Respectful Insolence

After having subjected my readers to all those posts about the antivaccination lunacy that was on display in Washington, D.C. last week, I think it’s time for a break from this topic, at least for a while if not longer. In the run-up to the “Green Our Vaccines” rally events on the antivaccinationism front were coming fast and furious, and I felt it was my duty to comment on them. Now, with great relief I can say that the rally is over. How many people actually attended the rally is uncertain. The organizers themselves claim that 8,500 people attended, while more objective estimates from people not associated with the march put the number at probably less than 1,000. What is certain is that the organizers’ timing was very bad (for them, at least) in that they marched on the day after Barack Obama clinched the Democratic nomination. Drowning out most other news, this event led to almost nonexistent news coverage of the rally, aside from a handful of television appearances by Jenny McCarthy, a point that has lead to much whining. I’m fairly confident that the effects of this rally will be small and short-lived, although I have no illusions that antivaccinationists are ever likely to go away. Vigilance will still be required.

In the meantime, though, now is as good time as any to go back to the roots of this blog, so to speak.

PalMD wrote an excellent meditation on a topic that’s always been a difficult issue for me to face as a surgeon, namely how one balances confidence in one’s ability with humility in the face of disease and uncertain science. He starts with a spot-on observation:

The practice of medicine requires a careful mix of humility and confidence. Finding this balance is very tricky, as humility can become halting indecision and confidence can become reckless arrogance. Teaching these traits is a combination of drawing out a young doctor’s natural strengths, tamping down their weaknesses, and tossing in some didactic knowledge.


PalMD then goes on to describe how he tries to teach physicians in training the right balance and does an excellent job of it. He’s absolutely right that pushing residents to make a decision and justify it to the attending, trying to get them to think like an attending who knows that the buck stops with him or her while they are still in the safe confines of the training program, with a real attending covering their backs.

In surgery, I think, the mix is different. Surgeons have to project confidence to their patients because surgery and other procedure-driven specialties are inherently different because of the technical skill involved. As much as it might be denied, proposing a course of treatment that involves cutting into a person and rearranging his or her anatomy for therapeutic effect is perceived differently by patients than proposing taking a new medication or even undergoing chemotherapy. It’s far more invasive and far more dependent on the skill of the practitioner. Teaching surgery is also different than teaching internal medicine because there are two elements involved. Like the case for medical specialties, there is the cognitive element, teaching diagnostic skills and the appropriate therapies for various diseases and conditions. However, in addition to these cognitive skills that must be taught, there is also a huge base of technical skills that must be mastered. It’s true that internists and other physicians must also learn a number of technical skills, such as placing IVs and central lines, doing lumbar punctures or bone marrow biopsies, and tapping pleural effusions, but the number and level of invasiveness of these procedures is nowhere near what surgeons must learn. In brief, no therapy can mess a patient up if it goes wrong quite like surgery, and every surgeon who does large cases has at some point in his career messed up a patient. That doesn’t make them bad surgeons; it’s the nature of the beast. No matter how good a surgeon is, complications are inevitable. How many complications and how the surgeon deals with them are what separate good from bad surgeons.

This realization makes the proper balance between confidence and arrogance arguably more difficult to reach. We surgeons have all encountered at some time in our careers the “cowboy” surgeon. This variety of surgeon seemingly has no fear and will plunge into even the most difficult and dangerous cases (“The patient has diabetes, severe coronary artery disease with an ejection fraction of 25%, and COPD? No problem! Let’s operate.”), seemingly oblivious to the risk. He not infrequently gets into trouble (“Oops, I severed the aorta!”) but usually manages to get out of it, seemingly unfazed by the experience and the close call that the patient had. In contrast, we have also all encountered the excessively cautious surgeon, the one who often hesitates and seems almost afraid to operate, even when it calls for. Both are extremes that a surgeon should try to avoid.

Add to this mix patient expectations. When I first started practicing after leaving fellowship, I thought that the best approach was to lay out the surgical options, the risks and benefits of each based on my best interpretation, and to try to let the patient decide, with my advice as needed. I soon found that this was a problem. Reports got back to me that some patients viewed me as indecisive and didn’t have the confidence in me necessary to let me operate on them. Then I learned that this wasn’t the case for all patients. Some genuinely liked this approach because to them it respected as much as possible their autonomy. Others hated this approach because they had expectations of what a surgeon should be, and those expectations included telling them what needed to be done and just doing it. No doubt the same is true of patients in other specialties, but the sheer invasive and personal nature of surgery tends to shift the balance of patient expectations more towards the paternalistic model. Surgeons see things in a patient that even their spouses never see, namely their insides, and this, coupled with the knowledge that it is the skill of one individual that can determine success or failure of even the correct course of action, makes surgery very intimate and personal to the patient.

