By Lauren Kosinski, MD
When I lived in Alaska, everyone knew someone who had died, whether seasoned outdoorsman or novice. Extreme weather, solitude and the wilderness are part of the allure of Alaska, but even small mistakes can have big consequences there. Exposure. Capsized boats. Floatplane crashes. Lost footing on a trail. Animal encounters. Even bad divorces.
But some stories grip the imagination and are told over and over again. One such apocryphal tale is of an obese woman fishing alone in her boat who cast anchor before turning in for the night but misgauged the bay’s depth and the speed of the incoming tide. As the tide rushed in, the anchored end of the boat tilted, ice-cold sea water rushed over the deck and the cabin door at the aft end submerged before she awakened to discover the crisis. By then, the cabin door could not be opened, and she was too large to escape through a cabin window. Her plight is haunting: trapped not just in her boat but in her body, waiting to die as minutes filled hours, hoping for hypothermia to numb the senses before the inevitable drowning.
Perhaps this story is a kind of cautionary tale. Like the bore tide in Cook Inlet× which can flood at up to 15 mph, the incoming tide of legislation and corporatization of surgical practice seems insurmountable, and we are like the obese fisherwoman, sleeping in her cabin. There is no doubt in my mind that we have contributed to our own potential professional demise by failing to reckon with the changing circumstances—cultural and financial—in which we work.
On one hand, a kind of fierce autonomy is necessary to function as a surgeon. “Trust no one.” This is a dictum of training and practice. A poem purportedly composed by a surgeon was recited to me in medical school by an incredulous internist:
Row upon serried row, they sit.
All masters to the rule.
But there is only one, my friend,
Who has to fight the bull.
Medicine doctors, it counsels, can sit in the tiered bleachers of the historical operating theater, arguing about the differential diagnosis, its work-up and subsequent treatment; but in surgery, one person has to perform the operation. One person stands in the arena and “fights the bull.” To be sure, this is not at all the same as working alone. This task is never performed in complete isolation, but one person has made an operative plan with the patient and must not only see that patient through the implementation of the plan but also technically execute the plan. One person makes the incision and gains entrance to the inner sanctum of another human body. The psychological preparation for this (which, by the way, is so critical and yet so unexamined among surgeons) is not necessarily what prepares us to see beyond one patient or to be trusting of, well, anyone. We are trained to be accountable for every aspect of the perioperative patient’s care. Their outcome, our reputation, and our sense of well-being and worthiness beyond what others think, depends on our shouldering responsibility for the operation.
On the other hand, we have been the cats who swish our tails and lick our paws, looking on with disdain at any attempts to herd us. Could a group of surgeons in a community hospital or an academic department agree to meet and negotiate contracts for operating room equipment? Could it ever happen that the robustly experienced robotic urologic surgeon would cede his suite or compromise in any measure to ease the way for a less-experienced robotic surgeon? Could laparoscopic surgeons evaluate stapling devices and assess the needs of a group, sifting through preferences, data and critical requirements to make unified purchasing recommendations? It’s hard to imagine. We are seen as thoughtless spendthrifts who are swayed by sales reps like children in a candy store. We commonly step on one another to assert our own needs and establish our place. In the wake of our disputes, we leave the distinct impression that we are self-serving prima donnas who are best governed by more altruistic nurses and administrators. Such stubbornness and lack of insight pit us against one another and seal our fate to drown in the cabin of our small boats.
A colleague was recently censured for exclaiming, “F@#%!” in a challenging case. An instrument he routinely used for this procedure was missing. Several efforts to locate it were unsuccessful, and he tried four alternatives before he could complete the procedure. His stress level mounted as successive alternatives proved to be inadequate substitutions. Perhaps he would have had difficulty even with the standard instrument, but his frustration was amplified by the absence of the familiar and dependable tool. It can be very lonely in the operating room—no one else could solve the problem for him; all they could do was bring what he needed, and even that wasn’t working, which can leave the surgeon feeling even more strained. Underlying this is always the anxiety of failing the patient, of being inadequate to a task that has high stakes.
Every surgeon knows the frustration of the incorrect preference card. Each time we ask for something particular (a stouter 7-inch needle driver to close the fascia, a right angle with a finer tip to facilitate delicate dissection, or undyed 4-0 vicryl on a PS-2 not a PS-3), or when we are disgruntled about a substitution (Demerol must be used instead of fentanyl for colonoscopies today), we are seen as temperamental. Yet it is a hallmark of expertise to appreciate the differences between instruments, to know the nuances of each and to select it precisely. Every circulator loves the surgeon who makes do with what’s already on the back table, but every scrub tech wants the surgeon to be quite specific about what instrument to place in an outstretched hand. Chaos ensues when a surgeon is incapable of specifying what she or he needs.
