Sunday, August 17, 2008

The Burden of Reproducible Excellence

I'm still slogging through my Greco-Roman phase of pleasure reading. At my current rate I ought to be done with the selections I've chosen by the year 2023. It's not exactly like blitzing through The DaVinci Code in a weekend marathon session. I'm drawn to the ancients, however, because of the similarities culturally and intellectually between our own circumstances and two thousand years ago. You know, the whole post-modernist, secular age we live in and the search for rational meaning rather than structuring our foundations on religion and metaphysics.... Blah blah blah. But anyway, I came across a quote from Cicero that grabbed me:

"For the better he is at his job, the more frightened he feels about the difficulty... about its uncertain fate... about what the audience expects of him."

(It's OK. Everyone has free range to make fun of me for quoting dead roman statesmen on a medical blog)

Cicero was talking about the stresses that afflict a great orator; the pressure to reproduce the excellence of past speeches. The audience has come to listen and expectations are high and even one minor insignificant error can ruin the overall impression of an otherwise articulate, inspiring speech.

In many ways, this is what we've come to in medicine. The expectations are almost insurmountable. Infallibility is the performance standard. The delivery of healthcare has been relegated to the category of "commodity", like automobiles and hair care products and soybeans. Where's my warranty, my guarantee? Why did I get an infection? Why didn't you realize I had breast cancer when it was 0.5mm instead of 2mm? Did you wash your hands well enough before you came into my room?

I had a day the other week with three gallbladders on the schedule. Usually this is a good thing. I love lap choles. Short case, requires a certain level of dexterity and technical expertise, occasionally can be challenging, and the patient goes home feeling great. But for some reason I felt this overwhelming sense of dread in the locker room while changing into my scrubs. I'm pretty anal on my gallbladders; no cutting or clipping until I'm certain of the anatomy, cholangiogram on almost every case. But the statistics don't lie. Bile duct complications occur in 0.5% of all laparoscopic cholecystectomies. Most of these are minor (cystic duct stump leaks) but every general surgeon's nightmare is some sort of major common duct injury. The number 0.5% seems small at first, but that's 1 in 200, baby. And considering we do thousands of cholecystectomies over the course of a career, the question becomes not if but when you're going to have to manage a complication of your own.

The patients that day were troubling. One guy weighed close to 400 lbs. Another was a very high maintenance lady who called every day for a week prior to surgery with questions. The other was a health care worker (highest risk factor for unexpected events, as the urban legend goes.) I just had one of those feelings. I felt tight and uneasy. The pre-op chatter was kept to a minimal. I was quiet and reserved during the prepping. I kept the music off (usually sirius radio on the internet tuned to the Grateful Dead channel). It was all business that day.

Things actually went just fine. The fat guy was a little tough but I was able to get it out by adding an extra port. The other two cases proceeded without incident. But at the end, I felt this bizarre sense of relief. The anxiety and doubt had passed. I had done again, adroitly, what I had done before. Another day to gather into my collective operative experience. But there will be more cases to come. More patients who expect nothing but a smooth, uneventful experience. Once again, I will have to gather my tools and perform....


Anonymous said...

The public does seem to have this odd perception that doctors can diagnose and cure anything: perfect babies born, no infections occur while in the hospital, the PA's are perfect, and on the list goes. The really sad part is that Medicare is buying into this mindset.

Anonymous said...

I love your blog!

I'm a second year british medical student and find that I learn things from your postings and then get interested to look into the subjects that you write about.

Plus, you are rather easy on the eye which is never a bad thing!

walt dandy said...

Cicero captured my growing dread as I get closer and closer to being out on my own perfectly. Well chosen quote, and another great post.

Bongi said...

great post. if you are half as good a surgeon as you are a writer then you would be not half bad.