There’s an old adage in Surgery that says: “It takes two years to teach a resident how to operate and another three to teach a resident when not to operate.”
Surgery is an active profession. Above all the Surgeon is expected to take action, even when that involves the decision to NOT do surgery.
Surgical sins are different from Medical sins. There are sins of commission – hubris, arrogance, pride, vanity – all of which we are guilty of at one time or another during our careers. Some of them are also surgical strengths depending on the situation.
There are also the sins of omission – carelessness, sloth, ignorance, and perhaps the most egregious, indecision. As a mentor once said, “A surgeon doesn’t have to be right, but he has to be certain.”
It’s incumbent on us by the nature of what we do to people in surgery to be affirmative in making decisions. By that I mean, any decision should be made actively, through consideration of the action we are taking and its potential consequences.
But wait, aren’t all decisions made that way? No, not always. Delay, procrastination ‘watchful waiting’ often lead to a decision of indecision where the patient’s condition changes in spite of our attention rather than because of it. If I, as a surgeon, chose not to operate on a patient, it should be because I have a valid reason for expecting that the situation will resolve without surgery, or perhaps because the patient’s condition is such that surgery presents an unacceptable risk.
I recently decided not to operate on an elderly woman with free air in her abdomen. Free air means there is air outside of the bowel or lungs where it belongs. It implies a perforation in the bowel or stomach that is leaking stool or intestinal contents. Under most circumstances, it’s a surgical emergency.
I looked at this frail woman who was pleasantly demented with a history of heart disease and a recent stroke and thought, No way. It was a gut reaction born of a reluctance to take on a complicated and high-risk surgery. I rationalized it by observing that she was having little pain; that the air seemed scattered and was minimal in volume; that the CT that showed the air gave no indication of where the perforation might be and that she had a high risk of complications. I made a good case for NOT doing surgery, but knew it was a rationalization.
At first it seemed like the right decision. I started high dose antibiotics, put her on a limited diet and repeated her labs and x-rays. Her blood tests improved, she had no fever, her pain almost completely resolved and her intestine seemed to be working.
By the fourth day, however, it should have been clear to me that she wasn’t getting better. Still, I rationalized and procrastinated. She wasn’t getting worse, after all. I couldn’t (or more accurately wouldn’t) make a decision to abandon my original plan and take her to surgery.
By the seventh day it was obvious even to the internist that not operating wasn’t working. I took her to surgery and drained a large intrabdominal abscess and searched throughout her abdomen for the site of the perforation. I never found it. I suspect it was a pinhole perforation in a colon diverticulum, but even with aggressive manipulation of the area, I couldn’t demonstrate a hole.
She did not do well after surgery. She got more septic, her lungs and heart started to fail and after a long discussion with the intensive care internist, and me the family decided on palliative care only. She died a few hours later.
I don’t know if she would have survived if I had operated sooner. Perhaps the outcome would have been the same. I will never know. But I do know that my decision to not operate, while justifiable on paper, was not motivated by an objective look at her condition. And when it should have been clear that my initial management was failing, I procrastinated. The sin of indecision led to a delay far beyond what was objectively justified.
Anyone who has been in this business for a while can list his or her own secret tally of sins. I have committed sins of hubris, of arrogance, where I over estimated my capabilities and patients suffered and died for it. I have let pride push me to cling to a course of action when I should have changed course, and patients have been harmed. I have allowed fear or indecision or fatigue or stubbornness to hold me back from doing necessary surgery and patients have died. We all remember those cases but we tend to forget the times when we did the right thing. I can name far more patients that I have lost than ones that I have saved.
How a surgeon handles sin is a deeply personal process. I know some surgeons who simply ignore it. They are able to rationalize their actions and put it all down to patient disease, or at worst, a learning experience. Others become paralyzed by the fear of making an error and refuse to get involved in difficult or complex procedures. Still others internalize the guilt, refuse to let it stop them from continuing to take on the challenging or emergent cases, but ultimately pay a price in the form of sleepless nights and endless private second guessing of each decision.
Sometimes we have the opportunity to confess through the Morbidity and Mortality Conference (see M&M, another essay) and receive closure in the form of peer review of our actions. Even when the review recognizes our failing and chastises us for it, the philosophy of ‘forgive and remember’ is strong and the ritual lends a form of absolution.
Just as often, though, the sin is private. We know in our hearts what really motivated our action, and even when that action appears appropriate to an outside observer, we alone know how we failed. We must handle that and find a way to live with it if we are to serve our patients and retain our sense of purpose.