COMMENTARY

My Invisible Surgeon

Ronald W. Pies, MD

Disclosures

May 22, 2019

Picture this. You are undergoing an outpatient surgical procedure that requires you to be in, well, an awkward and very exposed position, lying on your side (the well-known lateral decubitus position). The physician assistant (PA) standing behind you preps you for the procedure, chatting amiably about sports, the weather, and his grandkids. The surgeon performing the procedure, whom you have never met, comes into the room, mumbles something to the PA, chuckles, and begins to do his surgical thing. The PA continues to chat with you, but the surgeon says nothing—never says hello, never introduces himself, never asks how you are tolerating the procedure (the PA does that). The procedure goes by quickly and without incident. At the end, a nameless, faceless, disembodied voice—the surgeon's —quickly runs through a few postoperative instructions ("Call me if you develop a fever or have excessive bleeding," etc). Then the surgeon leaves the room, palming off the clean-up chores to the chatty PA.

And yet, there is much in the present climate of medical practice that should have prepared me for feeling a bit like a large slab of meat.

This was precisely what I experienced recently at a well-regarded hospital in the Boston, Massachusetts, area. As a physician myself, I had done my homework preparing for my procedure, so I knew roughly what to expect from a technical standpoint. I had also researched the surgeon, whose medical credentials were excellent. But nothing could have prepared me for the stark, depersonalized experience of lying cold and naked on the operating table while my faceless surgeon stood silently behind me, poking and probing certain intimate bodily regions.

And yet, there is much in the present climate of medical practice that should have prepared me for feeling a bit like a large slab of meat. Recently, Stephen Trzeciak, MD, MPH, and colleagues described the "compassion crisis" that has gripped much of American medicine. Writing in Medical Hypotheses, they cited research showing that fewer than 1% of physicians' communications with patients are expressions of empathy or compassion.[1] (Roughly speaking, empathy refers to the ability to understand a patient's feelings and concerns. Compassion refers to an empathic response coupled with an intention to take constructive action.) Trzeciak cites a nationwide survey of 1400 US adults, which found that 64% of the participants have experienced unkind behavior in a healthcare setting, including failure of a caregiver to connect on a personal level (38%), staff rudeness (36%), and poor listening skills (35%).

In fairness to my colleagues, the medical profession has come under tremendous pressure in recent years. One example is that for all of the advantages of electronic health records, the new technology often creates a physical and emotional barrier between the patient and physician. (My own primary care physician retired in his mid-fifties, mostly because he could not stand the electronic health record software required by his hospital.)

The syndrome known as burnout is now believed to afflict as many as 42% of practicing physicians in the United States, according to a Medscape survey involving more than 15,000 physicians from 29 medical specialties.[2] Indeed, maintaining a compassionate attitude toward patients is difficult in today's high-pressure medical environment. As Antonio Fernando, MD, has observed, "A toxic, soul-sapping weekend night shift in an understaffed after-hours clinic makes remaining compassionate towards patients who are abusive, intoxicated and narcotic-seeking difficult."[3] Fernando points out that empathy alone is potentially unhelpful, as the physician is likely to feel the patient's pain and distress but have no means of processing and working through these emotions.

So, there are many reasons why I'm reluctant to bring the hammer down on my silent, invisible surgeon, who, to his credit, performed his work efficiently and competently. At the same time, I recall wistfully the words of the great Canadian physician, Sir William Osler:

"Medicine arose out of the primal sympathy of man with man; out of the desire to help those in sorrow, need, and sickness. Our fellow creatures cannot be dealt with as man deals in corn and coal; 'the human heart by which we live' must control our professional relations."[4]

No, compassion is not easy to come by in today's medical environment.[5] I know I could have used a little, as I lay shivering and exposed in the lateral decubitus position. And my encounter with the Invisible Surgeon left me wondering about the future of healthcare in this country. Have we lost the "primal sympathy" and "human heart" that have connected physicians to their patients since the time of Hippocrates? Or are those priceless elements of our professional identity merely submerged, waiting to surface in a more humane healthcare environment? And, yes, I also wondered how many times I may have been "invisible" to some of my own patients—not physically hidden, but emotionally distant, far removed from the human heart.

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