was a bad outcome, as long as he believed I'd done the right thing at every step of the way, he'd defend me against whatever onslaught, from whatever lofty source. Some of his junior professors were not so solid. "I told him he shouldn't do that," they'd lie. One guy in particular, whom I won't name. A tough case with a great result, he was there to take the credit, as if he'd done it and not me. But if something was imperfect, he sidled away like a crab catching the tide, wagging his tiniest claw behind him: not me, not me, not me.

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.

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.

It's Complicated: part two

Speaking only for myself (but guessing I'm not alone), I can say when a patient develops post-op problems, there's a strong tendency to deny it: not to deny there's something wrong; not to dismiss the patient's concerns or symptoms. Just to grasp first at the less dire set of possible explanations. Maybe it's just the flu, constipation, drug reaction. That sort of thing. It's not about blowing it off -- because I never did. It's about hoping against hope, both for the patient's sake, and mine. Rationalization is a powerful instinct. In reading various forums and blogs and seeing innumerable patient complaints that their doctors took a long time to take them seriously, I'd guess that in many instances the desire to believe you didn't screw up is at work. That doesn't excuse it: maybe it explains it to a degree. For better or worse, doctors are human. I know I am.

When I saw my patient in the Emergency Room, her abdomen was distended, she had a low-grade fever and a bit of a red incision, and her Xray was the usual hard-to-be-sure early post-op belly film: possible obstruction, possible ileus (a condition of bowel laziness often seen for a while after abdominal surgery.) I admitted her, of course. Intestinal leakage -- from where the bowel has been sewn together, or from an unrecognized surgical injury -- is always on the list of possibilities in such a situation, but I didn't think so here. How tender is tender? How red is too red for an early incision? She didn't, I told myself, look all that sick. Time and a stomach tube, antibiotics for a possible sub-clinical (meaning not obvious) leak or abscess at her anastomosis ought to do the trick. Indeed, she looked better the next day. Not that "looked better" is an objective criterion.

When intestinal content began to drain from her wound after a couple more days, it all became clear. Since the point of the post is not to discuss treatment of intestinal fistula (leakage of intestinal contents to somewhere -- in this case, to the skin), let me simply say I opted for the safest and most frustrating approach: high-calorie intravenous feeding, local wound care, and waiting. And waiting. With drainage, she stabilized and we both hunkered down for a long haul. At some point, while inspecting the wound daily, I noted the suture with which I'd hooked the bowel while closing up. And I told her about it straight away. I explained why, in my opinion, going back in at this stage could cause more harm than good, and that there was a reasonable chance it could heal with no need for surgery; and that if not, it would be much easier and safer to go in after time for the reactions to settle down.

So there she was: a living, breathing testament to my failure, for all to see, for a couple of months. Each time I approached her room on rounds, I felt a tug in my gut. I imagined that everyone was talking about it, probably questioning my competence. (Years later, I sort of doubt it. But it's how I felt, with every complication, big or small.) The lady was remarkably hardy and good-hearted. That made it a heck of a lot easier. With each visit, we talked about it, about how it was going, about our comfort levels with the current plan. Frustrated at times, stir crazy on occasion, she never evinced anger toward me. I was deeply grateful for that. She healed. I fixed her incisional hernia a couple of years later.

It's a terrible triangle: the patient, the injury, and me. The patient first and foremost is in need. Whatever the effect on me, their situation is way worse. Yet facing him or her can be tough: it may be unspoken, but there's the sense of permanent accusation. My shame, my guilt, my sadness all interfere with my connection. Magical thinking can keep me from facing the reality of whatever is wrong. At some level, I want the patient and his complication just to go away, because of what they say -- or seem to say -- about me. So, as I titled this series, it's complicated. I was lucky, I guess: in those rare cases where bad things happened due to what I felt was an actual error, my patients stuck with me, and we got the problems resolved. It's a key point, however complicated in its own right: impossibly difficult as these situations can be, hostility from the patient only makes it worse. If my reaction is "complicated," the patient's is -- understandably and necessarily -- complex to the power of ten.