What I eventually learned was that not only does a surgeon have to find the right mix between paternalism and doing what the patient wants, between confidence and arrogance. The surgeon must also be able to size up patients to figure out what specific balance between these competing traits each individual patient expects and then titrate his behavior accordingly. Some patients really do just want the surgeon to tell them what needs to be done and then to do it, without all that confusing discussion of options based on the surgical and scientific literature. Such patients frequently ask the question, “What would you recommend if I were your wife/mother/sister?” The surgeon had better be able to give the answer to that question with confidence and still tell the patient enough about the risks to obtain truly informed consent. Others want a full discussion to the point of wanting references from the peer-reviewed scientific literature, in which case the surgeon has to titrate his demeanor to a less paternalistic manner. I like to think I’ve gotten better at this in the last decade. Certainly I haven’t heard word of patients viewing me as indecisive in a while.

In terms of training, the way PalMD describes training young physicians is certainly operative–if you’ll excuse the term–in training surgeons in the nonsurgical skills of diagnosis and nonoperative treatments of surgical diseases. Indeed, the best teachers I ever had did exactly that. Many are the times I recall calling an attending in the middle of the night and, after telling him about the patient, hearing the response, “OK, what do you want to do now?” Woe be unto me if I didn’t have a well-reasoned plan of action. Indeed, it was better to have a bad plan of action than to stammer back, “I don’t know.”

The differences between surgical and medical training become most apparent in the operating room. The art of teaching a young surgeon how to operate is incredibly difficult. Indeed, when I was a resident, I never appreciated just how difficult it is for a surgeon to take a resident through a case and keep his or her sanity. Now that I’m on the other side of the operating table, I know. When the resident falters, there is a very strong tendency to want to grab the instruments and take over the case, but doing so too quickly will prevent the resident from learning how to do difficult dissections or to handle other difficulties encountered in the OR. On the other hand, patient safety must be paramount. Letting the resident struggle too long (for instance, trying to dissect a structure free from a large blood vessel) runs the very real risk of harming the patient, and that cannot be allowed. I remember well one attending that I had whose wisdom I didn’t appreciate at the time. He leaned more towards the “cowboy” type of surgeon but his skills were so legendary that he really could almost always get himself out of any trouble that he found himself in. He forced residents beyond what they thought they could do, although he frequently yelled as they did it. What I realized later is that he was just so technically gifted that it drove him crazy to watch me and other residents clumsily try to do what he could do with slickness and utter aplomb, but he restrained himself from taking over the case unless the patient was in danger because he was just that dedicated to teaching. He also taught me a number of things that no other attending did, such as how to take down bowel adhesions with the knife instead of bluntly or with scissors, how to do a Stoppa hernia repair, and a number of other maneuvers that I still use to this day.

Another aspect of surgery that makes it difficult to avoid arrogance is that surgeons tend to have a mentality that surgery can fix things. And fix things it most definitely can, sometimes in a truly dramatic and satisfying fashion. The problem is, however, that because it is so difficult (and often impossible) to do truly “gold standard” randomized, double-blind studies on surgical therapies, the level of evidence supporting them is often based on a preponderance of retrospective studies and other inferences. This makes surgery, at least in my experience, more prone to the persistence of dogma beyond when scientific and clinical evidence doesn’t support a therapy anymore. Surgery residencies also tend to function in a much more hierarchical manner; indeed, I have often likened them to the military, with clear chain of command that is violated at one’s peril. Interns usually don’t go straight to the attending without going through the chief resident first, and orders tend to flow downhill from the attending, to the chief or senior resident, all the way down to the junior residents. Medicine residencies tend to be different, with less of an emphasis on rank. It’s not that rank doesn’t matter; it’s just that it doesn’t seem as rigid as in surgery residencies. Although it is changing, probably in response to overall societal changes that are less tolerant of rigid authority structures and mandated work hour limitations for residents, which increasingly force attendings to deal with whatever resident is there (often an intern), vestiges of a military-like hierarchy still remain and likely will remain. This can lead to what I call “tradition-based” medicine, typified by the remark, “This is how I was taught to do it and how I’ve always done it.”

