There’s an old adage in surgery that says: “It takes 2 years to teach a resident how to operate and another 3 to teach a resident when not to operate.”
Surgery is an active profession. Above all, the surgeon is expected to take action, even when that involves the decision to NOT do surgery.
Surgical sins are different from Medical sins. There are sins of commission—hubris, arrogance, pride, vanity—of which we are all guilty at one time or another during our careers. Some of them are also surgical strengths depending on the situation.
There are also the sins of omission—carelessness, sloth, ignorance, and perhaps the most egregious, indecision. As a mentor once said, “A surgeon doesn’t have to be right, but he has to be certain.”
It’s incumbent on us by the nature of what we do to people in surgery to be affirmative in making decisions. By that I mean, any decision should be made actively, through consideration of the action we are taking and its potential consequences.
But wait, aren’t all decisions made that way? No, not always. Delay, procrastination ‘watchful waiting’ often lead to a decision of indecision where the patient’s condition changes in spite of our attention rather than because of it. If I, as a surgeon, chose not to operate on a patient, it should be because I have a valid reason for expecting that the situation will resolve without surgery, or perhaps because the patient’s condition is such that surgery presents an unacceptable risk.
I recently decided not to operate on an elderly woman with free air in her abdomen. Free air means there is air outside of the bowel or lungs where it belongs. It implies a perforation in the bowel or stomach that is leaking stool or intestinal contents. Under most circumstances, it’s a surgical emergency.
“There are also the sins of omission—carelessness, sloth, ignorance, and perhaps the most egregious, indecision.”
I looked at this frail woman who was pleasantly demented with a history of heart disease and a recent stroke and thought, No way. It was a gut reaction born of a reluctance to take on a complicated and high-risk surgery. I rationalized it by observing that she was having little pain; that the air seemed scattered and was minimal in volume; that the CT that showed the air gave no indication of where the perforation might be and that she had a high risk of complications. I made a good case for NOT doing surgery, but knew it was a rationalization.
She did not do well. She got more septic, her lungs and heart started to fail and after a long discussion with the intensive care internist and me, the family decided on palliative care only. She died a few hours later.
I don’t know if she would have survived if I had operated. Perhaps the outcome would have been the same. I will never know. But I do know that my decision to not operate, while justifiable on paper, was not motivated by an objective look at her condition.
Anyone who has been in this business for a while can list his or her own secret tally of sins. I have committed sins of hubris, of arrogance, where I over estimated my capabilities and patients suffered and died for it. I have let pride push me to cling to a course of action when I should have changed course, and patients have been harmed. I have allowed fear or indecision or fatigue or stubbornness to hold me back from doing necessary surgery and patients have died. We all remember those cases, but we tend to forget the times when we did the right thing. I can name far more patients that I have lost than ones that I have saved.
How a surgeon handles sin is a deeply personal process. I know some surgeons who simply ignore it. They are able to rationalize their actions and put it all down to patient disease, or at worst, a learning experience. Others become paralyzed by the fear of making an error and refuse to get involved in difficult or complex procedures. Still others internalize the guilt, refuse to let it stop them from continuing to take on the challenging or emergent cases, but ultimately pay a price in the form of sleepless nights and endless private second guessing of each decision. We know in our hearts what really motivated our action, and even when that action appears appropriate to an outside observer, we alone know how we failed. We must handle that and find a way to live with it if we are to serve our patients and retain our sense of purpose.
Bruce Davis, MD, is a Mesa AZ based general and trauma surgeon. He finished medical school at the University of Illinois College of Medicine in Chicago way back in the 1970’s and did his surgical residency at Bethesda Naval Hospital. After 14 years on active duty that included overseas duty with the Seabees, time on large grey boats and a tour with the Marines during the First Gulf War, he went into private practice near Phoenix. He is part of that dying breed of dinosaurs, the solo general surgeon. He also is a writer of science fiction novels. His works include the YA novel Queen Mab Courtesy, published by CWG press (and recently reissued by AKW Books as the e-book Blanktown). Also published through AKW Books are his military science fiction novel That Which Is Human and the Profit Logbook series, including Glowgems For Profit and Thieves Profit.