I am too nice for general surgery

People often tell me I am too nice for general surgery. That I don’t fit the culture. But over the past few years, I have seen some of the greatest acts of compassion performed by my surgical colleagues and today, I’d like to ask you to challenge that stereotype. 

No one wants to have surgery. The day you are told you need a surgery, whether for gallstones, appendicitis or a newly discovered tumor, is often one of the scariest in a patient’s life. To allow another human to put you to sleep, paralyze you and cut into your body, entering portions of your self that you have never seen or felt with your own hands, and then sew you back together requires complete trust. So what kind of doctor would you like to see in that scenario? What qualities would you like this person to possess? 

I would hope for a physician who understands the fear that exists pre-operatively. My patient came to clinic one week prior to his surgery, a pancreaticoduodenectomy, or whipple, for pancreatic cancer. His initial imaging work up had shown a questionable liver lesion, so he had already had a diagnostic laparoscopy with a liver biopsy which luckily returned as benign. He went on to complete two weeks of neoadjuvant chemoradiation, which he tolerated remarkably well. So here he was to discuss his surgery. He had worked as an engineer his whole life, and wanted to discuss every detail. How long is the surgery? How will I feel when I wake up? Where will I recover? How long will I be in the hospital? When will I be able to eat? Will you update my family? How quickly will I be able to see them after I wake up? His questions shifted from surgical logistics to the wellbeing of his family. The surgeon I was working with remained until every question was answered. He drew pictures, he reassured the patient, he provided comfort to his wife and he got further and further behind in his clinic schedule. But in that moment, as that patient prepared for the scariest day of his life, he was 100% his. 

I hope that my surgeon is thorough. Our patient was asleep and prepped on the table for his whipple. My chief resident and I opened the belly and began to explore the abdomen for any metastatic disease. Now remember, this patient had already had negative liver biopsies one month ago. So our suspicion was low. But we felt something on the liver that wasn’t quite normal, so we sent a biopsy to pathology. We then proceeded with the first part of the operation, a cholecystectomy. Our attending scrubbed and we continued the case, mobilizing the duodenum and dissecting out the pancreas. 

The phone rang in the OR and it was pathology. “Calling regarding patient X, medical record number 159375. We have results from a liver biopsy. Biopsy shows metastatic adenocarcinoma.” The OR was silent. All hands stopped moving in the belly. “What? How is that possible? We have benign biopsies from a month ago”. The pathologist “we know, and we compared to those samples and this is definitely metastatic disease. Can you send more tissue?” “Yes definitely, we will send a second biopsy”. So we went back to the liver, to another place that didn’t feel quite right, and sent another sample. 

And then we waited. 

The phone rang. “Hello this is pathology, calling regarding patient X, medical record number 159375. We have results from the second liver biopsy. This also demonstrated metastatic adenocarcinoma.” 

So what does this mean? We are already in the abdomen, should we just do the surgery, we have already started? No. All we can do now is palliative procedures. The prognosis after a metastatic pancreatic cancer diagnosis is 3-6 months.  All we can hope to do is to make him more comfortable. So we performed a gastrojejunostomy, bc as the tumor grows it will obstruct his duodenum, making him unable to eat. Hopefully this will allow him to keep his digestive track open for longer. And we performed a celiac plexus block to help alleviate abdominal pain he will certainly develop soon.

I would like a physician who is honest, even when it is painful. After closing, our attending went down to speak with the family, his wife and daughter, and explain what we found and the prognosis. Our patient wheeled to recovery. After an hour, his family joined him in recovery, knowing his new diagnosis, while he lingered in the post op twilight. 

Later, we returned to the bedside to tell our patient that we could not complete the surgery. His wife held his hands and he looked to our attending for hopeful news. He explained that we took another liver biopsy when we got in and that it returned as metastatic cancer. I watched my patient’s eyes as it began to register. His shoulders tightened, he looked to his wife and back to our attending. Tears welled in his eyes. His wife squeezed his hands and cried and told him she loved him. He did not ask questions, he just was. My attending squeezed his arm and we left him with his family. 

We walked back to the floor in silence. Each of us lost in that family’s pain and their love.  

Unfortunately, this is not the first or the last of those conversations that my attending has experienced. He has dedicated his life to pancreatic cancer and caring for patients as they face a terrifying diagnosis. 

So I ask, is he too nice? Is the pediatric surgeon operating on your child, too nice?

These are the surgeons that I have worked with. And these are the physicians who have shaped me, inspired me and taught me that compassion exists in every specialty, even general surgery. I hope that none of you will fall into the trap of believing these stereotypes, and you will be too nice for all specialties. 

Taylor Coe
MS4

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