It’s worth your while to browse through Sid Schwab’s sampler one rainy Saturday afternoon when you get a chance.
The old man can write. I was reading through a couple of his old posts the other day when I stumbled upon this one. It’s a shorter post (for him) but very powerful and moving.
He describes what it’s like to enter an abdominal cavity of a patient, with all its metaphysical implications:
I will reach in gently and caress the liver, the stomach and spleen. Slide over the top, into the recesses, curl the fingers enough to sense the texture, the fullness. The bowels move away and under, and over the top as I direct my hand. I can describe your kidneys now, I’ve circled the top of your rectum, held your uterus, measured your ovaries between my fingers. Part of you is gone at the moment, but I’m here, I know you now. You trusted and let me in, you opened your belly to me, and I entered with force. I’ll stay until it’s right. It’s what I must do. You think you’ll never touch me so intimately as I’ve touched you. But you have. You have.
It’s beautifully rendered.
But reading it, I kept feeling this nagging disconnect between what Doc Schwab feels and the way I feel when I perform surgery. He seems to suggest that the invasion of surgery brings him closer to a patient, allows him to connect with him in a deep and meaningful day that transcends anything that occurs when the patient is conscious. It’s funny, I don’t feel anything like that at all. I actually never feel further from the patient, as an individual, than when they’ve been put under anesthetic and I’m calling for the scalpel. The patient as I know him disappears the minute I put my mask on. He doesn’t exist anymore.
It sounds terrible but let me explain. Trust me, I’m not some Mengele slicing and dicing my way through a bunch of mere specimens.
Doctors and patients establish relationships. That’s not a controversial statement. Roles are played, boundaries are delineated. The patient seeks wellness and the artful physician hopes to provide it with equanimity, humility, and excellence without compromising the patient’s dignity. It’s a simple transaction that occurs in the light of day. There are no hidden agendas in this game. We’re talking about a rare human moment of openness, vulnerability, and non-judgemental compassion. It’s the real deal. And that’s why, for all the strife and stress and inconvenience of modern medical practice, it’s still the best job in the world.
The strange thing about being a surgeon, for me at least, is that my time in operating room is not so much a continuation of that relationship as it is a temporary rupture in the connection. The patient ceases to exist for me as they do while conscious. The sterile drapes are placed, the face is hidden, all I see is the pale white glare of exposed flesh under OR lights. A small segment of working space in which to intervene, repair, remove.
There is no connection anymore between what I see and experience in the OR and the the person who was nervously smiling in the preop holding area a half hour prior. A certain objectification of the patient occurs for me and it’s unconscious and automatic. I can’t help it. Even the individualized aspects of the operation — the way this liver feels compared to another, the inflammation of one gallbladder compared the the previous patient, the toughness of the skin of a younger patient and how I have to press the knife with force versus the parchment-like gossamer skin of the elderly and the light passage of the blade like I’m tracing my name in the icing of a cake — none of that is translated to how I perceive the individuality of the patient outside the operating room.
I file away the memories of the cases, certainly; the subtle variances in anatomy, different approaches I’ve taken to handle unexpected problems, but I don’t attach those details to the patient. The disconnect is complete. I don’t feel touched by a patient while I operate. I don’t have time for that sort of sentimental softness. It’s all business in the OR. I have a job to complete. A gallbladder to remove. A hernia to repair. A cancer to resect. An artery to ligate. These things need to be accomplished with a certain cold and dispassionate technical excellence.
You can’t afford to have your mind clouded by invasive knowledge of what that person is like outside the confines of the OR suite. I can’t afford to be thinking about how the patient likes Twizzlers for breakfast or has bad breath or always seems to have lipstick on before I make rounds at 6:30 AM or has twin 3-year old girls named Kiley and Kelly or how she raises alpacas for some reason or how he loves Dale Earnhardt Jr or how she has to drive her elderly husband around town all weekend because he has the “maklar generation”.
I can’t be distracted by that stuff when I’m operating. I fall into a pleasant trance of technique and purposeful movement. The patient fades from view, further and further the more smoothly the operation proceeds. You finish, the dressings are applied, and the drapes are pulled down to reveal an actual patient; sometimes you can hardly believe you’ve ever even met this person before, so distorted and helpless they can appear with their ghostly slackened faces and gaping mouths, an endotracheal tube erupting from the corner of their lips, the initial coughing spasms as the anesthetic starts to wear off. It’s disorienting.
And that’s why it’s crucial that all surgeons find some way to reconnect after an operation. Go see your patient in the recovery room or that night in their hospital room, once he’s had a chance to be roused from the anesthetic. You have to bring things back full circle.
This is the part about being a surgeon that is so difficult to master, the constant gear shifting between detached, cold-hearted objectivity and a warm compassion that recognizes each patient as a valued individual. Too much of the former renders you as just another automaton technician, an assembly line machine. Too much of the latter can fog your brain during a tough case.
When patients come to see me in the office after an operation I always take a look at their wounds. I swear, half the time I don’t remember making the cuts. I just can’t reconcile that momentary act of controlled violence with how I feel about this person sitting across from me. I accept it though.
The healing scars demand that I at least acknowledge the existence of the two realities.
Jeffrey Parks is a general surgeon who blogs at Buckeye Surgeon.
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