Respectful Insolence

Back in time in medicine

i-e7a12c3d2598161273c9ed31d61fe694-ClassicInsolence.jpgEvery so often, real life intrudes on blogging, preventing the creation of fresh Insolence, at least Insolence of the quality that you’ve come to expect. This is one of those times, thanks to three grant deadlines. So enjoy this bit of Classic Insolence from back in November 2010 and be assured that I’ll be back tomorrow. Remember, if you’ve been reading less than three and a half years, it’s new to you, and, even if you have been reading more than two and a half years, it’s fun to see how posts like this have aged.

Every so often, the reality of trying to maintain a career in science-based medicine interferes with the fun that is writing for this blog. Basically, what happened is that I spent the entire weekend working on three different grant applications and, by the time Sunday night rolled around, I was too exhausted to write what I had originally planned on writing. Fortunately, one advantage of having been blogging so long and also having blogged under a pseudonym over at my not-so-super-secret other blog is that there’s a lot of material which is pretty damned good, if I do say so myself, that I can draw on for just these situations. Even better, it’s old enough that it’s unlikely that most of you have actually come across it before, which makes it new to you (well, at least most of you). As a special bonus, the jumping off point was a post by an occasional contributor to this blog, Peter Lipson. Actually, I wish Peter would contribute more regularly, but he’s too busy moving on to bigger things at Forbes.

This time around, I’m half-recycling, half-revising a post that was a bit more navel-gazing than usual. However, as the only surgeon on SBM I think it’s actually useful every now and then the trials and tribulations of practicing science-based surgery. It began when Peter 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 started 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.


Peter then went 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 the technical skill involved makes surgery and other procedure-driven specialties somewhat different. It’s not just about knowing the science. it’s about being good at the technical skills that are so important in surgery. 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 raw 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, even in the more procedure-oriented internal medicine specialties, the number and level of invasiveness of these procedures are 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%, COPD, and is on aspirin and Plavix? No problem! Let’s operate!”), seemingly oblivious to the risk. He not infrequently gets into trouble (“Oops, I severed the aorta! Don’t worry. I can fix this.”) 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 the situation calls for, as I like to put it, maximal invasiveness. 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 came back to me through my division chief 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, all the while choosing courses of action that are supported by science. 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 15 years. Certainly I haven’t heard word of patients viewing me as indecisive in a while. (Cue a patient finding this blog and telling me how wishy-washy I am.)

In terms of training, the way Peter described 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 can never 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” surgery, 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, 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 Mark Thorson
    June 24, 2013

    I’ve heard there are certain times of the year that patients should avoid surgery (if possible) because that’s when new surgical teams are being formed, and they need to get experience working together. Could you comment on that?

  2. #2 janet
    out in a meadow looking at cows
    June 24, 2013

    My surgery teacher in vet school had quite a few sayings. We’ve all heard the “a chance to cut is a chance to cure” or some version thereof. As vet students we were very into that (well, those of us that liked what little surgery we had done that far in our training.) Our surgery teacher had a twist on that old saying. He said, “A chance to cut is a chance to drive the tractor.” That refers to the tendency of farmers not to call the vet until the last possible breath of life, when the cow should have had surgery two days previously. If the vet tried surgery THEN, well, someone would be driving the tractor to haul off the carcass. The other thing he said (once was enough, although we heard it many times) was, “All hemorrhage eventually stops.” We were comforted by that until we thought it through. I imagine our surgery teacher despaired of all of us many times, but, kind of like Orac’s very gifted surgeon/teacher, he spent a lot of time not snatching instruments out of our very inexperienced hands.

