As a surgeon, my relationship with patients (and, by extension, families) commit me to take on a disease, not just perform a procedure. It is a psychological contract, or surgical covenant, that involves sharing hope as well as risk. Allowing me to do the surgery is the patient’s part of our contract, and my part entails concern for their full recovery. This mutuality of respect and commitment to each other begets loyalty and trust. I feel like most surgeons–the operating room is the thrilling part–but I never overlook the value of caring for patients after surgery. By seeing my patients after an operation, I leverage the ‘therapeutic relationship’, a concept that implies the surgeon-patient relationship involves psychotherapy. and that the surgeon has a strong impact on a patient psychology. This component of our relationship is what motivates them to follow my advice, enhance recall of information I tell them, and help them believe that they can fully recover even when the going gets tough.
The therapeutic relationship means that frequent postoperative visits are an inexpensive, practical way to improve care. As the surgeon, I am the best person to determine the relative success of the operation and decide whether additional interventions may be needed. I communicate with the patient’s care team as precisely as possible—using both written and verbal means—about any specific concerns I have about the recovery process. This enhances situational awareness among the team, which is a critical aspect of patient safety. Even when some aspects of postoperative care are delegated to others, I always maintain an essential coordinating role. Like a coach, I can’t do everything myself; I must remain aware of the big picture for successful team performance.
The indispensable impact of a postop visit reveals something more fundamental: being a surgeon requires a lot of you and gives you even more in return. Renowned surgeon Frank Spencer described ‘a personal warm glow’ that happens when his patient gets well that tells him once again what being a doctor is. I’ve heard other surgeons say that when a patient recovers after their particularly risky operation, they feel like a conquering general after a great battle. Memories of success are an intrinsic reward far more motivating than fame or fortune. The intrinsic rewards are why surgery is what we live to do, not what we do to live. Medicine, and surgery in particular, is a ‘calling’, which is an uncommon way to describe other jobs. Patients and their relatives always feel grateful for that level of dedication and need to see us after surgery for the chance to extend gratitude. More importantly, surgeons need to allow themselves to hear it.
Surgery differs from other professions in many ways. First is its intensity and immediacy. Wonderful memories of success mix with inevitable gut-wrenching failures. We make dozens of major and minor decisions during an operation, instantly. Next, the OR has no hiding places; failure is crystal clear for all to see. Finally, surgical culture does not make it easy to fail. Like Vince Lombardi, our motto is: “Winning isn’t everything, it’s the only thing.” When we fail, shame is inevitable. Our response to shame can be either helpful or damaging.
The optimal response: talk with the patient: describe why things didn’t go as outlined during informed consent, what could have been done better, etc. Next, we should explain our plan to make things better and provide an honest appraisal of whether that plan will work. This face-to-face interaction yields invaluable feedback on the most fundamental aspects of our job: whether a surgeon knows his/her limits and is willing to accept responsibility. Based on the principle of restorative justice, using this approach turns the shame of an unexpected adverse event into an effective tool to reintegrate the surgeon back into the team (and patient’s) good graces.
Unfortunately, surgeons tend to follow the easier, but more dysfunctional, response to shame—self-deception, often without realizing it. Surgeons are trained to make intuitive, fast-paced, time-pressured decisions without conscious thought. Harvard scholar Chris Argyris shows how the subconscious contributes to self-deception using the terms ‘espoused theory’ and ‘theory-in-use.’ Espoused theory describes the reasons we attribute to our actions; theory-in-use explains how we actually behave. For example, the espoused reason why a patient was not seen after the operation was the surgeon’s busy schedule. In fact, the actual reason was self-deception: to avoid exposure to negative information and maintain plausible deniability based on the faulty aphorism, “What I don’t know can’t hurt me.” Some surgeons are inclined to not admit the whole truth if a partial truth seems preferable.
Specific examples help us understand the harmful impact of this self-deception. Paolo Macchiarini became a superstar surgeon in 2008 after he published a case report of the first human tracheal transplant. However, that report and 5 others about his patient outcomes and one on animal tests of the procedure were later found to be “a systemic misrepresentation of the truth…and false impression of the success of the technique.” According to colleagues that were acquainted with the clinical outcome of these procedures “the results published by Prof Macchiarini do not correlate with the patients’ actual clinical outcome.” (letter to President of Karolinska 2014). Macchiarini implanted artificial tracheas in patients in Sweden, the U.S. and Russia from 2011 to 2014, and all but one patient died. The sole survivor had the implant removed.