It is, of course, unreasonable and probably impossible to expect patients to hang in there no matter what. It's like, oh, saying questioning a war emboldens an enemy. If there comes a point when you think your surgeon is simply a screw-up, it's time to pack up and go. Yet, I'm trying to say, early on it's at least a theoretically good idea to give him/her a little breathing room. Sometimes figuring things out takes time; sometimes problems can't be resolved as fast as the injured party would like. Hell, they never can. I think it's a truism that the attitude of both the doctor and the patient is crucial to how things end up when facing complications. If it's true that the patient's attitude is heavily influenced by their doctor's, so is the opposite. But, given that it's the patient who's the injured party no matter how upsetting (violins, here) it is to the doctor, the patient has first right of refusal to take the advice. Still: in the ideal world (remind me where that is again?), it's immeasurably better when each side keeps his powder dry for a while.

A commenter on the first post in this series raised an important point (and had he not veered into vile vituperation and personal pejorative, I'd have kept it in.) Why, he asked (in a manner of speaking) had I not canceled my bill or offered to pay her expenses? (In fact, he has no idea what I actually did, but it's a good question.) It is something about which I've ruminated a great deal -- maybe it should be another post sometime. I have generally, for example, (and despite suggestions from insurance companies to the contrary) not charged for a re-operation for bleeding -- a rare occurrence. That's a small thing. The larger question, I think, ought to be addressed in a larger way: something like flight insurance, as a top-of-the-head analogy. Patients deserve compensation when things go wrong, and it ought to be available outside of the adversarial court system. But if every surgeon -- every doctor -- were expected to pay out of his/her pocket for every adverse outcome, I daresay even fewer good people would choose the profession than are now doing so. I don't have an answer. I've wished I did...

In my view, there are three categories of bad outcomes: the ones I've already mentioned are those that clearly result from an error -- the most horrible to face because there's nowhere to hide. The second is imperfect results from proper and well-managed care; and the third is.... having to clean up another doctor's mess. That middle one can be the most frustrating of all, posing the greatest challenge on many levels. I'll see if I can explain it -- and figure it out myself -- in the final post(s?) in this series....

It's Complicated: part one

One of the hardest things about being a surgeon is the inevitability of complications. It's true for any doctor; but with surgery, it's as if they are lit in neon and given a soundtrack. At least to me. Aiming for perfection (as do we all) and beating myself up (more than healthier people) when I miss the mark, I found bad outcomes of nearly any magnitude deeply disturbing. The big ones are there for lots of people to see: nurses on the surgical floor or ICU, operating room personnel when you have to re-operate. And of course, the patient. The family. My family, for that matter. Smaller problems might just be between me and the patient; but they still are painful. Carrying the responsibility for having done harm to people who gave me their trust can be nearly too much to bear. Thankfully rare, it's never been easy. Nor should it be.

I don't know the extent that I speak for other surgeons in this matter. I actually believe I took it too hard, and too personally; so what I say (which I'm sort of anxious to find out myself) may be fairly singular. But I got a specific request to tackle the subject, and I think it's an excellent one. So here goes.

There are two cardinal sins, in my estimation, for the general surgeon. The first, the sine qua non of a surgical screw-up, is injuring the common bile duct. Nailing the bowel with a suture while closing an abdominal incision is the other. Each tends to bespeak carelessness, and I'm sorry to say I've done both. Only once each, thank God, in what I'd conservatively estimate to have been around ten thousand operations (not all, of course, subject to those particular errors.) Actually the cardinal error -- more like the pope error -- of bile duct injury is to do it and not recognize it at the time. THAT, I've never done. Unrecognized bile duct injury can lead to a tragedy for the patient. If you're gonna ding it, at least see it at the time and fix it. That usually works out ok.

