Recently BuckEye Surgeon offered a compelling window on what it is like to be a surgeon (or, for that matter, any type of physician), and realize that patients think that you are practicing pure science.
First, he admitted that he had been reading Cicero, (yes, that Cicero—the late, great Roman orator and statesman), and had come across a quotation that “grabbed him”:
"For the better he is at his job, the more frightened he feels about the difficulty… about its uncertain fate… about what the audience expects of him."
“Cicero was talking about the stresses that afflict a great orator; the pressure to reproduce the excellence of past speeches,” Buckeye explains. “The audience has come to listen and expectations are high and even one minor insignificant error can ruin the overall impression of an otherwise articulate, inspiring speech.
“In many ways, this is what we’ve come to in medicine. The expectations are almost insurmountable. Infallibility is the performance standard. The delivery of healthcare has been relegated to the category of ‘commodity, like automobiles and hair care products and soybeans. Where’s my warranty, my guarantee? Why did I get an infection? Why didn’t you realize I had breast cancer when it was 0.5mm instead of 2mm? Did you wash your hands well enough before you came into my room?
I had a day the other week with three gallbladders on the schedule. Usually this is a good thing . . . Short case, requires a certain level of dexterity and technical expertise, occasionally can be challenging, and the patient goes home feeling great.
But for some reason I felt this overwhelming sense of dread in the locker room while changing into my scrubs. I’m pretty anal on my gallbladders; no cutting or clipping until I’m certain of the anatomy, cholangiogram on almost every case. But the statistics don’t lie. Bile duct complications occur in 0.5% of all laparoscopic cholecystectomies. Most of these are minor (cystic duct stump leaks) but every general surgeon’s nightmare is some sort of major common duct injury. The number 0.5% seems small at first, but that’s 1 in 200, baby. And considering we do thousands of cholecystectomies over the course of a career, the question becomes not if but when you’re going to have to manage a complication of your own.
“The patients that day were troubling. . ..”
I’ll let you go to Buckeye’s website http://ohiosurgery.blogspot.com/2008/08/burden-of-reproducible-excellence.html to find out what happened.
But first, let me add that I agree. Patients don’t want to know about the uncertainties of medicine, or the very simple fact that in any labor-intensive profession, human error will play a role. Over the course of a career the most conscientious health professionals make mistakes.
While I believe that we should raise standards for reducing hospital errors—and here I blame hospital executives who spend money erecting monuments to themselves rather than focusing on patient safety—we need to recognize that in medicine, there are no warranties; there are no guarantees.
Healthcare is not a commodity like a Toyota that can be turned out, day after day, in exactly the same way. Every human body is unique. At any moment, a surgeon may run into a surprise. Your cancer may be hiding in place that makes it very difficult to detect on a mammogram—not impossible, but very difficult. And while the person reading your test probably would have caught it nine days out of ten, this is the day that he didn’t.
Expecting our physicians to be perfect only tempts them to “cover up” any mistakes, which leads, in turn, to worse outcomes. (Not to mention endless hours and dollars wasted in legal “discovery” just to get to the facts of what happened. )Patients need to trust that their doctors are doing their very best, but doctors also need to trust their patients enough to be able to say “I’m sorry . . .but.”
At one time, a great many doctors wanted to believe that they were gods. Now, too many patients are still clinging to that false idol.
Funny, we seem to expect the same superhero characteristics in our presidents as well.
Maybe people have grown up watching too many Superman movies…
Robert–
Well-put
I think you may find this apropos and amusing:
http://stumblingandmumbling.typepad.com/stumbling_and_mumbling/2008/08/doctors-vs-economists.html
If you want to read a scholarly treatment of this expectation/ communication thing: Jay Katz, The Silent World of Doctor and Patient… He focuses on informed consent, but has a whole chapter on uncertainty. He’s a MD(shrink)JD. He suggests that truly honest communication between doc and patient shares that uncertainty, thus treating the patient as an adult, responsible and able to grasp the nature of this guessing game of medicine. In so doing we(docs) can learn the preferences important to the patient. And maybe better treat the individual. It takes a great effort to maintain this expectation in the face of fatigue and cynicism. We so quickly dismiss the patient as unable to grasp the subtleties, the data, the pathology….When it might be our bias or ignorance that we are most uncomfortable with..
Maggie,
Maybe the profession has fostered this sense of infallabillity as its sales tool. It can be likened to the marketing of pharmaceuticals and other new technologies where the consumer is often given information in a very positive light with little mention or discussion of the chancs of success of a particular treatment or its potential complications. It is something that maybe we physicians are uncomfortable discussing since to say you are uncertain, although honest, does not always foster the confidence that patients need that their physicians are capable of managing and treating their problem. In primary care, we are probably more accepting of stating we do not know since w are not “specialists” who are expected to have a total grasp of their area of expertise.
