Category: Communication

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Behind the Mask – The (Socially) Distant Acute Care Surgeon

Social distancing has now become the norm across the land. This is a necessary effort to prevent the spread of the coronavirus and its potentially deadly consequences. The ‘COVID lockdown’ as I call it in my casual conversations has had a ripple effect across many lives and industries beyond the patients and families and day-to-day work of the US healthcare-industrial complex.

In these days of COVID, the new normal for me is covering myself for all encounters. Asymptomatic infection is high. In any given day, I will see multiple new patients in short order and even with the highest level of hygiene, I might be the greatest risk to a patient for whom a trip to the hospital is unavoidable. I do not shake hands. I do not begin with a warm smile to ease the anxiety. I do not hand out my card with a reassurance that my partners and I are available 24/7 – just call.

I am a surgeon. I am no stranger to donning a mask for sterility in the OR or for bedside ICU procedures. I am no stranger to donning a mask to protect a vulnerable cancer patient who nevertheless needs me to examine their abdomen. And when my hands will be touching a body part during an exam, I am no stranger to donning gloves.

My hands and cuticles are raw year round because they are no strangers to repeated contact with 70% alcohol-containing solutions.

I still perform the exam. I still explain the diagnosis and my rationale for the treatment options in a level of detail that would make residents roll their eyes (if they were still allowed to see patients by my side). But I don’t ask for permission to sit at the foot of the bed while I do so. I don’t gently lay a hand on a covered knee while having a very difficult conversation.

Often, family members will ask if it’s okay to hug me at the end of an encounter (even if the outcome was their loved one’s death). Currently, patients are not allowed visitors outside of very rare exceptions. There is no hugging in COVID lockdown.

Sometimes, I cry with my patients who never expected to need a surgeon until the day they met me. Tears are a body fluid. There is no crying in COVID lockdown.

But my patients are so very alone right now. Whatever they are stricken with – and luckily for me and for them so far it hasn’t been COVID-19 – these are dark and scary times in their lives and they are all alone. Completely, totally alone. And I can do nothing to ease that loneliness behind my mask.

The warmth and non-medical touch during these encounters matters as much as detailed explanations but I am trapped behind my mask, unable to be the kind of surgeon that I truly am on the inside. I feel inadequate even though my clinical acumen and technical skills are unchanged by the COVID lockdown.

I am compliant with the need to be distant and sterile during these encounters because it is how it must be. However, the heartbreak of every encounter is real for me and my patients. Some will survive; some will not. Will they or their families be grateful for the surgeon behind the mask who played a role in some way?

Who am I to say. 

An Explanation: The #1 tool in your physician’s toolkit

It was almost a formality, me rounding on that patient that day.

The obstruction had resolved. The nasogastric tube was out.   If the diet advanced as expected he could be discharged to continue his chemotherapy. He was not even my primary patient. He was on the heme-onc service so I wasn’t even responsible for the paperwork.

Yes, he was dying of cancer. That was not news to him. Nor was the nausea and vomiting that he had come to expect in the wake of periodic infusions of poison. That which was intended to kill the cancer cells also killed a little bit of his insides with every dose. But the distention and obstipation was new. He had not felt right 4 days ago and he had rightfully come to the ER.

His diagnosis was small bowel obstruction. However, one could not tell from the CT scan if it was due to adhesions from his cancer surgery some years ago or due to new tumors scattered in his pelvis which had in recent months made him the unfortunate bearer of the “stage 4 cancer” moniker. As if the side effects of chemo for his cancer recurrence were not enough, now he had to suffer through this. But he was better by the time I met him as the new attending on a consulting service.

My exam confirmed the residents’ optimism that the obstruction had resolved. It was likely adhesions given the swift improvement and I noted how the nasogastric tube works to relieve such obstructions to the patient and his wife. But I explained that we were not sure, based on the original CT scan, if the cancer was playing a role in impeding the flow of GI contents. Either way, as long as he was able to tolerate oral feeds he could resume his cancer treatment with the hopes that the same symptoms would not recur. He did not need an operation in the immediate future. The patient and his wife were relieved.

