by Claire Rosen, 2022 Medical Fellow
If you wound the body of a dying man, the wound will begin to heal, even if the whole body dies within a day. – Primo Levi1
I worry that we learn and practice in a world where surgeons are incentivized to operate, prioritizing the treatment of wounds over care for the dying. As with all things in life, we are ruled by time and money. But cultural expectations also play a role: we’re influenced by the litigious nature of modern American society, by our hesitancy to sacrifice any form of success. Extrinsically and intrinsically, selfishly and well-intentioned, there are myriad reasons for surgeons to act on diagnosed injuries and physical abnormalities. But treating wounds without a focus on the whole patient shouldn’t be the role of the surgeon, no matter the incentives. To re-prioritize treating the patient over the wounds, to provide the care that our patients deserve, we should recognize the force of these motivations and work collectively to overcome them, using our scalpels when we should and not only because we can.
In medicine, time is always of the essence, and always insufficient. When a patient is transferred into our care, perhaps teetering on the edge between life and death, time matters. We learn to triage and treat within the golden hour of patient presentation; our quick actions can save lives. Outside of those emergent settings, time is still of the essence, and meaningful conversations with patients about their life goals, and about whether our surgical care can support those goals—these take time.
A few months ago, I spent longer than a golden hour on the phone with a septic patient’s daughter. Her father was transferred to our institution with a perforated (metastatic) esophageal cancer, previously deemed unresectable, his health too poor for even palliative chemotherapy. Even though she knew his days were numbered, this acute problem came as a surprise, and the idea of not trying to fix it, of his dying more quickly than she’d expected, was overwhelming. She searched her mind for memories of his stated wishes as I scoured his medical record for palliative care and oncology notes, both of us finding evidence of his consistent and persistent refusal of feeding tubes, drains, or any invasive procedures. As she cried about her mixed fears, torn in opposite directions between letting go now, or treating him with a surgery he may not even want, the intensive care unit pushed our team to decide faster while he slipped into worsening sepsis, delirium, and instability. Speaking with his daughter was not only time-consuming but also emotionally exhausting. While I could have been basking in the instant gratification of operating, I was instead trying to explain to a daughter her father’s dismal prognosis regardless of treatment, discussing life and death and the often-un-miraculous realities of modern medicine. When she eventually decided upon pursuing comfort measures, I told my attending that it would have been easier just to operate. He agreed.
Patients value our abilities to interact as humans, to relate honestly and openly,2 sometimes even more so than our technical abilities. These interactions, for all their importance, can take meaningful time away from the operating room, from other patients, from rest amidst a 24-hour shift, and from the money we earn by operating (especially if a patient chooses not to pursue surgery). Medicine is a business, and operations are a major source of income for hospitals.3 Working within such wearying time constraints, incentivized to operate over taking time to connect, surgeons must dig into reserves of empathy to see beyond diagnosable and treatable injuries. I worry that my ability to empathize will wane as I grow more jaded, that my patience will grow thin, that I too will value the financial incentives behind my knife. Recognizing this now will, I hope, act as a bulwark against degradation, to stave off this transition. But it won’t be easy, and I certainly can’t do it alone.
Even this fear isn’t so simple: empathy, when misdirected or overzealous, can incentivize us to treat diagnoses over people. As often as we repeat anecdotes like “not everyone needs to die with their belly sliced open or a limb cut off,” it’s hard not to act. It feels wrong not to offer a possible surgical intervention when medical colleagues call, searching for help and any possible solution for their patients in distress. Even if we think that the likelihood of benefit is overshadowed by the risk of an operation, it can go against our nature turn away from action, to leave our colleagues and patients feeling untreated or abandoned.
When the 22-year-old, lung transplant patient was found down in his hospital room, he received seven minutes of chest compressions before his heart started beating again. When his belly distended, when his imaging showed ischemic intestines and liver, and when his vital signs continued to worsen, we rushed him to the operating room for a “Hail Mary” operation, wanting his parents, our medical colleagues, and ourselves to feel that we had tried everything for this young person. But when his purple and black intestines were too dilated to squeeze back into his abdominal cavity after we cut him open, I felt the powerlessness of surgical steel in my hands; I saw and lamented a life already claimed by death. And yet—it felt good to tell the patient’s family that we had done everything, even when we knew everything wouldn’t work.
When I talk about cases like that, about what we should have (or should not have) done instead of operating, I have one mentor who tells me to imagine myself in court. He asks me what choice I would feel more comfortable defending should the patient die, and their family sue. He preaches the notion of an effective safety net around treatment; people, after all, have more confidence in a surgeon who does everything they can than in a surgeon who doesn’t seem to try. In our litigious society, in which over 63% of general surgeons are sued during their careers,4 these concerns are real. But defensive surgical action shouldn’t be the answer. It’s not equal to good medical practice and doesn’t reduce malpractice claims or improve outcomes.5 Though often not with malintent, defensive surgery is a poorly understood, and sometimes harmfully executed, defense mechanism. If we communicate better with our patients, maybe we can alleviate these fears of litigation; maybe skill in comforting those in need is just as much a part of surgery as operating.
It’s an intrinsically human thing to want to fix problems; as surgeons, we are extremely fortunate—our hands and instruments can do just that. But human beings invented surgery to treat people, not just their problems. Without recognition, the extrinsic and intrinsic incentives to operate can overshadow our role as physicians. At our core, we are just people trying to heal and help other people. As our nation slips towards distrust of science and medicine, we owe it to ourselves, to our patients, and to our profession to question our motives, to connect with our patients, and to honestly communicate our abilities. It will, I think, help us to know best when we should operate, if we remember to treat the dying man over his wounds.
Claire Rosen was a 2022 FASPE Medical Fellow. She is a General Surgery resident at the University of Pennsylvania.
- Levi P. Survival in auschwitz. New York, NY: The Onion Press; 1958:134.
- Hogikyan ND, Kana LA, Shuman AG, Firn JI. Patient perceptions of trust formation in the surgeon-patient relationship: A thematic analysis. Patient Educ Couns. 2021;104(9):2338-2343.
- Hoshijima H, Wajima Z, Nagasaka H, Shiga T. Association of hospital and surgeon volume with mortality following major surgical procedures. Medicine (Baltimore). 2019;98(44).
- Guardado J. Medical liability claim frequency among U.S. physicians. American Medical Association Policy Research Perspectives. 2017:1-10.
- Williams PL, Williams JP, Williams BR. The fine line of defensive medicine. J Forensic Leg Med. 2021;80:102170.