The flip side of this ability to “fix” things is that surgeons really do love bright, shiny, and new surgical procedures and technology. In other words, surgeons (as a specialty) have a distressing tendency to be susceptible to “bandwagon” effects. I’ve written about this before with respect to the rapid adoption of laparoscopic cholecystectomy years before clinical data demonstrated it to produce equivalent relief of symptoms with an acceptable complication rate. “On the ground,” laparoscopic cholecystectomy looked so dramatic in its ability to alleviate symptoms of gallbladder disease with a greatly decreased level of pain and time to recovery from surgery, but until the clinical studies were done it was impossible to know if the long term complication rate, particularly the rate of bile duct injuries, was unacceptably high. To balance this out, however, I’d be remiss if I didn’t mention once again that some of the best and most rigorous controlled studies (such as in breast cancer surgery) were done by surgeons. These two tendencies are often in conflict in surgery and must be balanced, and it’s not easy.

Finally, PalMD mentioned that excessive arrogance in the face of disease and science can lead to quackery and crankery:

It takes years of training to develop the decision-making skills that go into being an effective attending physician.

This is one place where we part ways with the cranks and quacks.

Cranks and quacks lack humility in the face of disease. They have confidence without knowledge. As a real doctor, I know, with complete certainty, that I will have failures. I know that there are some diseases I can’t beat. The variety, complexity, and horror of human diseases have taught me my place. I can’t promise miracles, but I can give statistics.

Quacks and cranks do promise the improbable. They promise to stop you from aging. They promise to stop autism by fighting vaccination. They promise to twist your chi until your malaise relents. Most important, they don’t know what they don’t know, and that makes them dangerous.

I sometimes wonder if surgical training and surgical culture, with its emphasis on confidence and action over introspection, makes surgeons particularly prone to quackery and crankery. Certainly, Dr. Roy Kerry, the head and neck surgeon-turned quack whose quackery killed an autistic child gives me pause, as does the case of Dr. Lorraine Day, a prominent academic orthopedic surgeon who embraced not only quackery but all manner of conspiracy theories, including Holocaust denial. Another thing that gives me pause is the number of surgeons who seem to embrace “intelligent design” creationism, including a prominent neurosurgeon and a general surgeon. I realize it’s a small sample, but I tend to wonder whether surgeons seem especially prone to the arrogance of ignorance when it comes to areas outside their expertise and prone to their confidence leading them astray within their field.

The bottom line is that practicing evidence- and science-based surgery is, as for all specialties, exceedingly difficult. Balancing the confidence to make a decision and persuade the patient of its correctness with humility in the face of disease, uncertainty, and conflicting evidence, leavened with a firm knowledge of facts and the scientific method sufficient to allow a surgeon to interpret the data in the light of his or her own experience and the unique situation of the patient and then apply that interpretation in a manner most likely to benefit that patient represents the core of surgical excellence. This knowledge and these skills are very hard to acquire and teach, but not by any means impossible if the teacher wants to teach them and the learner wants to learn them.

Comments

  1. #1 andrea
    June 9, 2008

    “The organizers themselves claim that 8,500 people attended, while more objective estimates from people not associated with the march put the number at probably less than 1,000.”

    Oh, what’s wrong with being off by a mere factor of 10? (rolls eyes)

    “Others want a full discussion to the point of wanting references from the peer-reviewed scientific literature, in which case the surgeon has to titrate his demeanor to a less paternalistic manner.”

    As for patient types, I have degrees in science, and would fall into this second category, and find the overly paternalistic sort of docs to be generally condescending.

    For reasons I cannot fathom, the fact that I am female and have chronic problems seems to — in their minds — delegate me to a childlike level of discussion, if indeed, the word “discussion” can be used for a conversation that is didactic and directed towards anyone with me. This is especially annoying if that other person is my hubby, as he takes the submissive Good Patient role and won’t ask for extra information and tries to shush me when I do. Ye gods and little fishes, this is MY body that someone is rummaging around in!

    I do find remarkable the process by which docs can slide into woo — I used to have a doc who went from merely railing against the stupidities of insurance companies and slid into the lighter end of alternative “holistic care”. It’s a shame, really.

    andrea

  2. #2 Liesl
    June 9, 2008

    Very interesting post, Orac. This is a subject I’ve thought about at length as a patient. When I was diagnosed with antiphospholipid syndrome and had every kind of doctor, resident or intern coming to see me in my hospital room to study me (rare disease) or give me MORE bad news, they were always surprised by how calmly I took the news. I think, though, that I am unusual as a patient in that respect and I can’t imagine how hard it would be for a doctor to find the right balance between stating thing outright in the most direct way and adding a bit of cushion or even paternalism to the mix. People criticize doctors for being too arrogant without realizing the weight and depth of your knowledge and responsibility. I think we’ve tried to humanize doctors so much that we often forget that we should offer a general respect for that knowledge and responsibility. Yes, I am way off topic.