As I concluded my visit, I asked (as I always do) if there were any other questions.

“No,” replied the patient’s wife. “But thank you so much. In all our time here, no one has explained what was really happening. Thanks for making it so clear. We really appreciate it.”

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I know I have written about this before-about the power of clarity in the medical encounter.

But seriously, I was at least the 4th attending physician to meet the patient not to mention the countless 1st through 6th post-graduate year trainees who had cared for the patient before I met him. Yet no one had taken the few minutes it would take to explain why the patient felt so miserable and how an uncomfortable tube down his nose might help.

Understanding the disease process is pathophysiology 101. Explaining it to the patient is doctoring 101. Sure, doctoring 201 is the art of explaining it in a way that caters to a patient’s educational and verbal capacity without instilling fear; but that no one had even tried just made me sad as a physician and as an educator. Once again, I took solace in the fact that there was a resident with me to both observe the explanation and to witness the words of gratitude. Hopefully, that’s my way of paying it forward just a little bit.

So at the risk of sounding too preachy let me leave you with this: If you take care of patients, remember they and those who love them are humans in a state of crisis. Amidst the pain, the fear, and the uncertainty of what’s to come, taking a moment to offer an explanation for the suffering can go so much further than any medication or procedure. Consider it the #1 tool in your physician’s toolkit.

Hot Heels, Cool Kicks, & a Scalpel

It was almost a formality, me rounding on that patient that day.

The obstruction had resolved. The nasogastric tube was out.   If the diet advanced as expected he could be discharged to continue his chemotherapy. He was not even my primary patient. He was on the heme-onc service so I wasn’t even responsible for the paperwork.

Yes, he was dying of cancer. That was not news to him. Nor was the nausea and vomiting that he had come to expect in the wake of periodic infusions of poison. That which was intended to kill the cancer cells also killed a little bit of his insides with every dose. But the distention and obstipation was new. He had not felt right 4 days ago and he had rightfully come to the ER.

His diagnosis was small bowel obstruction. However, one could not tell from the CT scan if it was due to…

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The Miracle Worker Gets a Hug

The tension between the desire to provide the best care and the system putting up road blocks was building the entire day. As the surgeon advocating for my patient, it felt like the smoldering rapidly progressed to full on conflagration. And, yet the patient and his family were calm and filled with grace.

On morning rounds, I told my patient that his hernia remained reduced but there was an area along the bowel that had been stuck the prior evening that looked worrisome on CT scan. His vitals, exam, and blood work were reassuring, I explained. There was no imminent rush, no immediate threat to bowel or life. But, it made sense to get this done as soon as possible. The patient, and his wife at the bedside, understood. I had explained a clear set of options for what to do about the hernia depending on a) how the bowel looked when we put the cameras in and b) based on my understanding of his baseline co-morbidities. He was a smoker with a chronic cough that exacerbated his hernia. I spent a little bit of time counseling him that this might be an ideal time to quit. Anything to ameliorate the cough during the recovery process and beyond would reduce the chance of recurrence.

Those words “as soon as possible” resonated in my head as the wait for OR time dragged on all day.  Circumstances were at a systems level well beyond my control; the absence of an immediate life threat meant I had no real leverage other than rants about patient satisfaction and costs of prolonged length of stay. This meant nothing given that there were patients who truly needed life or limb saving interventions, including one of my own who arrived at 5pm with free air.

This patient was too stable.

I had run up to his bedside a few times during the day with updates to the effect of “not sure yet…but you continue to look good…as soon as possible” He and his family–thankfully–were remarkably affable while I was becoming more and more agitated at the OR inefficiency in between urgent cases.

[I could write a dissertation on OR efficiency, or lack of it. And, certainly this is not a problem limited to my workplace. But that’s not what this blog is about.]

I was not on call that night. The OR could finally accommodate the case in the late evening. It went as well as could have been expected. The bowel looked great. The patient got the best case scenario of the options I had presented to him some 16 hours previously.

