Tuesday, May 10, 2005

Thanks....and, No Thanks

When I was a medical student, a simple "thank you" from a patient was a welcome gift to a worn out young man. As a surgical resident, those "thank yous" were even more cherished, coming from patients who were kind enough to recognize that my at times disheveled appearance reflected limitless hours at the hospital away from the attentive eyes of SWIMBO. Now, as a practicing surgeon for almost 11 years, I have come to cherish the times when a patient (or family) takes the time to give me a hug, say "thanks," or otherwise express their gratitude for the care I have delivered. I even keep a file in my desk of all of the cards and notes I have received over the years; they comfort me when I have had a particularly difficult week, and the ones from deceased patient's families remind me of exactly what I am unable to do.

A patient that I have operated on a few times recently died of unrelenting lymphoma. While I was providing no direct care for her, I did have the chance to speak with she and her family a few times recently in the hospital. When the eventual outcome was apparent to all, I ran into her mother and husband. Both were effusive in their thankfulness, even though I could do nothing to make her any better or more comfortable. That type of gratitude is very humbling, and really helps me keep going at times.

Recently, however, I had the opportunity to see the "dark side" of this process. A patient came to the office with the complaint of an incisional hernia. Neither I nor my partners had seen him before, but this is not unusual in this age of great mobility and frequent insurance changes. He was a rather large man -- somewhere in the 350-375 pound range -- and had the standard list of weight-related medical problems: sleep apnea, hypertension, AODM, chronic venous stasis changes, etc. All in all, a formidable surgical challenge. My visit with him quickly devolved to the issues surrounding the development of this incisional hernia:

Mr. Big Dog: This is really all Dr. Older Established Surgeon's fault.
Me: Really? How so?
Uh-oh, where is this going?
Mr. Big Dog: Yeah, he really screwed this up. First he let the thing get infected, and then... well, I really don't have any confidence in him.
Me: What was the surgery done for?
Mr. Big Dog: I had appendicitis. I tried to tough it out and sat at home for about 3 days with a burst appendix, and was pretty sick when I came into the hospital.
Me: So, Dr. Older Established Surgeon took out your appendix.
And saved your life! This guy had to have been pretty sick!
Then what happened?
Mr. Big Dog: Well, my incision got pretty infected and took a long time to heal.
Me: no surprise there
Mr. Big Dog: After a while, I got this big bulge! And Dr. Older Established Surgeon says that while it can be repaired, I might have it come back!
Me: again, no surprise there
Mr. Big Dog: I have no confidence in Dr. Older Established Surgeon. First the infection, now the hernia. What else can go wrong with him?
Me: biting my tongue
What would you like me to do?
Mr. Big Dog: I want you to fix this so that it won't ever come back, and I don't want another infection! I don't want Dr. Older Established Surgeon operating on me!
Me: no longer biting my tongue
Well, let me give you my two cents. If I had seen you that night, I can guarantee you that you would have [1] gotten a wound infection, and [2] developed an incisional hernia. At your weight and with your medical problems, those things are a given! What you don't realize is how sick you were, and how much farther down the drain you'd have gotten without Dr. Older Established Surgeon's care. As far as your hernia is concerned, I would tell you that you have such a high chance for recurrence that I'd lay good money on it at the Bellagio. Your problems did not start with Dr. Older Established Surgeon, they started with your weight; if you want to get better, that has to be your starting point. And given what he was able to accomplish, I would have nothing but confidence with Dr. Older Established Surgeon, if I were you.
Mr. Big Dog: So, you'll fix it?
Me: sigh....and it's a REALLY big hernia!
This is one of those times when I wish I could explain get a patient to understand how great his care was! The other surgeon deserved this patient's gratitude, not his scorn, and I felt powerless to change his perceptions. His attitude also worries me, as if I do operate on him and he has complications (once again, there's a reasonable chance), what does he tell the next surgeon he sees -- or his attorney? Now you know why I keep that collection of thank you notes.