    The one surgical onc. “I know always says: A chance to cut is a chance to cure.” Is that arrogant or realistic? I wonder…

  3. #3 SES
    June 9, 2008

    That’s the genesis of that old line about surgeons – “often wrong but never in doubt.”

  4. #4 PhysioProf
    June 9, 2008

    Surgeons have to project confidence to their patients because surgery and other procedure-driven specialties are inherently different because of the technical skill involved. As much as it might be denied, proposing a course of treatment that involves cutting into a person and rearranging his or her anatomy for therapeutic effect is perceived differently by patients than proposing taking a new medication or even undergoing chemotherapy. It’s far more invasive and far more dependent on the skill of the practitioner.

    Dude, you trying to start a surgery versus medicine blog war!? HAHAHAH!

    Just kidding! Excellent post. Every discipline has its issues with arrogance, except for physiology. We are a brilliant, yet humble, bunch.

  5. #5 PalMD
    June 9, 2008

    I actually expect a bit of, um, I guess “arrogance” in a surgeon. I don’t like to refer to a surgeon who displays a sense of hesitancy or a lack of confidence. As Orac says, things can go spectacularly wrong quickly in surgery—a surgeon has to have the confidence and quick thinking to DO.

  6. #6 Lancelot Gobbo
    June 9, 2008

    “That’s the genesis of that old line about surgeons – “often wrong but never in doubt.”"

    But, “if in doubt, cut it out!” Hence, no doubtful surgeons.

    I was always told one can distinguish surgeons from physicians (English parlance for Int. Med.) by the fact that the physicians walk along the wall in a corridor whilst the surgeons stride down the middle. Never yet met an exception.

  7. #7 Barn Owl
    June 9, 2008

    I teach first-year medical students, and spend a lot of time in lab with them, and I can often correctly guess which ones will end up in surgical specialties. If they aren’t particularly confident to begin with, they will develop confidence rapidly, as long as they are able to demonstrate competence in their course and lab work.

    Which brings me to my question for Orac: As a surgeon, do you think it’s a good idea to phase out traditional “hands on” gross anatomy dissections, and replace them with virtual simulations and video dissections?

    As a gross anatomy instructor, I think it’s a terrible idea, but of course I’m biased. I think cadaver dissection gives students a 3D, process-oriented view of anatomy that they will require later on, and it shows them that every human body is different, and they have to adjust accordingly. Fat, adhesions, scars, tumors, injuries, congenital defects…we’re all different. One group of students in my lab section were struggling mightily to do the laminectomy to reveal the conus medullaris, cauda equina, etc., because as it turned out, they were trying to chisel through the vertebral bodies and pedicles. The scoliosis was so bad, that the students thought the transverse processes were spinous processes. We sorted it out together, but it required a lot of poking and prodding and exploratory cuts and changes in approach, as the scoliosis changed the orientation of the vertebral column at different levels. At the same time, we noticed and discussed other things about the “patient”- screws and a plate from orthopedic surgery on the spine, hemivertebrae, signs of bedsores and osteoarthritis, clubbed feet, etc. We also talked about what life may have been like for the individual: pain, disability, mobility issues, breathing problems, etc.

    I’m a PhD, not an MD, but I guess my point with that anecdote is that many procedures in medicine seem to require hands-on, process-oriented learning approaches. The whole “Here’s one I prepared earlier” instructional approach isn’t going to work, not for a first-year anatomy student, and certainly not for a surgical resident.

    Or perhaps I’m wrong, and most can learn this stuff by watching a few podcasts. ;-)

  8. #8 Sid Schwab
    June 9, 2008

    It’s an interesting thesis that “surgical training and surgical culture, with its emphasis on confidence and action over introspection, makes surgeons particularly prone to quackery and crankery.” Off the cuff, I don’t buy it. Because confidence and action presupposes having a basis for believing you’re right. Surgical training, as I experienced it, emphasized the need thoroughly to think a problem through, to consider all alternatives, gather all relevant data. Having done that, one gains confidence. Conversely, as I wrote recently in my blog, the worst mistake a trainee can make — worse than having a bad outcome — is proceeding without careful attention to those steps. I agree there are a lot of crazies in that family of ours; but without having data to support it (a crime, as I’ve stated) I’d bet the incidence is no higher than in other high-functioning populations.