Macchiarini veered off track because of a conviction that was so strong his ego replaced reality. In other words, a God complex. That made him hard to change, particularly because his passion involved a topic like stem cell transplant that was widely hyped at the time (now largely debunked). At some point as he kept on operating, the fog from this hype cleared away and he recognized (at least subconsciously) that his tracheal grafts were not working out. That realization resulted in cognitive dissonance, even if only in the dark corners of his subconscious. For Macchiarini, like many others with his degree of passion and conviction, it becomes easier to tolerate the dissonance than admit the idea was wrong.
Another force that steers surgeons to self deception is money. Christopher Duntsch, the neurosurgeon labeled by the press as “Dr. Death”, operated on 37 patients in Dallas with 33 suffering severe complications. He was hired by the Minimally Invasive Spine Institute with a $600,000 advance paycheck but was soon fired when he never rounded on one of his first patients after surgery; he was busy spending his money in Las Vegas instead. Duntsch operated on a personal friend who testified in a 2017 deposition that he was abandoned after surgery, as both his surgeon and his friend. Like fame, money is an extrinsic incentive. In contrast to the intrinsic rewards, extrinsic rewards can harmful by “crowding out” ethical behavior in favor of actions that enable the pursuit of these powerful incentives. That fosters short-term thinking and encourages cheating and shortcuts. For Duntsch, it ultimately left him bankrupt with his license revoked.
If we accept that Macchiarini and Duntsch deceived both patients and clinical peers by leaving out critical information about their abilities and results, then it stands to reason that both would deceive themselves in the same manner. This is why statements from their patients in the documentaries about Macchiarini and Duntsch were so revealing. According to interviews of patients and their families, neither surgeon regularly visited their patients after surgery. In this context, we see that this failure cannot be explained away as “being too busy”. A more likely explanation is an act of self-deception, a way to avoid unwelcome information and resolve the dissonance caused by the continued pursuit of wrongheaded goals. Meeting patients face to face after surgery is a powerful tool against self deception. It’s the best way to learn. They are either doing well or they aren’t. Accepting that reality mitigates against biases and egos.
In the end, both Macchiarini and Duntsch were convicted of criminal assault and ended up in prison. At their trials, prosecutors conceded that neither were guilty of a crime just because of their severe complications. All surgeons have complications. Any surgeon saying otherwise is either lying or not operating. Nor was there evidence of their intent to harm patients. Both guilty verdicts were based on the legal doctrine of willful blindness; they proceeded with dangerous surgeries despite being willfully blind to poor results. Their obvious errors in technique and judgment were forgivable. Their crime was not visiting the patients that suffered complications, abandoning them in their time of need and failure to hold themselves accountable. Had they been willing to meet face-to-face with each of their patients after surgery, the most they would have been guilty of is civil negligence. Society does not easily forgive moral errors, particularly from those in positions of power.
Punishing any error seems harsh, but in this case it benefits society. Dostoevsky, the Russian author of “War and Peace”, highlighted the dangers to society when he wrote: “Above all, don’t lie to yourself.” As he explained, self-deception makes it hard to distinguish the truth within and around yourself. If perception and experience help us orient ourselves in the world and to discern reality, then allowing willful blindness to remain unchecked could end up in a society that becomes deranged and unable to make proper sense of the world. The punishment needed to deter self-deception in surgeons is not always a prison term. The reintegrative shame that comes from knowing your patient is the suffering and finding ways to make it better is often enough.
To conclude, we have all heard the adage: “What you focus on grows.” This theory, grounded in quantum physics, makes sense because we tend to gather evidence to confirm previously held beliefs. Like an ostrich, many humans stick their heads in the sand to avoid seeing new data, leading to missed opportunities for personal and professional growth. This ostrich effect might prove beneficial in certain fields like investing, but for surgeons and their patients, this habit is highly detrimental, even dangerous. To improve patient safety, surgeons should focus on communication with patients and their families which entails regular visit to our post-op patients. Take their temperature, in the figurative sense. Just a few minutes with them and our ICU teams could make all the difference.
It is paramount for living up to the surgical covenant that we keep on learning, particularly from the one most interested in teaching you: the patient. If at my funeral they say that Dr. Poston learned from his patients, then I’ll call that a win.
robpostonblog 