In the community of my first job as a surgeon, each newbie was subjected to a monitoring process in which every other surgeon in town was to scrub with him/her at least once at to render some sort of judgment. So the first time I was able to do a case unmonitored, I had the referring doc assisting me on a very routine gallbladder removal. It was the classic situation for injury: the easy case -- when the going is tough, you tend to have all the feelers out for problems. (I'd add, apropos a comment I received on my mini-gallbladder post implying it was the worst of all possible worlds, this was in the days of the big incision, and well before laparoscopic surgery.) My patient was a tiny woman, with tiny ducts. Her gallbladder had practically no length of duct connecting it to the main bile duct, so I thought I was dissecting the cystic duct (normally much longer, it's the tube that connects the gallbladder to the common duct), when in fact I was working my way down the common duct. Somewhere along the line, I discovered I'd cut it clean in half. As my heart sank and my hands got clammy with the realization, my forehead and armpits drenched themselves with sweat and I told the referring doc I'd be wanting to get my partner in to help at that point. He was only too happy to vacate. I repaired the duct -- among the smallest I've ever seen -- over a baby-sized T-tube, drained it, and closed up. And for the first time as a real doctor, I had to face my patient and tell her what happened.

It's excruciating. I hate everything about it. There is a very real temptation -- to which, even in this age of attorneys under every rock, some people still succumb-- to fudge it, not to tell it like it was, to protect oneself. In my case, I think, the urge is motivated less by fear of lawsuit than of confronting my own inadequacy. And the acute awareness that I'm telling a person things will not be as she expected; that her life could be very unpleasant for awhile. It's not what she signed up for, and it's my fault. Face to face. You're screwed. My fault.

I doubt I could successfully bullshit a person if I tried. My car got stolen when I was in med school. In the glove box was a small amount of what might be called an herbiferous stimulant (that it was small and had been in my glove box for months bespeaks the extremely limited use to which it was put.) For what may be the only time in the history of the local police, they found my car, and called me to pick it up at the station. Finding the glovebox contents strewn about the car, I noted it was all there; except for the one item. To the query if anything was missing, I said no. Couple of days later, there were two cops at my door, holding badges at eye level (narcotics boys) and asking for me. Had they just graduated from cop school, had they never seen a guilty person in their lives, they'd have known I was as guilt-ridden as if I were holding a bloody dagger. They displayed (holding it by a string: no fingerprints) the Alka-Seltzer bottle which held the offending material, and asked if I knew what it was. "Well," I said. "You guys being here and all, I suppose it's some sort of drug...." Fortunately, they also knew that the car had been stolen and there was no way to pin the contents on me. A stern warning was what I got, as my future career and my father's wrath passed before my forebrain: the one waning, the other waxing. I'm a lousy liar. (And since then [well, not too long after] a confirmed non-user.)

I told my patient truthfully what had happened, but I was not above trying to put it in the best light. Her anatomy was unusual, I explained, with her gallbladder so close to the bile duct that removing it left the duct damaged. True. But passively stated. To my retrospective regret (because it was less than entirely forthcoming), I glossed over the fact that I hadn't recognized the anatomy until I'd done the damage. I didn't lie. Yet I didn't resist the urge to sugar coat it. She was disturbed, but not beside herself: ultimately she had to put up with a capped-off tube with no drainage for three of months, after which it was gone and she had no further problems. (Being just out of training, I wrote to my professor to ask his advice about how long to leave the tube. In doing so, I said "I was recently called upon to repair a bile duct...." It was not untrue. I hoped he'd assume it was someone else's injury. He never said otherwise, but he was a very wise man.) It could have been much worse. As to the conversation I'd had with my patient, it's weighed on me ever since, and it was a long time ago. So many issues are at play in such a situation, it's hard to enumerate them, let alone fully understand them. I'll try.

The suture thing was quite different: the whole spectrum of terribleness, way worse for everyone. It had been a routine colon operation, and she'd gone home quickly, doing fine, only to come to the emergency a few days later, sick. My clamminess didn't take over right away, because my first instinct was to try to fool myself, to convince myself it wasn't what it was....