  9. #9 Shygetz
    June 10, 2008

    The organizers themselves claim that 8,500 people attended, while more objective estimates from people not associated with the march put the number at probably less than 1,000.

    It was a homeopathic crowd; the fewer people who attended, the more potent the response.

    As for the confidence versus arrogance issue, I’m smart enough to know that, when it comes to issues where I am ignorant (like surgery AND internal medicine) I can’t tell the difference between educated confidence and skillful bullshit. So, I prefer my surgeon/internist tell me in detail exactly why s/he is recommending a certain procedure, and what the alternatives are, but I will usually trust what s/he tells me because I know I am in no condition to argue intelligently.

    And speaking as a medical outsider, I have to agree with Sid. I don’t think that there are more crazies in surgery. I DO think that surgeons still enjoy a certain cachet among the general population that other medical professionals do not, and that this cachet would tend to make surgery professionals more high-profile.

  10. #10 cathyf
    June 10, 2008

    Wow, this one is timely Milan clinic probed for alleged needless surgery

    Jun 10, 1:34 PM (ET)
    .
    MILAN, Italy (AP) – Police have arrested 13 doctors from a clinic in Milan who investigators suspect performed needless and sometimes fatal operations to make more money.
    .
    Police said Tuesday the charges resulting from the investigation of Santa Rita Clinic ranged from fraud to homicide.
    .
    Three of the doctors were arrested on suspicion of murder for allegedly having performed on several patients “abnormal or invasive surgeries, without taking into consideration the fragility of the patients because of age or their medical condition,” the police statement said.
    .
    Police officials said five patients at the clinic are believed to have died after suspected needless surgeries. A hospital official was also arrested, police said.
    .
    Repeated calls to the clinic Tuesday afternoon went unanswered.
    .
    One man who said he was a patient told Italian state TV that he was given a lung operation instead of thyroid surgery.
    .
    “When I awoke, I found these tubes under my armpit,” Giovanni Rizzitano said, pointing to his side as he was interviewed on state TV Tuesday. “They had operated on my lung.”
    .
    The head of thoracic surgery was among those reported arrested.
    .
    La Repubblica, a Rome daily, quoted Riziero Scocchetti, the 72-year-old brother of Maria Luisa Scocchetti, who died shortly after lung surgery in 2006 at Santa Rita. The woman, 65, was dying of breast cancer in the hospital, the brother was quoted as saying.
    .
    “I asked the doctors to let her die in peace,” Scocchetti said, according to the newspaper. “They reassured me that they were doing everything to save her. Instead they operated on her lung. But everybody knew she wasn’t going to make it.”
    .
    The newspaper quoted former patient Alfredo Scordo, 76, as saying part of his lung and some lymph nodes were removed in 2005 while he was recovering from pneumonia in the hospital.
    .
    “They cut open my back, four hours under the knife for a long and painful surgery,” Scordo was quoted as saying.
    .
    Police contend that the clinic doctored patients’ charts so it could obtain higher reimbursement for the costlier surgeries from the Italian national and regional health service in 2005 and 2006, for a total, police allege, of some US$3.8 million in extra money.
    .
    Italian news reports carried what were said to be transcripts of wiretaps in which doctors sound eager to do expensive surgeries. In one wiretapped conversation, a doctor reportedly cursed when told that a 90-year-old patient had been rejected for lung surgery because of breathing difficulties.

  11. #11 Alvaro
    June 11, 2008

    Thank you for a very illuminating post. I read recently (sorry, can’t locate it now) an article advocating the use of cognitive assessments to evaluate medical students in the UK. As I recall, it was pretty basic stuff, not so much into executive functions.

    It’d be fascinating to define the cognitive profile of successful surgeons, develop assessments to help identify the most promising students, and offer the most effective training regimes.

  12. #12 Tracy W
    June 12, 2008

    I work in the forecasting sector, and I find there you need a pretty weird mental balancing act. On the one hand, I turn out to be wrong all the time. On the other hand, initially I would let myself be persuaded by some arguments that my view was wrong, and then often found that my initial view turned out to be right. On the third hand, often initial “facts” turn out to be wrong. So I have to strike a balance between being aware that I might be wrong, but not being too fast to run to that judgment. It’s fun.