In the allegorical wilderness of the operating room, seemingly small divergences can have big consequences. A 1 or 2 cm displacement of a suprapubic port can make the difference between successful and unsuccessful stapled transection of the rectum in an ultra-low laparoscopic proctectomy. Similarly sized endostaplers from different vendors may have identical performance parameters, but they will still not handle or behave identically. The discriminating surgeon will recognize these differences and learn to make adjustments, but the period of adjustment can have deleterious consequences for patients. The surgeon’s stress level is higher during the transition, as it should be. In addition to the patient’s well-being, the surgeon’s stature and self-worth—and potentially referrals and reimbursement—depend on achieving good operative outcomes. No one else in the operating room or the hospital bears that burden more vividly. Clinical decisions, material and instrument substitutions are sometimes relatively inconsequential or are made to realize the benefits of new technology, but the assessment of the magnitude of that impact and strategies for overcoming it cannot be made by administrators who do not use and depend on the performance of those supplies and equipment.
My colleague’s behavior was not tolerated. Whether reported as merely temperamental or more seriously as disruptive, he depended on the resourcefulness of staff who had less visible and personal investment in the outcome than he did. After the report of his behavior, the instrument he needed was found 10 feet from the operating room in which he struggled.
Where do we begin? How can we set anchor more thoughtfully and be more fit and flexible? How do we surf the bore tide rather than be swamped by it?
Perhaps we can begin by taking small steps, by finding more effective ways to communicate our endeavor that more successfully draw team members into the solution. Paradoxically, at a time when it seems there is pressure to diminish the relative contribution of the surgeon to the performance of a successful operation, it actually may be critical to clarify it. This may require that we surgeons overcome maladaptive behaviors for reckoning with the psychological task of cutting another person open and hurting them to help them. We can minimize our awareness of this monumental event in a number of ways, one of which is to obscure just how remarkable it is. We make it mundane. We also tend to exteriorize or project outside of ourselves uncertainty and risk. We cultivate our own mythology that we have almost superhuman powers: We don’t need to sleep; we don’t need to eat; we don’t need to wear coats in cold weather or seatbelts in cars (Cult Med Psychiatry 1987;11:229-249). Like epiphytes that appear to live on air alone, we subsist on a steady diet of surgery, research and consultations.
We may need to recognize our vulnerability, not in an angry and victimized way but rather as a matter of fact. We simply need the very best help we can get in the operating room and clinic. The environment must support our relaxed concentration. Every other person in the room can more easily take a break or be replaced. The surgeon cannot leave the job unfinished. We may need to admit that a little juju helps achieve this state of mind. We make choices because we have to, and then we wed ourselves to those choices because when we make as much of an operation as routine as possible, when we work out the little kinks and establish a mental template for what things ought to look like at every step of the procedure, things go more smoothly. We cannot settle for letting these positive adaptations be characterized negatively. “Master,” “expert,” “hero” and “heroine” are synonyms for prima donna.
So, how do we reverse the tide? Perhaps we can’t reverse the tide, but we can adapt to changing needs and help shape expectations. We can ask for help. I may still be a bit naive, but I continue to believe that most people who work in health care were drawn to this work because they actually want to help. I also still believe that regardless of the skill level, every person derives satisfaction from a job they do well and basks in appreciation and the feeling that he or she counts. We all want to be on a winning team. By asking for help and admitting exactly what we need and why, we let our team members know how much they matter. It’s possible, then, that instead of resenting what seems to be our demanding, dismissive attitude and healthier income, they might want to help protect our time and support our performance. We do not, despite our professional mythology, have endless private resources to draw on. Finally, by doing a better job of expressing our needs and limitations, our humanity, we might better account for what we can and cannot do and more faithfully take a seat at the table to help shape the decisions that affect us so profoundly. We can ride the tide more gracefully, in full cognition of our original intention and help chart the course, one step at a time, one conversation at a time, one honest moment of reflection at a time.
Dr. Kosinski is an assistant professor of surgery in the Division of Colorectal Surgery at the Medical College of Wisconsin, Milwaukee.