Sunday, June 7, 2015

When "nice" is a surgical skill

“You’re too nice to be a surgeon.”

I have heard this comment—and its variations—from patients, families and more frequently, other healthcare practitioners. Yet the underlying implication—that surgeons have no need to be “nice” or display social skills is misguided. In fact, I would argue that the exact opposite is true—that social skills and emotional intelligence are essential to maximize the healing skills of surgeons. I consider bedside manner to be the surgeon’s second most powerful tool to promote health and wellness. Particularly when the blade has failed to cure disease, kind words and understanding may be all the surgeon can do to foster healing and a sense of wellbeing.

When the gunshot victim arrives to the hospital without a pulse and the ED thoracotomy is fruitless, the only healing a surgeon can offer is to be emotionally present when telling the family of the loss of their loved one. When a patient is faced with surgery that may or may not cure his disease, it is the surgeon’s intuition and emotional intelligence that guide her in explaining the options to the patient in a manner that empowers confidence and peace in his decision. When surgery fails the patient and she enters the journey of dying, it is the surgeon’s bedside manner that can bestow the family with courage to let go.

These are all privileges unique to the surgeon and they all require nuanced interpersonal skills and emotional intelligence. Just as surgically entering the body is one of the most intimate experiences a person can share with a fellow human being, to share with the patient and their family the psychological impact of their disease is a similarly intimate experience. 

As surgeons, we often have the privilege to be present with patients and their families as the patient hovers between life and death. While surgery and expert technical skills can tip the patient towards life, there are inevitably times when even the most expert hands and advanced technologies of modern medicine can not bring back the patient from the process of dying. At these times, only our words and capacity to bear witness to suffering enable us to comfort families and promote healing through graceful acceptance of the natural process of death.

It is these experiences that keep me from ever feeling “too nice” to be a surgeon. My “niceness” is not wasted by my choice to be a surgeon; rather it is an essential tool in my armamentarium to offer health and healing to patients and their families. I look to my mentors on a daily basis for ways in which I can be nicer to my patients and their families. I am inspired by surgeon bloggers, Mary L. Brandt, Amalia Cochran, and Kathryn A. Hughes and grateful for the mentorship and influence on the evolving culture of surgery. I close with links to their words of wisdom and experience.

Monday, November 5, 2012

Modern Medicine: Technology Will Advance, But Human Connection Remains

In a recent NY Times article, “Redefining Medicine with Apps and iPads,” Katie Hafner describes a “generational divide” in medicine. On one side sits the younger generation, at ease navigating EMRs and diagnosing disease with the assistance if digital apps. On the other side of this presumed generational divide, she describes the older generation, worried “that the human connections that lie at the core of medical practice are at risk of being lost.” This juxtaposition begs the question; does the use of digital medicine preclude human connection?

As a recent medical school graduate who has enthusiastically embraced technology, I have no fears that my use of digital technologies handicaps me from sharing the human connection essential for a healing and therapeutic patient-physician relationship.

In medical school, I witnessed much fanfare surrounding the teaching and “importance” of the physical exam. Still I found myself somewhat suspicious of what I was being taught—would it really warrant a workup if a healthy patient displayed “diminished reflexes”? Would I really be able to elicit an abdominal fluid wave in an obese patient, and even if I did, wouldn’t the patient have more urgent symptoms and treatment dictated by more accurate diagnostic testing?

A few times I ventured to express my skepticism, and across the board, my instructors responded as if questioning any aspect of the traditional physical exam was an act of blasphemy. They all assured me it was “very important” and often had an obscure anecdote to illustrate this importance to me.

I tried so hard to believe them. Yet, once I hit the wards in third year, the clinicians’ actions spoke louder than words. Early on I took time to report the minor changes in the patients’ daily physical exams. With great care, I documented new murmurs and the onset of crackles. But quickly I realized that no one cared. If the patient did not have corresponding symptoms, these details were brushed off as a waste of time.

Still I tried to maintain my enthusiasm for the physical exam by doing mini presentations based on material from JAMA’s “Rational Clinical Examination” articles. During these presentations I sensed the attendings reminiscing and the residents appreciating the refreshers. Still, the information I presented seemed little more than a nostalgic intellectual exercise. When it came to patient care, I couldn’t help but notice how rarely we changed our treatment plans based on the clinical exam.

As I look forward to residency, I worry about the limited time I will have to spend with each patient. Knowing the time constraints, I do not want to waste time percussing my patient’s heart when an X-ray or echocardiogram is more efficient and accurate. Does this mean that I do not value human connection? Of course not. Fortunately, I do not need the excuse of an obsolete physical exam maneuver to touch my patient. In forgoing the unnecessary exam, I will have time to take the patient’s hand in my own and ask her what scares the most or how we can make him more comfortable.

Please be assured I am not suggesting the physical exam is obsolete. The physical exam was and always will be an indispensable tool to diagnose and treat patients. Indeed it is imperative we continue to teach and maintain these essential skills. Acknowledging the technological advances in medicine and teaching a strategically streamlined exam would allow educators more time to emphasize the human connection and teach students skills to better connect and relate to their patients.

In his article, A Touch of Sense, Dr. Abraham Verghese extols the importance of the physical exam as a means to convey the message, “I will always, always be there, I will see you through this, I will never abandon you, I will be with you through the end.” Call me crazy, but I hope to take the time saved by my digital technologies and gently place my hand on the patient’s shoulder, look them squarely in the eye, and share the same message in my own words. Technology will never replace this privilege of human connection.