Observations of a Retiring Surgeon

Pliny is retiring from clinical practice, if all goes well in the next few months. As I go, I have a few observations to share with those who will follow. Being a doctor is hard and often a challenge. It is still an amazing privilege if you keep your perspective. Some thoughts in no particular order.

1. Fear of the unknown spirals out of control: In the absence of knowledge and informed discussion, people will seek to fill the dread void of uncertainty with anything available. This is in large part why quacks succeed. Uncertainty breeds fear, which seeks comfort anywhere that looks promising. Keep people informed. Let them know what to expect. Be their advocate.
2. It’s their data, not state secrets: The job of a physician is not to shield a patient from their own data, it’s to synthesize it for them and help them understand its meaning. Most need to see it at least in passing in order to have trust in the synthesis presented. All this HIPAA nonsense is just an excuse to be lazy and not talk wit patients and families.
3. If their call is important to you, then why not bloody well take it! Individuals care very little that you are busy. Nothing says ‘my time is more valuable than your angst’, than a voice-mail decision tree. You can’t complain about patients lacking loyalty when you treat them like an airline complaint desk.
4. Schedule phone appointments: Delivering medical news is not the same as receiving a major appliance. Don’t expect a patient to wait around during some 4 hour window to get the results of their path.
5. Say what you are going to do and do what you say.
6. Honesty is the only policy: Often, what we do is really a life and death matter. You will forget. You will make mistakes. These are inevitable and forgivable as long as you are honest about it. Lie once, and it’s the dark side for you.
7. Share your battle plan: Years ago, a colleague of mine related the following story to me on Monday morning after covering my practice for the weekend. A very ill ICU transfer patient developed a known complication of their very complex emergency procedure that was caught early enough to successfully intervene. The covering surgeon went out to talk with the family and as hem-hawing around about the complication, when the spouse said, “Oh you mean X occurred. Dr [Pliny] told us that if that complication was going to happen it would likely be this weekend, and that you would do Y to try and fix it.” The family was appropriately concerned but confident in the team since we had been very open about their loved one’s condition, the risks and benefits of our therapy and our battle plan for when things, on occasion, go wrong. My practice motto to patients and families was always simple - You hope for the best and I’ll prepare for the worst. I’ve never found a better method for helping patients and families achieve realistic expectations.
8. Medicine is a business - being a doctor isn’t: It’s best to decide early on whether you want to be a well-paid technician or a patient advocate. It really is that simple. Good luck trying to be both. Like Darth Vader, you will eventually succumb to the dark side.
9. You work hard? So what: A lot of people work just as hard or harder for a lot less money. If life were fair, urban firefighters would have the highest salaries in the world, not you.
10. Tough love: Like parenting, being a physician isn’t always being popular. It’s being the adult. The truth is often unpleasant but it's always easier to remember.
    
11. You’re the expert, take some responsibility: Imagine finding yourself thrown into a canoe a hundred yards from some ominous looking rapids ahead. There’s a guide along the shore who responds to your pleading gaze with, “well, you have a couple of paddles, an oar, your hands and feet, and an empty tin can. Any one of them may be appropriate in some circumstances. Let me know what you decide.” Patient autonomy is fine. But patients lack a physician’s knowledge and are (often) emotionally compromised. Be their advocate. Most of us would prefer the guide to yell, “Take an oar and paddle as hard as you can to the far bank and jump in the shallows.” On occasion, some know-it-all might ignore the guide’s suggestions and go over the falls. Regardless of what the person in the canoe decides to do, the guide can still walk up the hill and go home at the end of the day. Like the guide, the physician can take solace in the knowledge that bad patient decisions affect them, not you. I don’t need a waiter for a cafeteria plan. If it’s just a matter of reviewing my options and making up my own mind about it, what am I paying you for again?
12. Imagine you are buying a car: A lot of docs I know are notorious pains when it comes to shopping for a new car. They investigate and study and check out this and that, visit and grill the sales staff, and are generally suspicious of anything they are told. Why then, do these same people get so upset when a patient they have never met, has a few questions and concerns before you trot them off to surgery where someone they meet the morning of surgery will poison them to the brink of death (otherwise known as general anesthesia...) and you will rearrange their internal organs? The residents always were shocked when before a really major surgery, I automatically suggested a second opinion and provided them a list of excellent surgeons to pick from. We belabor our choice of cellular phone plan more than our choice of surgeon. Very strange.
13. Embrace the Internet. The patients will be looking stuff up. Be proactive. Have a list of authoritative sites available for your patients. Explain why you prefer them.
14. Invoke Pliny’s test engine anytime you have doubts: Pliny’s test is simple. I have found it to be very useful over the last 25 years. If you are unsure about something clinical, use test one: Say what you are thinking out loud but preface it with the following phrase - “Well, Your Honor, it was like this...” You’ll know what to do. For ethical dilemmas use test 2: Say what you are considering, again out loud, but preface it with the following phrase - “Well, Dad, it was like this...”