Perhaps the single most awkward conversation that a third-year medical student can have with an attending physician is the one that begins with the attending asking, “So, what medical specialty are you interested in going into?” This became increasingly awkward when the student was me, and I was not particularly interested in the career analogous to that of the physician. Arguably, this conversation was especially awkward because I was interested in psychiatry while being scrubbed, gowned and gloved in the operating room during my surgery clerkship.
I would be lying if I said I was interested in surgery; in truth, this was perhaps the one clerkship for which my only goal was survival. I had heard the horror stories from classmates: long, grueling hours, endless retracting, suture trimming, entering and leaving the hospital in darkness and never quite getting a good night of sleep. Given these anticipated experiences coupled with memories of an arduous time in pre-clinical gross anatomy during my first year of medical school, I could safely say that I was not intrigued by the prospect of cutting patients open, navigating an anatomic space and proceeding to resect or dissect or transect. But, as a third-year medical student who could not finagle a way out of a required clerkship, I was resolved to do my due diligence and make sure that I was the same enthusiastic, eager-to-learn member of the team as I had been on every other rotation over the course of the year.
Prior to the start of this clerkship, a fourth-year medical student told an anxious classmate of mine, “Merely surviving the eight-week rotation would suffice because surgery is about as far away from psychiatry as one could get.” This classmate was also interested in psychiatry but was stressed about how a poor surgery evaluation might impact her chances of eventually matching. Although the two fields may be far apart in a clinical sense, I learned during my brief time in surgery that the two are far more connected than I ever thought possible.
Needless to say, I had my work “cut out” for me — no pun intended.
I proceeded to put my best foot forward and resolved to make my time in surgery as meaningful as possible. As someone interested in psychiatry, I used my time on pre-rounds and the precious time before cases began to build rapport with patients. In the early hours of the morning, I made sure their questions were answered and their concerns were heard. In pre-op, I did my best to put anxious patients at ease by reassuring them that they were in excellent hands and that they would be well taken care of by everyone on the team.
I knew that one day I would be forced to grapple with human beings’ deepest, darkest secrets, fears, hopes and dreams, and I knew that I could always practice the time-honored art of human connection in the clinic, the operating room or the coffee shop. If these aforementioned encounters with patients in pre-op were how I contributed to my team’s work, then I was content to do so and hoped that this would be viewed as enough for my superiors to notice and thus evaluate me favorably. Helping patients to believe in us, through these encounters I had with them, initially seemed to be where the lines between psychiatry and surgery would begin and end. Building not just rapport with these patients but also gaining their trust are paramount in any field and specialty.
One patient and one attending (with whom I had the aforementioned, initially awkward, exchange), however, would show me how close psychiatry and surgery truly are. On one of my handful of clinic days, I saw a surgical oncologist’s patient. She was an older woman, about seventy, who was referred to my attending after previous physicians had incidentally discovered a mass on her pancreas during a workup for another medical issue. She had no symptoms and felt reasonably well in spite of an extensive past medical history of diseases that have come to define the modern American healthcare experience: an endless list of ailments that began with hypertension, hyperlipidemia and arthritis.
Now, on this snowy New England morning, even though it was noted only succinctly in her chart, one more ailment would come into sharp focus: a pancreatic tail mass likely representing adenocarcinoma. “There is no biopsy,” my attending admitted, “but the CT scan is probably enough.”
I watched as he explained to the patient and her husband what he saw in the images; he informed them that the mass was likely cancerous and would need to be taken out as soon as possible. I watched her reaction to the word “cancer.” The patient’s mind seemed to be elsewhere as she pondered this news while my attending continued to describe the surgery that was necessary to remove the tail of her pancreas. I watched as, eventually, the weight of the news became too much and the patient began to openly weep.
It was a reaction I should have expected, yet it still caused my heart to pound in my chest and my mind to fill with a sense of dread. Cancer alone is difficult, but pancreatic cancer seems to strike fear in the hearts and minds of patients and providers alike. “We have to stay positive,” the patient’s husband urged.
I could see him doing his best to keep his own tears from falling, but it seemed of little use to the patient. She seemed to stare off into a distance beyond the exam room’s walls and only intermittently looked back at my attending as he outlined the next steps of additional imaging and pre-anesthesia testing. I appreciated the chance to debrief with him afterward. “We’re the bearers of bad news, always,” he told me as we sat in his work space. “No specialty avoids it. You, at some point, are going to have to give bad news to someone, no matter what specialty you practice.”
I thought about this as he shared how he coped with helping patients weigh the options of treatment and the ramifications of their diagnoses. I would never have to tell patients that they have cancer, but I might be required to have difficult conversations with patients about other devastating diagnoses and prognoses. How would I tell patients suffering from intractable depression, for example, that it didn’t seem like their latest medication regimen was working and that we would once again have to try something else? How would I talk to people with substance use disorders about how I was worried about their abilities to stay sober and take care of themselves? How would I tell people who desperately wanted to go home that they had to stay in a locked unit because I feared for their safety?
The honest answer, as I learned from watching my attending speak to our patient and thinking about my own future career, was that I really did not know. I could not comprehend the awesome responsibility that all physicians share in regards to delivering less-than-happy news. I failed to wrap my head around how physicians are able to maintain patients’ trust and cooperation when the physicians cannot give the patients the solutions they want or the cures they need. Finally, I wondered about how we as future providers will cope with the realization that, whether we become surgeons or psychiatrists or internists, we will not be able to cure everyone.
I kept the encounter in the back of my head as I marched on through the clerkship. There would be more clinic and a myriad of surgical cases, but none had so lasting an impact as that one day and that one patient.
I had the chance to see this patient again a few weeks later, when my attending and I were scrubbed in for her pancreatic tail removal surgery. As we were proceeding, he stated, “We’re dealing with very intimate things.” Our patient had agreed to the distal pancreatectomy that my attending felt was best. My attending and I were together in the OR as we utilized the wonders of laparoscopic surgery to resect the tumor before our colleagues in medical oncology did their part to rid her body of the so-called “emperor of all maladies.”
“Surgery and psychiatry: they’re both very intimate,” my attending told me after a brief conversation about my interest in the study of the human mind. “Either way, you’re dissecting someone. You’re dissecting a person in ways that most people cannot.”
This entire clerkship made clear for me not only the connections between surgery and psychiatry, but also those throughout all of medicine. As physicians we are allowed to connect with other human beings in ways that most people will never be able to. We talk with patients about the most personal subjects, be it a breast lump that will not go away or feelings that they do not belong. Regardless, our patients trust us to be there for them in ways that very few others can.
Across the practice of all specialties of medicine, we should not only recognize what is physically or mentally within our patients, but also recognize the many ways to see inside of them. We should fully empathize with their experiences so that we can do our very best to make them feel better. I learned all of this in the throes of surgery.
Even though I will not be applying for a surgery residency next year, I am forever thankful for this lesson that blossomed during my eight-week surgery clerkship. I am grateful for team members who made me feel welcome and feel that I was making a difference. I am forever indebted to the attendings who took the time to teach me about their fields. Most of all, I will carry with me the lessons that I learned about what happens before the scalpel is ready to cut and then after all the incisions are closed.
I am thankful for the fundamental lessons I learned about connecting with my fellow human beings and what it means to be a good doctor. During my surgical clerkship, I looked inside most areas of the body searching for anatomical landmarks, but I also found the connections between mind, body and spirit.