Commentary

Introspection – the Next Surgical Time-Out


 

The Town Hall Meeting held at the Annual Meeting of the American College of Surgeons in Washington, DC, on Oct. 8, entitled, "Introspection – the Next Surgical Time-Out," was cochaired by Geoffrey Dunn, M.D., FACS, and Ann Mosenthal, M.D., FACS, with panelists Dan Hinshaw, M.D., FACS, and David Page, M.D., FACS.

Well-attended, the discussion raised specific issues that addressed the growing need for surgeons to care for themselves in a sometimes chaotic and hostile practice environment. Given a reported 30%-40% burnout rate among surgeons, it was felt prudent to explore a side of the surgical personality too often resistant to self-examination. And like scheduled time-outs before starting a case in the OR, it was felt that a personal time-out before diving into the next procedure or busy office session might blunt the frustration born of time constraints and excessive documentation demands piling up on surgical practitioners of all stripes.

For example, an attendee raised the issue of humanizing the otherwise sterile EHR with personal patient information, perhaps insights about the interior life of the patient unrelated to the diagnosis. Another attendee addressed the need for surgeons to model compassion as well as their reactions to grief for learners at all levels. The notion of using videos to teach introspection was raised and discussed, as was the technique of "reflective" or free (uninhibited) writing and journaling as methods for probing one’s inner landscape and deeper feelings and emotions.

The panel addressed the paradox all surgeons face: the need to confront with objectivity organic surgical disease in all of its anatomic-pathologic complexity, employ technical skills in a time-compressed stressful operating room, interact with other caregivers involved in employing complex technology, and then step away from the operative field and become transformed into a compassionate physician. It is fitting that surgeons understand that draping a patient is both a requirement of sterile technique as well as a metaphorical "hiding of the humanity on the table" in order to shift gears and become engrossed "in the moment," to become focused on the mechanical tasks of cure and not distracted by emotional issues.

What challenges the surgeon in ways he or she may not have anticipated is the act of undraping a wounded human who now needs the surgeon’s empathetic attention as the blood stops flowing. Only self-reflection and a consideration of the profound challenges of these diametrically opposed sides of the surgical personality will sustain surgeons through endless daily lists of complex operations and their associated political, cultural, and psychological burdens. And when cure is no longer possible, confrontation with the patient’s imminent demise too often echoes the confrontation between the surgeon and his or her self-image of invincibility.

Also discussed were two recent changes in the matrix of modern surgical practice that were thought to positively shift the traditional image of surgeons as action hero with relative insensitivity to their patients’ suffering. These features include the minimally invasive surgery revolution which transformed the surgeon from blood-splattered aggressor to a delicate-handed laparoscopic wizard capable of heretofore unseen indirect motor skills maneuvers, a quiet ectomorphic individual rather than the traditional mesomorphic "linebacker" persona. The second change is the rise of women in surgery. Once derided, discouraged, and humiliated at every turn, women are now a valued cohort of colleagues whose innate caregiving skills are matched by an admirable and unflinching work ethic. Introspection seems more natural for women, something the macho surgical male ought to learn from.

Finally, introspection was seen to be somewhat like the "second effect" in opioid administration (hastening death is justifiable if the intent is to reduce suffering, not to cause death). Because although the intent of introspection is ultimately to improve the care of our patients, an unforeseen consequence of introspection may center on the arrival of profound insight into the meaning of the surgeon’s own life.

The potential role of artistic expression by surgeons such as painting or creative writing was entertained and will be further explored in a similar format at next year’s ACS meeting in San Francisco.

Dr. Page is professor of surgery at Tufts University School of Medicine, Boston, and director of Undergraduate Programs in the department of surgery, Baystate Medical Center, Springfield, Mass.

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