Patient vs. Self in Surgical Practice

When I first graduated from surgery residency and entered into practice as an attending general surgeon, I felt like I was no stranger to ethical challenges facing surgeons. In fact, it was, and still is, precisely the difficult decision–making so often encountered in general acute care surgery that drew me to my chosen field. I have found that I thrive on the dilemmas regularly encountered on general surgery call; diagnostic dilemmas, ethical dilemmas, and treatment dilemmas are the stuff of life in acute care surgery. The quintessential case is that of the patient who has been dying for weeks, or even months, but whose sub–acute decline has gone unrecognized by the generalist, oncologist, or other–ist taking care of him or her, until an acute event—typically an intra–abdominal or vascular catastrophe—prompts surgical consultation. In these situations, often at odd hours and in less than ideal surroundings, I break into my role of patient and family counselor, determining the decision–makers and stakeholders, and delving into a process of narrative inquiry to elucidate the patient’s goals of care. Often, I need to break bad news . . . and then offer hope for a better—more humane, more comfortable, more peaceful—way of death. As one of my fellow trainees once put it, one of my most important skills as a surgeon is my ability to “glide the plane down for a soft landing.” My general surgery education, coupled with specialized training I have specifically sought out in ethics and palliative care, has prepared me well for these situations.

What I was less well prepared for as I entered into practice was a different sort of ethical dilemma, the one that plays out not on the wards, but in the academic halls and offices and homes and hearts of surgeons. It is the tension between obligations to the self (be it personal, academic, or other commitments) and the patient. No doubt surgery residency provides fertile ground for honing one’s sense of self–sacrifice, and, to a lesser extent, work–life balance. But my first week on call as an attending at a large academic medical center had me in for some big surprises. The sentinel event that signaled a new reality occurred on the day following a long string of nights on call. During that last overnight, I had taken on an ICU patient whom I had been asked to evaluate for an intestinal obstruction. My impression was that the patient did not have a mechanical blockage, but rather a functional reason for her bowel to be distended beyond its normal capacity, almost but not quite to the bursting point. Although she had no signs of impending catastrophe when I examined her one last time at the end of the day, I knew that she would need careful attention overnight so as not to miss a red flag indicative of deterioration in her condition. So, before going home, and looking forward to a good night’s rest, I telephoned the on–call surgical attending. I reached out to him as a courtesy to let him know that the residents, who remain in–house for 24 hours a day, would be assessing the patient every six hours overnight. My hope was that the attending, having heard about the patient and her context from me, would be better poised to react to a report from the residents if a change were to develop. The reaction that ensued opened my eyes to the fact that my understanding of patient ownership had been completely misguided; contrary to the attending group practice model I was familiar with from residency training, the culture among attendings at my new institution was one of strict individual patient ownership, 24/7, on call or not. Should a problem with my patient develop, it would have to be me who would come in overnight and take her to the operating room, even though I was not “on call.”

Although in retrospect I think my family and I had been hopelessly naïve, at the time, we didn’t feel adequately prepared to handle the uncertainty and...