The other dilemma from my perspective is dealing with patients with vague complaints that are often psychogenic in origin. While I can nevr be 100% certain there is not some underlying organic condition with many of these patients, I find what they most benefit from is coming to their physician that they presumably trust, to tell them there is nothing physically wrong with them. This in itself may releive much of the anxiety that is further fueling their symptoms and prove therapeutic. In many respects we are the modern day Shammans or witch doctors that other cultures go to to in essence to receive their placebo. Do we want to destroy that aura of seeming invincibility and respect? This is why we always have to conduct double blind studies. many of the patients will often respond to the sham treatment, even if we know it is worthless (say a sugar pill).
Prior to my CABG surgery nine years ago, I was told up front that there was a 2% risk of death. On the other hand, I knew I needed the operation, so I didn’t think I had much choice other than to go ahead with the procedure. I know certain fertility related procedures are unsuccessful a significant percentage of the time as are back surgeries. If a patient needs to have a gall bladder or appendix removed, by contrast, it really needs to be done, at least most of the time, and it doesn’t matter if the risk of complications is 0.5% or 20%.
That said, any risks of death or complications that a doctor would like to be aware of or would want a family member to be aware of if he/she or they needed the procedure should be communicated to patients. This is particularly true of procedures contemplated in connection with care at the end of life. Indeed, the California legislature is considering legislation right now to make the communication of information about end of life care options mandatory. I hope that legislation is approved, and I hope it spreads nationwide. Information about medical options and risks is a good thing, and we could use more of it.
Mr. Carol describes the 2% risk of death with CABG. Do you also know the marginal benefit? Interventional treatment (angioplasty, CABG) of acute MI offers an improved mortality compared to “conservative treatment”, ie oxygen, bedrest, morphine, monitor…The difference between the treatments is 4/1000. That is, of a thousand treated in each group, four less will die in the intervention group. Number needed to treat:250….
Aren’t statistics wonderful? So reassuring, like a mothers hug….NOT
Ddx:dx, Barry, Keith, DDx:dx, Robert–
Good to hear from all of you.
Ddx:dx– This is a good point. I should add, it may or may not apply to Barry. But you are absolutely right, collectively the benefit is very low. People always think: but I might be on one of the 4 out of 1000 you benefits! But there is also the danger that you will be one of those who dies. . . .
Barry–
Let me add that I am in no way suggesting that you made a poor choice. I know nothing about the details of your situation, and I am not a physician.
Based on the reserach I’ve done, I do believe that a significant number of people can benefit from these operations. It’s just that a significant number don’t—and they are exposed to risk without benefit. Often, they don’t realize this.
That is why I absolutely agree that doctors should level with patients about risks. And I would go a step further–in cases like these, I think patients should go through the whole “shared decision-making” protocol-which provides videos, pamphlets and decision -making coaches who make sure that patients understand the material, the odds, and have a chance to sort out their own priorities.
Probably you did this on your own. But you’re not the average patient.
I’ll be writing more about “shared decision-making” soon.
Keith–
YOu write: “Aother dilemma from my perspective is dealing with patients with vague complaints that are often psychogenic in origin. While I can nevr be 100% certain there is not some underlying organic condition with many of these patients, I find what they most benefit from is coming to their physician that they presumably trust, to tell them there is nothing physically wrong with them. This in itself may releive much of the anxiety that is further fueling their symptoms and prove therapeutic. In many respects we are the modern day Shammans or witch doctors that other cultures go to to in essence to receive their placebo. Do we want to destroy that aura of seeming invincibility and respect? ”
This, I think, is a very good point.
I doieve belthat much of what a very good doctor does is reassuring patients.
These patients are not necessarily hypochondriacs, but they may be suffering from something for which we have no cure–often something that is a fucntion of aging. It’s not going to kill them, but they become fearful that it will.
So many ailments are a combination of mind and body.
Since you can’t “cure” it, it’s very helpful simply to reassure them. . .
And if you go to great lengths to tell them how ambiguous medicine is . . . well, that’s going to undermine your ability to reassure.
It strikes me that doctors just have to walk a very fine line. you say will depedn on the particulars of the situation, the patient’s tempermaent, etc. This is part of why medicine is at least as much an art as a science.
Ddx:dx–
Thanks I’ve heard very good things about the book and plan to read it.
Robert– Yes, it’s very funny– thanks.
I, too have had a CABG following the reocclusion of two PTCAs. Did I have a reasonable sense of risk and benefit going into it? In addition, I recognize that the decision had to be made with the information available at the time. All would agree, I suspect, that the retropectroscope is the most powerful tool in medicine. Unfortunately, we can’t build it until the nuclear chemists can sytnthesize an adequate quantity of unobtainium.
