Monday, May 18, 2015

A new surgeon confronts self-doubt

A chief resident about to graduate wrote the following to me:

I just read—twice—The New Yorker's review of Henry's Marsh's [a renowned UK neurosurgeon] memoir you tweeted about. Wow.

It seems like he is grappling with so many of the things I'm feeling now, as I'm trying to sort out if I'm trained "enough" to head out into the world. Of course, Marsh is at the other end of his career. So fascinating how the same anxieties can flourish and grow in entirely different soil.

I want to read the book, but I wonder if now is the right time. Seriously! Might be better to wait a few years.

Only 38 more days to go until I complete residency.

Congratulations on finishing your training and becoming self-aware.

When I was a program director I used to laugh at residents who felt that they were so stressed. I would say to them, "If you think you're stressed now, wait until you're on your own and have to make a life-and-death decision in the middle of the night with no attending surgeon backup."

I haven't read Dr. Marsh's book, but the excerpts had an impact on me as well. I've been retired for 2½ years, and I still go over complications and mistakes in my mind. Even now, it is so real for me that sometimes I can't sleep.

I once had hoped to become a stand-up comedian, but after several months of auditioning at comedy clubs, I realized that I couldn't pursue that and still practice surgery.

In the process, I took a class in comedy. Although it was 35 years ago, I still remember what the teacher said about observational humor. "The more personal a story is, the more universal it is." The same goes for writing in general.

Dr. Marsh has written a personal memoir which should resonate with any conscientious surgeon. He has done all of us a service by confessing that even the great ones make mistakes which haunt them throughout their careers and beyond.

I'm sure Marsh's book is very much worth reading. I think the next 38 days would be a good time for you to read it.

That you appreciate the gravity of the situation you will find yourself in come July 1 is a very good thing. It's a sign of maturity. You are ready to go out on your own.

You will make mistakes. We all do. It's part of the job. I once had a surgeon tell me that he had been in practice for 22 years and had never made a mistake. The only surgeons I knew that didn't make mistakes were not very busy, deluded, or liars.

You just have to be certain that you have given your very best effort for every patient you encounter. I have no doubt that you will be a fine surgeon.

To which the young surgeon replied:

I'll see about reading the book. I definitely want to, it's just a matter of when is the right time. Marsh is courageous in sharing these complications, but he has the benefit of a lifetime of knowing that he can "do it" (presumably much more often than not). While useful, I do think there is an attendant risk to engaging so fully with one's complications and mistakes and for a more sensitive person, or one still working to establish the foundation that he or she can "do it", it seems as though there is some risk that he or she could become paralyzed by self-doubt. That's what I meant by the timing has to be right.

All that said, I suspect it's a masterful book and I look forward to hearing more of his stories.

Should he or she read the book now, later, or not at all? What do you think?


Anonymous said...

I think the fact that the aspiring surgeon wants to read the book is a good sign. I agree with their observation that the timing has to be right.

I'm struck by Marsh's admissions of guilt and remorse over his mistakes. Trying to balance those feelings with the necessary concentration to continue to perform surgeries must be a tremendous challenge.

Skeptical Scalpel said...

Anon, good comment. It is hard to focus on other things when a patient is not doing well especially if you could have done things differently. The truth is you can always second guess yourself, and if you don't do it, plenty of others will.

Anonymous said...

I'd say it read it, but talk to patients and ask them how they would feel when a doctor doesn't return the trust we are expected to take in someone who doesn't see us before surgery, doesn't see us after. Think about how and what that says about surgeons. We have no reason to trust you when this is what we deal with and you can't even be bothered to spend some time with us.

William Reichert said...

He should read the book. He might learn something. He might be exposed to a situation he has not been exposed to in his training.
I used to ask the administration to have a conference to discuss
the malpractice cases brought against the hospital . They always refused. Too bad. There are thing to be learned from bad outcomes.In my experience bad outcomes
almost always were the result of a weird combination of factors,
some medical, some administrative, some social , some due to events that were bizarre and never brought up in training. Always listen when things go wrong. It is shared experience .Experience is invaluable even bad experiences.

Skeptical Scalpel said...

Thanks for the two comments above. I'm sure our young surgeon will take them to heart.

Anonymous said...

Lord knows the poor young surgeon won't get anything out of this: This is scary. How do you learn, teach young surgeons? What happens when it is THEIR turn to teach?

Skeptical Scalpel said...

Anon, I share your concern about this. I do not see how the 1200 or so chief residents in surgery can all be trained at the select high-volume hospitals. I asked Dr. Birkmeyer, one of the proponents of the policy to restrict low volume operations to major centers, how this would impact surgical education, and he said, "If teaching hospitals aren't meeting those low volume bars, they're mainly teaching bad habits."

I also asked if the data on volumes and outcomes could be biased by patient selection. Maybe people who can afford to go to high volume centers are better socioeconomic and physiologic specimens than those who must be treated at low volume hospitals. I didn't receive a response.

Anonymous said...

I would say he/she should read the book later, having already grasped the key lesson: that even the best are prone to make mistakes. He/she is already miles ahead of the surgeon who never made (was unaware of) any mistakes.

About the only consolation of making mistakes is the opportunity to serve future patients better. There is always something to read, and a natural "hook" is to use personal experience as a guide of what to explore in greater detail. While the retrospectoscope is often a cudgel in the arena of medical malpractice, it can be a useful tool when used to conduct personal CQI.

He/she probably already has a series of patients who are memorable in part because of the conclusion that something could have been done differently and that with better knowledge, doing the different something could have been known. Those are the cases where an in-depth exploration will have the highest retention rate.

He/she should set the memoir aside for now, but put it at the top of whatever time constitutes reading for pleasure. That may be awhile in the future.

Skeptical Scalpel said...

We've heard from both sides. Our chief resident was leaning toward waiting. I hope we find out what happens.

Garner said...

Nice Post!

Post a Comment

Note: Only a member of this blog may post a comment.