When I went to talk to the patient’s wife afterward in the waiting area it was almost midnight. She was exhausted from a day of anticipation. From two hours of anxiously waiting while her husband was in the OR. She gave me a giant hug and thanked me so profusely for sticking by him. “I know you have been here since so early this morning,” she said. In the moment of that most genuine embrace, the fire went out and the frustration of the day slipped away.

The next day, in preparation for discharge, the patient was exuberant. “You’re a miracle worker doc!” he exclaimed. “I’m done with the butts now. Forever. Thanks to you. And you fixed my hernia. You’re a miracle worker.”

It took me a while to figure it out since it’s been forever since someone referred to cigarettes as butts to me. The miracle was not that I fixed the hernia. It was that for the first time in 50 years he was motivated to quit smoking. His wife would stop too, she told me that day.

It was a tough day at work but this lovely couple thought I was a miracle worker deserving of a hug despite it all. No anger. No bitterness. Just genuine gratitude, a case that went textbook well, and some preventative medicine to boot. What more could a beleaguered surgeon ask for?

[Posted with patient’s permission.]

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Hey Doc!

“Hey Doc!” I heard the patient say as I blazed by Bed A.

Bed A is the ‘door’ bed. My patient was in Bed B, the ‘window’ bed. I had just met him; it was a new inpatient consult. For all the rules and regulations surrounding patient confidentiality, the curtains between beds do little to protect privacy since inevitably there will be audible conversations about symptoms, diagnosis, and management between patients and the doctors, nurses, or family who visit them.

…

The residents had already seen the patient in Bed B and were reviewing his case in detail with me between OR cases. I looked at my watch, contemplated typical OR turnover time for a moment, and decided we had enough time to get the consult done.

When I got to Bed B, I introduced myself to the patient and sat at the edge of his bed. I explained that I had already reviewed his story, lab data, and imaging and confirmed these facts. I stood briefly to perform my physical exam before beginning to scrawl on an index card. I simplistically portrayed the complex anatomic relationships between the liver, the gallbladder, and the pancreas and the series of tubes (the biliary tree) that connect these organs. I described how stones form when the balance of three ingredients (bile salts, lecithin, and cholesterol) in the viscous fluid (bile) made by the liver, and stored in the gallbladder, gets off kilter and how those stones can then cause blockages at various points along that biliary tree. I showed the patient where his problem was and used hash marks to explain the operation and what would be removed.

Before getting my patient’s signature on the consent form, I made sure any questions were answered and asked if he wanted me to call a family member to summarize the details. He said no and signed.

Conversations like this take time. Whether it is the 4 patients per 15 minute block in clinic or the patient who I am rushing to see between OR cases, I invariably feel pressed for time when talking to patients. But I do what I have to do, often skipping meals or holding in bodily functions while incorporating a brisk walking speed to keep up with competing demands, none of which seem to incentivize having thoughtful and thorough conversations with patients and/or their families.

After telling the patient in Bed B that I would see him in the pre-op holding area the following day, I upped my walking pace so I could run back down to the OR to my next patient. I had already taken too long and was anticipating the reprimand of the OR board. And that’s when I heard the patient in Bed A.

…

“Hey Doc!”

“Ugh” I thought to myself, “I really don’t have the time to find this guy’s nurse for his pain meds or to figure out how to keep his IV from beeping…”

But how could I not stop? He was addressing me directly so I paused and turned to him from the threshold to the room.

“Hey Doc! It ain’t none of my business or anything but I just wanted to say that there would be a lot less fear in healthcare if all doctors explained things the way you do.”

I was humbled by this man’s feedback. I hoped my residents were listening, both to the man in Bed A and to what had just transpired before Bed B.

I find it very irritating when students or residents peel away or talk among themselves, as if they are sick of hearing what I have to say, while I am having conversations with our patients. To me, modeling doctor-patient communication is my greatest gift to them as a teacher and a mentor. I want them to listen, to observe, to understand that every encounter is a chance to learn.

As we hustled back to the OR, I turned to the residents and proudly said “For as much pride as we surgeons take in doing the perfect operation or nailing a difficult diagnosis, what happened back there might have been the highlight of my career.”