Pennies From Heaven


There has been a pall of negativity descending over the surgical profession in recent years. The cause is almost certainly multifactorial – likely contributors are health care reform, lack of tort reform, real or potential declining compensation, and the ongoing transformation from independent practice to surgeons as employees. These elements, combined with the stresses of long hours at work, life-and-death decisions often made with limited data, insufficient time for personal/family activities, and too-frequent on-call nights and weekends, have led to varying degrees of unhappiness within the surgical community.

The overall degree of despondency was brought into focus by a survey conducted by the American College of Surgeons (ACS) in 2008. The results derived from the 7,900 Fellows of the College who responded demand our attention. Burnout, defined as emotional exhaustion, depersonalization, and/or the sense of low personal accomplishment, was present in 40% of participating surgeons. Clinically significant depression was found in 30% of those surveyed and almost 50% of respondents said they would not recommend that their children pursue surgery as a career path (Ann. Surg. 2009;250:463-71).

These alarming findings should not be minimized, and they will continue to be addressed by the ACS and others concerned with the future of surgery. As one who is among the fortunate 60% of surgeons who have not suffered burnout or depression, I feel blessed and privileged to have spent the past 35 years caring for surgical patients and training residents. I would like to reflect on some of the joys and rewards that can be encountered during a life in surgery.

Participating in the remarkable transformation that takes place between the first year of surgical training and completion of the chief residency year is a gratifying experience that I have been privileged to observe annually throughout my career. Surgeons in private practice might derive similar satisfaction from mentoring a junior colleague in the art and practice of surgery.

However, nothing trumps the nonmonetary rewards I have received from grateful patients and their families. I believe that surgeons enjoy a special relationship with their patients that most other physicians do not experience. Maybe it is because we alone invade the sacred space that is their body, or because they believe that what we do to them is a mystical mixture of technical skill and magic. Whatever the reasons, the sincere gratitude expressed by patients and their families after removal of a life-threatening tumor or even a modestly problematic gallbladder has sustained me through challenging times in my professional life. Especially amazing is the appreciation expressed even when complications or death compromise the outcome.

Occasionally, a patient’s thankfulness has been conveyed by means of a gift reflecting an interest or passion of mine – for example, home-baked cookies, bottles of wine, tickets to sporting events, and Green Bay Packers jackets and other Packers memorabilia. As lovely as all of these gifts have been, the most memorable and the one that best defines the special relationship that we are privileged to have with our patients is "pennies from heaven."

Some years ago, a woman in her late 50s presented to me with proximal bile duct carcinoma. I removed her tumor by means of an extrahepatic biliary resection combined with a right hepatic lobectomy. Although the bile duct margin was negative on frozen section analysis, as is so often the case with this aggressive tumor, the final pathology revealed bile duct cancer cells at the proximal bile duct margin. Adjuvant radiation therapy was considered, but the patient suffered a pulmonary embolism in the early postoperative interval and never received it. The patient recovered from her operation and was discharged.

Nearly every time I met with this lovely woman before and after her operation, in or out of the hospital, she was accompanied by her two very attentive and equally delightful daughters. Despite the positive margin, she did quite well for 4 years. During that time, I saw the patient and her daughters regularly, and we became friends.

Unfortunately, her cancer recurred in the fifth year along with distant metastases. The patient and her daughters decided to use only palliative measures, and she soon died. I sent my condolences to the family, and several weeks later an envelope with a hand-written inscription "Pennies From Heaven" appeared on my desk. Inside, I found $2.83 and a note that read: "These are pennies from heaven that we saved during our grandmother’s illness. We would like to donate them to Dr. Rikkers for research on bile duct cancer." It was signed: "The grandchildren of BG."

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