Back in time in medicine

Every 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.