    I’ve personally encountered quite a few surgeons, both from personal need, and as researchers using animals. I’ve discovered that I need the more collaborative approach from a surgeon–I’m the truly annoying patient who comes in with the publications printed out and highlighted. I’m also the annoying lab animal vet who can read and understand the research papers. That approach worked well for all but one and I would NEVER see him for anything. Oh, and I threw him out of my surgery room. :) (nobody gets away with throwing an instrument at me)

  3. #3 Bronze Dog
    June 24, 2013

    Guess I missed this post the first time around. Interesting to know a bit more about the world of surgery. I’m reminded of an episode of Scrubs where they depicted the surgeons and doctors like the rival gangs in West Side Story. Given the differences, I can see how there might be friction when they disagree about whether or not surgery is best for the patient.

    Other aspects that come to mind for the surgery/crankery link you’re wondering about here:

    “Good medicine tastes bad.” A lot of quackery out there seems popular precisely because it’s unpleasant. That unpleasantness tells the patient it’s doing something, and presumably that’s going to lead to a positive outcome, because otherwise they wouldn’t do it, the rationale goes. A lot of alties like to one-up other people about the pains they go through to “earn” their health. Surgery isn’t exactly pleasant, and unsurprisingly, fiddling with people’s organs tends to do something. I suppose some surgeons might fall into that rationale when used to justify quackery, since they’ve seen their patients go through uncomfortable recoveries to benefit in the long term.

    “Technician Surgeons”: I’m not sure if I initially heard the idea here or maybe Neurologica, but I remember it came up alongside the topic of Egnor. From what I gathered, there are some surgeons out there who just get by learning how to cut, without trying to expand their knowledge much beyond that. I think it might be similar to engineers who are Creationists, believing their skills in one field makes them an expert in a field they haven’t studied. A little bit of knowledge is dangerous, since they only have enough to gain arrogance without being aware of how much more knowledge the relevant experts have.

  4. #4 TBruce
    June 24, 2013

    Old Joke Alert:

    Three doctors go duck hunting, a GP, an internist and a surgeon. They’re sitting in the duck blind when a duck flies over.
    The GP looks up, says “Looks like a duck”, he sights through his scope, says “Yep, it’s a duck”, aims and shoots. Down goes the duck.
    Another duck flies over. The internist says ” Looks like a duck, but I had better do a GIS on my iphone for “ducks” for comparison, just in case it’s a passenger pigeon”. While he’s doing this, the duck flies off into the horizon.
    Another duck flies over. The surgeon fires till his magazine is empty, down goes the duck. The surgeon says “Was that a duck?”

    You can tell it’s a really old joke because all the docs are male.

  5. #5 Roadstergal
    June 24, 2013

    I didn’t see this post the first time around, and I’m very happy to see the revival. I’ve definitely come across surgeon creationists and arrogant “I’ll fix you!” surgeons in interactions on the behalf of family members, and this post makes it easier to understand where they came from.

    I’ve also come across wonderful surgeons, I should mention to balance that out, who were very willing to talk about the decision-making process with me and tell me the whys and possibilities, and they were the only surgeons who have had their hands in me (for two different broken bones – I’ve been fortunate not to need anything more extensive yet).

  6. #6 Nick Theodorakis
    June 24, 2013

    @TBruce: In the version I heard, one of the docs is a pathologist, and the surgeon tells him, “tell me that was a duck.”

  7. #7 Nick Theodorakis
    June 24, 2013

    Not really a joke, but once a surgical resident I knew told me about one of his attendings, “Dr. xxxx’s indication for cholecystectomy is ‘presence of gall bladder.’”

  8. #8 LC.
    June 24, 2013

    @Bronze Dog
    Forget Scrubs – the factional politics in real world hospitals are a nightmare which makes West Side Story look like a playschool episode. Surgeon X thinks Surgeon Y is a hack and only works there because Nurse Z persuaded Administrator A. Resident R agrees because he heard that Doctor Q had…

    As for surgeons being arrogant, I am somewhat of mixed opinions. Within their field many have every right to be confident and as Orac points out it can be a good thing rather than crippled by being indecisive. But dealing with them outside their field of expertise can lead to one tearings ones hair out – “Yes Doctor X, I know you can perform surgery blindfolded, with one hand behind your back, whilst performing the chorus line from ‘Ragtime Gal’, but you still need to plug in ‘that useless machine run by those overpaid basement rats downstairs’ before it will work. Have a nice day”.

