Reflections in a Head Mirror

Insight, I believe, refers to the depth of understanding that comes by setting experiences, yours and mine, familiar and exotic, new and old, side by side, learning by letting them speak to one another.
-Mary Catherine Bateson    


Last week, a group of third-year medical students completed their first rotations through Surgery. They spent eight weeks doing things that no normal person would ever be asked to do. Many days, these students arrived at the hospital at 5:30 a.m. to begin 30-hour shifts seeing patients, checking laboratory reports, making rounds, and observing surgery.  

In the operating room, these students saw, heard, and experienced many unthinkable things for the first time. They held retractors for hours. They felt the warmth of another person’s intestines envelop their hand and forearm as they listened to the surgeon describe findings deep in the belly. They watched as a heart resumed beating after bypass or transplant surgery.  

The students also spent time talking to patients and learning their stories. Many of the students were present as a person that they had gotten to know died.    

When I was in medical school, the end of the surgical rotation meant merely that it was time to move on to the next, certainly less intense, clinical experience.

For this group of students, though, their teachers planned something different.  

These students were offered the opportunity to prepare a creative piece to reflect on what they had just experienced. Almost half chose to write a poem, create an essay, or paint a picture.    

This was not your standard bookshop reading! There were poems about bowel movements and horrific odors. There were pieces about cardiac arrests. There were appreciations of patients’ stories. There were evocative poems about sick children. Some of the pieces were very funny, some displayed great tenderness. Many of the students admitted that this was their first attempt at reflective writing or verse, yet all of the pieces reflected their shared immersion in a rich, vast, and powerful experience.  

When the session ended, all of the participants and their classmates sat stunned. As one later shared, “I've experienced many emotional moments throughout the past two months and it wasn't until this hour did I finally have time to realize and reflect on my personal experiences and their impact on my life.” Importantly, one student wrote, “I learned that perhaps I do need to put some effort into maintaining empathy.”  

Medical school involves thousands of hours of instruction. This was unique. This was a single, planned, intentional hour of reflection.   

Perhaps none of these particular students will go into a surgical field, and that is just fine, yet I hope that one of them becomes my own physician when the time comes. Having heard them read and reflect, I know that I will be in good hands.    

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The following is feedback received for this blog: Interesting post. It takes a special person to want to go through all that. Has to be a calling! certainly... most people could not withstand the rigors of a medical education. I never realized how empathetic doctors are toward their patients until I joined the med blogosphere. I'm glad to know they are. :) I thought surgeons weren't supposed to have feelings though. ? That they were supposed to be the non-feeling specialty? generally speaking. - SeaSpray seaspray-itsawonderfullife.blogspot.com Thanks for the comment! "Surgeons weren't supposed to have feelings"!?! Ouch! Occasionally, a little empathy slips out! Actually, a research study a few years ago confirmed that medical students that have higher empathy scores are more likely to go into primary care specialties, so I guess you are on the right track. -Bruce It's not that we don't have emotions, or are not caring; its that we have learned to suppress our emotions in order to perform the incredible tasks that are required of us. If a surgeons hand slips, or his concentration wavers, even for a second, while performing a routine operation, loss of life can ensue. Procedures tends to be much more routine and methodical when you have the distance separating you from what you are actually doing. It is this ability that makes us successful as surgeons. I would hate to have an overly emotional, frantic surgeon's hands in my abdomen while I was bleeding out. - Steven Savage Dear Dr. Savage, Thanks for your comments. What you say strikes at the heart of one argument I have heard about the ACGME's core competencies for residents. A resident can excel in all of the competencies and still be technically dangerous surgeon. Still, I don't think that a side effect of including reflective or narrative experiences in a Surgery clerkship is to make surgeons more caring or less capable of making hard, rational, dispassionate choices. There is value in having a person whose hands hold my life in the balance being a person capable of insight and compassion. Think of Richard Selzer, Sherwin Nuland, Pauline Chen, Atul Gawande, and Loyal Davis...all renowned surgeons, accomplished writers and keen observers of their own motivations and their patients' dilemmas. These people, at least in their writing, did anything BUT suppress their emotions. Thanks again. -Bruce Both...very interesting comments! :) "technically dangerous surgeon. " Scary thought... that someone could have a surgeon like that. God Forbid! I'd take a competent surgeon over a sensitive one... but if I can have both..then that's just icing on the cake. If you haven't read this..one of my favorite surgical posts is Dr Schwab's "Taking Trust". I believe he wrote it in October, 2006. A moving post. :) - SeaSpray seaspray-itsawonderfullife.blogspot.com