My surgeon was an exceptionally good communicator and born teacher, and, as those that know me might suspect, I did a thorough literature review. I’d guess that we spent at least three hours of discussion, in person and on the phone, preoperatively — he was delighted to know that I understood the details, and, with angiograms in front of us, mapped out what he expected to do, and the risks and choices at each step.
He explained that he would do all the grafts with reversed saphenous vein, because I was young enough that he expected reocclusion, and wanted to reserve the left internal mammary artery (LIMA) for a subsequent procedure. Were we doing it today, we’d probably use the LIMA, because by doing the true arterial graft in the first place, there is a much lower incidence of reocclusion than with a venous graft. As it was, two of four grafts reoccluded 6 months post-op.
I did have a complication, and my only complaint was that it wasn’t worked up faster: apparently, I threw an embolus (or some type of detritus) to my left auditory nerve, and I’m now deaf there. It’s unlikely anything could have been done if the situation was recognized earlier. Still, there are many worse places an embolus could have landed.
At the time, the large scale PTCA data wasn’t available, but my newer occlusions would not have been approachable with a catheter. Medical management, which could have been more aggressive (again retrospectrally), was not controlling angina of effort.
Sometimes, there it’s a question of picking the least bad option, based on the information available. Better, I suppose, than the Birkenhead Drill.
Keith is right that the aura of infallibility is too lucrative a marketing tool for physicians to completely distance themselves from it and their ambivalence on the issue is tied to a lot of the rage about malpractice suits – we can’t have it both ways.
As far as the Shamanic value of the physician/patient encounter, its value to the patient is tied much more closely to a sense of being listened to and understood than a belief in the infallibility of the physician.
It’s all well and good to talk about the importance of communication between physician and patient, and another to actually do it. I’ve read some good examples of physician-patient communication here. I’ve witnessed some horrors.
Recently, I was working as a traveler in various ED’s in Texas. I chaperoned a genital exam by a PA on a patient who had genital warts. The PA explained what genital warts were. The patient got upset, and wanted to know how she’d gotten them–more accuratly wondering WHO had given them to (her boyfriend sitting right there). The PA responded to her by saying, “it’s hard to say, it’s no big deal any way, your regular doctor can just burn them off.”
I cringed. It was a big deal. She needed a lot more education about her diagnosis. When I discharged her, she was still focused on who gave her genital warts. I re-directed her, and told her, “the most important issue you have to deal with is treatment.” As in getting a full STD workup, regular Pap smears, and practicing safe sex, and also informing her partners so they could be tested and seek treatment. As soon as she realized there was a lot she needed to know, she calmed down and started asking questions about what to do.
I explained how contagious genital warts are, the increased risk of cervical cancer, and I also gave her some options for symptomatic relief in case cryotherapy didn’t work.
She didn’t leave happy. But she left calmer and more sure of what she had to do next.
I’ve had charge nurses complain about the time I take giving discharge instructions and patient teaching. But teaching is one of the most important parts of my job. Handing them an instruction sheet and their prescription is not enough.
Physicians have a hard time achieving that level of communication because they have problems with their own supervisors for “being unproductive” if they don’t see so many patients per hour. In some cases physicians spend as little as ten minutes per patient. This is no where near enough time for patients to ask questions, or get answers, especially if the news is bad.
One of the biggest complaints I hear about doctors is the scare amount of time they spend with the patient.
This is why surgeons amputate wrong body parts. Everyone is in such a rush to be “productive.” The false perception of infallibility is driven by poor communication. It won’t be resolved until docs actually have the time to educate their patients . . . and insist on taking it.
HC Berkowitz, Marc abd Panacea–Thank you.
HC–
You write: “Sometimes, it’s a question of picking the least bad option, based on the information available.”
What you say is absolutely true. Good doctors explain the risks and the benefits. And make it clear that, in some caes , there just isn’t an ideal, slam-dunk option.
The patient needs to weigh his priorities, fears and hopes–with the help of a wise and empathetic doctor.
Marc– I suspect you are right when you say that “the Shamanic value of the physician/patient encounter, its value to the patient is tied much more closely to a sense of being listened to and understood than a belief in the infallibility of the physician.”
Though my guess is that the patient who feels that he was “heard” also believes that his physician is very, very wise–in a way that may make him think his doctor is infallible.
But I also think that the doctor who listens is much, much wiser. So this is not necessearily a bad thing.
Panacea–
Thank you. This is an excellent example of a doctor diagnosing, and not following through.
The patient was very lucky that you were there.
As you say, much of medicine is about “teaching”– making sure that after being diagnosed, or hospitalized–the patient understands what she/he needs to do.
Expecting perfection in medicine
We need to do a better job in managing patient expectations:
Healthcare is not a commodity like a Toyota that can be turned out, day after day, in exactly the same way. Every human body is unique. At any moment, a surgeon may run into a surprise. Your ca