  9. #9 Mephistopheles O'Brien
    June 24, 2013

    “That’s God, but he thinks he’s a Surgeon.”

  10. #10 Grant
    June 25, 2013

    OT – There’s this from Diane Harper, who is pitched as “the lead researcher in the development of the human papilloma virus vaccines, Gardasil and Cervarix”:
    The Lead Vaccine Developer Comes Clean So She Can “Sleep At Night”: Gardasil And Cervarix Don’t Work, Are Dangerous, And Weren’t Tested.

  11. #11 Chris Hickie
    June 25, 2013

    I had completely forgotten about this from early in 2012, but a local tv station in Tucson ran a story on TV “cutting edge treatment available for children and adults with Down syndrome” (http://www.kvoa.com/news/tucson-family-changing-minds-about-down-syndrome/). What is the treatment? ginkgo biloba, Prozac, essential fatty acids, oils and vitamins..

    Yep. Little did I know you could give prozac to your 1 year-old with Down Syndrome.

    This is relevant, because the father of this child is an orthopedic surgeon, who of course, says: “”I think pediatricians have so much to know that it really takes these warrior moms to learn about the new information in Down syndrome.”

    Yes, we pediatricians have so much to know that I missed the “cure” you have for Down Syndrome (here’s the quackadoodle web site that pushes this “treatment”: http://www.changingmindsfoundation.org. (of course they sell all this stuff, ‘cept for the prozac, for which they tell you to keep pushing your child’s doctor on it and if needed change doctors until you find one who will rx prozac for your infant/toddler with Trisomy 21.

    So I wrote this news station and actually got a rather apologetic response from their asst news director:

    Dear Dr. Hickie:

    Thank you so much for responding with your concerns about the down syndrome story that aired this morning on Tucson Today. I take full responsibility for the omissions in the story. I dropped the ball. I approved the script and now realize that, indeed, our reporter did not have a doctor’s take on the treatment, in addition to the family’s story. I will be discussing your concerns at great length with the reporter herself and plan to make sure something like this doesn’t happen again.

    I hope you will consider keeping in touch with us, as we would love to use you as a reference and a resource for future medical stories that involve children.

    Once again, I apologize for doing a disservice by omission in our story, and I hope you will continue to be a KVOA viewer.-

    Best Regards,

    Leasa Conze

    KVOA-TV Assistant News Director

    Of course, I never saw a retraction of this story, and as you can see, it still exists online a year later.

  12. #12 TBruce
    June 25, 2013

    …because the father of this child is an orthopedic surgeon

    What’s the difference between an orthopedic surgeon and a carpenter?

    A carpenter knows more than one antibiotic.

  13. #13 Chris Hickie
    June 26, 2013

    In medical school it seems that the orthopedic surgeons took a lot of razzing (or even crap) from the non-orthopedic surgeons, which seemed unfair (I’m very grateful to some orthopods for some knee work I’ve needed, and being able to exercise is important). I’ve found all surgical fields amazing to study, and I’m grateful there are doctors who can make it through all the extra training and time (and lack of sleep) that it takes to be a surgeon (because I realized there was no way I could work 120 hours a week and be functional, which is what it takes for surgical residents.)

  14. #14 TBruce
    June 26, 2013

    My apologies to the orthopods out there. That was an old joke aimed at that goof@IRM – I guess the whole aluminum angle isn’t sexy enough for them…..mercury is much scarier….of a father, who really should know better. I can sympathize with a non-medically trained person who falls for this stuff, but an MD? No excuses.

    Incidentally, in my training, I found that the attending orthopods as well as the ortho residents to be the kindest surgeons to the lowly med students and interns. As a result, I have always retained a soft spot for them.