On the first day of my surgery clerkship, our chief resident gave us a few instructions for our next two months together. We had to carry certain types of gauze and tape in our soon-to-be overflowing white coat pockets, create a clear and confident daily plan for each patient we followed, and be ready for rounds at 6 a.m. the next morning. He emphasized that hedging the plan for the day was his pet peeve — even if we didn’t know exactly how to advance a patient’s diet or choose an antibiotic, he preferred we hazard a guess than not try at all. “Surgeons,” he told us, “are sometimes in error, but never in doubt.”
A few mornings later, I reported that a patient was mildly distended. In the plan for the patient, I stated we should advance their diet from nothing by mouth to clear fluids.
“It is never appropriate to add food if someone is distended,” my chief told me. We then all went into the patient’s room, and the chief pressed on her belly, noted the distention, and told the patient they wouldn’t be eating today. I made a note in my pocket notebook: “Any amount of distention = nothing by mouth.”
Later that afternoon, the attending on the case asked the resident why our patient wasn’t eating. “She was distended,” the resident told the attending. The attending rolled his eyes, and said most patients are mildly distended after major surgeries, but that a diet would help move things along — the patient would do better if they ate food, to activate the GI tract. I took my notebook back out, and crossed out what I’d written early that day.
A few days later while rounding in the afternoon, I was asked for a patient’s medication list. I pulled out the cards where I keep track of patient information and reported he had been taking an anticoagulant twice daily. The fellow told me either I had written it down wrong or misread the med list, as no one prescribes it that way. So sure was he, he called the attending right there in the hallway, using one of the wall-installed hospital phones, to then be told himself that twice daily was preferable and not to alter the dosage.
A week later, I was following a young man, Mr. T, who had part of his intestines removed due to a severe case of inflammatory bowel disease. It was a three-part surgery, and I met him after his third and final operation. He had intense pain from each prior surgery, and as a result the pain management team was now following him and carefully titrating his medications. It was now four days after the operation, and he was recovering well, eating solid food and passing solid bowel movements. He was still on three IV painkillers, though, and each time the pain management team tried to ease down the dosage, his pain had roared vehemently back.
Stating my plan for Mr. T’s during morning rounds that day, I said that because he was eating and having bowel movements, he could leave when his pain was tolerable, pending consultation with the pain management team. My chief told that was not the plan. I tried again.
“I am not sure how long it will take to titrate down his IV meds down,” I said. “He might leave in maybe a few days.” He told me not to use the word “maybe” and asked me to make a specific plan.
“Perhaps tomorrow,” I offered. He told me I should not say “perhaps,” and said, “He goes today.”
I was self-conscious and embarrassed at how poorly my presentation had gone. They had given me explicit instructions to give straightforward plans and yet there I had been, hedging left and right. Maybe! Perhaps! I should have been confident from the beginning — he goes today!
Later than day, I went to see Mr. T. As I walked pass the curtain separating the beds of his shared room, he asked, “So you are trying to get me the f— out of here?” The physician assistant from our team had told Mr. T about our plans for discharge that morning, and now he was livid.
“How can I go home like this?” he asked. He still rated his pain as seven or eight out of 10, and consistently used high doses of painkillers. I wasn’t sure what to say. I was not sure how he could go home like this, either. I had no reason to doubt his perception of pain remained tremendously high. Worse, now he felt that we didn’t believe his pain, and as result I felt our relationship was sufficiently damaged, if not ostensibly over.
The pain team slowly inched back his more powerful IV medications as they eventually added oral ones — it was a slow dance of two steps forward and one step back. In the end, Mr. T left five days later.
In a sense, the plan I had given that day was, “I don’t know.” I didn’t know how long it would take to take down his IV meds. I wasn’t sure what his pain levels would be in response to the titration. Given his history of extreme pain, we would have guessed, if anything, his would be a longer course than most. And yet, when I tried to say, “I don’t know,” I had been not allowed to. What I had done wrong was try to voice doubt. As our chief had told us on day one, surgeons know no such thing.
The thing is, medical students aren’t the only ones unsure of the best course of action; residents and attendings experience this, too. Pain research demonstrates how differently similar pain experiences are to different people. Preferred anticoagulation regimens can be highly variable. From my experience on surgery, it appears nobody has any idea when to let patients eat and when to make them wait. But instead of allowing for multiple points of view or weathering the discomfort of equivocality, there is a surgical mandate to gloss over it with confidence and certainty. Taking accountability for patients and creating plans is a necessary step towards becoming a doctor, and I appreciated the opportunity to do so every day on surgery. Not being allowed to voice hesitation, however, leads medicine and medical training down a slippery slope, towards resolute preference, and its kissing cousin, decisions based solely on egotism.
I heard the surgeon battle cry “sometimes incorrect, never in doubt” from more than one surgical resident and attending during those months. Conviction is a tactic I am sure many patients find reassuring. It can be exhausting, for patient and doctor alike, to entertain and analyze various possible paths of action. It is so much easier when there is but one trunk and no branches on the medical decision-making tree.
The truer lesson, I think, would be how to maintain your sanity living fully within the uncomfortable borders of the uncertain. How to explain irresolution to patients, or how to describe a surgery that may do much harm, but may help. Not knowing is often a prickly place for students and doctors alike, yet it can offer great rewards. It is a place from which great research questions are formed and creative medical solutions take shape.
As I look back at how we treated Mr. T, it does not feel like a medical victory. We didn’t respect the amount of pain he was in. He likely suffered from our attempts to reduce his meds faster than pain management might have otherwise. So I say, surgery, you can try to take the maybe out of the girl, but I’m holding on to the honesty, the awkwardness and the brute reality of not knowing. Often, I do not know the one best answer. Often one does not exist. And I am okay allowing Mr. T to stay for a period of days, the number of which I am not sure, as we work through a plan on getting him home.
Pleural Space looks at the experiential curriculum of medical school, the many things that are taught and learned that aren’t listed in a syllabus.