January 22, 2001
The Compleat Surgeon: Decisive And Empathetic
M.J.McKeown, MD, FACOG, FACS
The surgical personality is one of problem solving. The stereotypical surgeon has the aura of being able to solve any problem one can give to them and to do it quickly, incisively and completely. Thus the image of the surgeon as he/she announces, We got it all.
If one observes a surgeon in the clinical environment and compares him/her to an internal medicine specialist in the same situation the internist is, Hmm, well let's see. and the surgeon is, OK Let's go we've got to get this fixed now.
The internal medicine physician slowly attaches to the patient (problem) and builds a communication bond with the warmth of empathy..
The surgeon fixes the patient (problem) in the glare of his/her problem-solving gaze and with a few, perhaps disjointed, questions announces the solution and proceeds with the necessary action.
When it comes time to evaluate the outcomes of these two approaches the internal medicine physician has that bond of empathetic communication to connect to the patient. The surgeon usually announces the outcome of the procedure as successful (complete) or unsuccessful (incomplete). Announce is the operative word and is in contrast to the communication of the internal medicine specialist.
This projection of competence, incisiveness and almost omnipotence is needed by both the surgeon and the patient. The surgeon needs to know he/she can solve a problem with the strength of belief of the Naval pilot landing on a heaving carrier deck at night in a storm. The patient needs to feel the projection of that inner belief in the surgeon's competence before feeling comfortable in having this person disassemble and reassemble their body while the patient is asleep, paralyzed and powerless.
However the surgeon needs to have empathy when discussing the results and associated outcomes of the operative procedure. This is particularly true in those surgical procedures involving that most terrifying of diagnoses cancer. In my 35 years of clinical experience the patient frequently turns off all rational thinking when the word cancer is spoken.
The patient knows that this most terrifying of enemies, cancer, must be fought tooth and nail with a fierce intensity. The patient population in general broadly understands that cancer therapy involves removing the problem or poisoning the problem in some fashion. The details of the surgical approach with survival statistics and the details of various poisoning techniques with attendant discomfort and survival statistics are usually not known by the patient. It is in the communication of these concepts where the surgeon can have problems in the relationship with his/her patient.
I do not remember any discussion by my teachers about an empathetic connection with the patient. My father was a physician, a Family Practicioner, who had that touch with patients. Perhaps I learned some of that from discussions with him during my training. I watched physicians during my training years congratulating each other on keeping the terribleness of a diagnosis and prognosis from the patient. I was always of the opinion that their behavior was because they were afraid of dealing with the emotions associated with an adverse outcome or diagnosis.
I was fortunate that Elizabeth Kubler-Ross was at the University of Chicago when I was training there. I attended her Death and Dying conferences. I think that all life-threatening diagnoses put the patient through those five stages that Dr. Kubler-Ross outlined; denial and isolation, anger, bargaining, depression, acceptance. I firmly believe that all physicians should have training in helping patients through these stages in times of life threatening illness. I am sure that just as in TV's ER there are times when things must be done quickly and one just can't navigate through all these stages. However I am impressed that even in ER there are episodes where the emotional and personal impacts of events are covered.
Where does that leave us in relation to therapy of the patient with a malignancy? It would be my recommendation that all health care workers that are involved in dealing with patients with such a diagnosis should be trained in communication skills to guide their patients through the emotional changes of those times. The best training would be videotaped training interviews in handling this aspect of certain diagnoses. I don't know if medical schools have ever done that or if residency training programs have ever done that.
There is a caveat forced on us by the current state of healthcare delivery in this country (USA). The infamous managed care has placed the healthcare delivery person in a tight corner. The time constraints of patient interaction time forced by the profit motives of those running managed care have limited the time the health care practicioner has with each patient. I could only hope that these green eyeshade managers might factor some time into that allocated for these life-threatening diagnoses. I think if they had done that and had promoted this caring aspect of managed care then they would not be the recipients of public dissatisfaction as they are now. I would hope that 30 minutes to an hour spent helping the patient through the five stages of a life threatening experience would be very cost effective in the long term view. However the current CPT/ICDA coding with its attached allowable dollar values does not contain any room for such. The managers of this managed care system would not care if the healthcare practicioner gave more time in these situations as long as it didn't impact their productivity profile adversely and as long as the practicioner did it as a donation of their own time.
I don't know if such caring can be brought into the system in a general fashion. My somewhat cynical nature leads me to believe that the long-term political planners want to make the business of medicine so difficult that its practicioners will gladly accept becoming time-card-punching workers. Perhaps if that happens and the costs of healthcare are predictable in large measure because all the healthcare practicioner costs are predictable there will be time for such compassion and caring because it will not be allocated to a per-minute cost to the system.
Thus surgeons and oncologists should lead patients through the thickets of uncertainty in caring for malignancies and should never announce the unequivocal, got it all or cure. There is a wonderful saying from the French that sounds better in that language, Never say never and never say always. Life is uncertain and healthcare is uncertain. It is our job to guide and educate those that come to us so they may understand the realities of whatever situation they are in. It is our job to support them through this time of learning.