Blood, sweat and tears: are surgeons prepared for the challenges of self-reflection?

625 HISTORICALLY, SURGEONS HAVE ENDEAVORED to cure disease by designing operations to remove cancers, bypass stenotic blood vessels, resect scarred flesh, replace worn out tissues, and recycle organs. The work sustains immeasurable good. However, when the end of a patient’s life arrives, the final phase of the caring continuum finds many surgeons ill at ease with their dying patients. It is certainly not indifference as much as a sense of non-ownership, the surgeon’s focus narrow, unfettered by ambiguity. The mind-body dichotomy many surgeons embrace leaves the patient’s personal experience of surgery, the emotional minefield beyond cure, to someone else. Not only have surgeons done poorly treating pain,1 we rarely reflect on how we contribute to our patient’s suffering. In this regard, Eric Cassell2 has pointed out that the identification of suffering strictly with somatic pain is misleading and distorts the issue because it depersonalizes the sick patient. Richard Selzer, M.D., spoke of the agony of metastatic pancreatic cancer in “Mercy,” a story from his prescient 1982 book, Letters to a Young Doctor. He wrote, “In his bed at home he seemed an eighty-pound concentrate of pain from which all other pain must be made by serial dilution.”3 When a patient transitions from a goal of cure to a need for caring, surgeons often drift away from the bedside, as if practicing “emotional itinerant surgery.” Behaving thus, surgeons risk no small measure of self-extinction, losing little pieces of themselves each time they turn away from the bedside. This is unfortunate because surgery runs at the head of the therapeutic pack in absolute cures and innovative solutions to old problems. Yet, something in our professionalism seems amiss.4 Medical students who are disenchanted with the surgical persona often suggest we have no one to blame but ourselves.5 Women comprise 25% of general surgical residents,6 despite harboring doubts about whether surgical educators can meet their special needs.7 Why are we only now learning about our own inadequacies as preceptors? The contention that surgeons often are not tuned in to the needs of students and patients is supported by Cassell’s remark that to successfully alleviate suffering, doctors need to know more about illness than the name of the disease and the science behind it.8 Surgeons champion aggressive invasions of the body, accomplished with a measure of indifference and a talent for maintaining a tight focus on the architecture of the flesh; yet the spasms of terror on the outskirts of bloodshed remain invisible to us. This insouciance, if not outright disdain for pity, has a well-documented historical origin in the era before anesthesia. Still, a surgeon’s professional life is surely more than sutures and silastic. As Rachael Remens, M.D., admonishes, life is small when defined only by science (R. Remens, personal communication). Anthropologist Pearl Katz wrote in her book, The Scalpel’s Edge,9 “Who but a surgeon routinely and boldly cuts into the most intimate depths of people’s live bodies, penetrates their innermost body cavities, exposing blood, guts, and excreta, and cut and remove their organs, burn blood vessels, saw bones, and sew layers of skin?” Katz