"I have every sympathy with the American who was so horrified by what he had read of the effects of smoking that he gave up reading."
- Henry G. Strauss


I have worked in hospitals long enough to remember when there were few smoking restrictions. The air in the emergency room where I had my first hospital job as an 18-year-old nursing assistant was thick with smoke from the nurses and physicians. As a medical student, I recall conferences where the slides were projected through a haze of smoke. I remember one of the most prominent surgeons at my medical school smoking cigars while making hospital rounds. One of my deans kept his pipe half-lit in the pocket of his lab coat, pulling it out between patients.  

During my residency, there was a smoking lounge adjacent to the operating room where some of the surgeons gathered between cases. Across town, the VA had the cheapest cigarettes anywhere and patients would leave after their appointments with shopping bags full of low-cost smokes. Because the VA did not allow the veterans to smoke in their rooms, we residents would often head first to the smoking lounge when we needed to find one of our patients. Even at the cancer hospital where I did my fellowship training, patients smoked on the hospital floors and several of the doctors smoked in their offices.  

My, how things have changed!  A recent report confirms that 45 percent of hospital campuses nationwide are, like our own, completely smoke free including the buildings and surrounding open spaces. In 1992, only 3 percent of hospital campuses were smoke-free. 

Despite the declining number of smokers, though, some hospital employees and patients continue to struggle with tobacco addiction. Every day, I watch people duck out though the garages to go for walks around the grounds and then catch the odor of smoke on them as they return from the out-of-doors.  

A while back, I spotted an employee with whom I work heading out for a walk. “Where are you going?” I asked. “Isn’t it time to quit?”  

“Y’know, Doc, I’d love to,” he responded.  

“Talk to me when you get back.”  

Later that day, I reviewed smoking cessation strategies with him and confirmed that he was truly motivated to quit. I handed him a prescription. “I think you can do it!” I said.  

“Me, too,” he replied and he meant it. He has been smoke-free for a year.  

To be honest, when it was first proposed, I was not certain that a smoke-free campus would work. Certainly, there are those who continue to break the rules. On the other hand, I know several employees who have cut down or even quit smoking because of the policy.  

Over 15 percent of lifelong smokers will develop cancer. The average smoker loses decades off of his or her life. Having someone quit smoking before they become a patient of mine is a real pleasure for me. As much as I love my work, I love my friends and colleagues even more.

Welcome to the Aug. 9, 2009 edition of surgeXperiences! I'm happy to be hosting again. Here in the Northern Hemisphere, these are the "Dog Days of Summer," so in honor of dogs everywhere, lets chew into the best of the surgical blogosphere. Along the way, we will sniff around a few categories and search for the "Best of Show."


Candidates for the "THAT'S REALLY AMAZING" Trophy:

MedGadget posts about a remarkable chain of kidney transplants. Sixteen people in four states received organs! The chain was started at Johns Hopkins where one of their administrators donated her kidney for a co-worker. She has kept a blog about the experience including a nice post on the therapeutic benefit of staying in your pajamas. Amazing!

Dr. Wes has a post that links to a video of a 34-year-old man who was born with his heart outside of his ribcage. 

In a post entitled weighty issues, South African surgeon and blogger bongi tells about treating a substantial woman who was mauled by a hippopotamus. 


Candidates for the "I NEED A BREAK IN THE ROUTINE" Trophy:

T., who crafts the blog Notes of an Anesthesioboist, reflects on the healing moments. In a post entitled Detour, she writes "Sometimes it's the moments between procedures, the tucked-away opportunities to participate in healing (even if it can't be completely achieved), that remind us why were called to medicine in the first place..." 

Here's a post by someone who needs a different kind of break. Gizabeth Shyder, a pathologist, in her blog Methodical Madness tells how the odor of  Tuna Salad affected her day.


Candidates for "THE LIFE OF A SURGEON" Trophy:

Ramona Bates at Suture for a Living provides some great links this week! Here's a discussion and photo of macrodactyly that would set any hand surgeon to planning a series of procedures. She also provided a link  to a patient blog with photos of his ulnar nerve transposition. And here she provides a link to a blog with a photo of a cute young man showing off his Colles Fracture.

Kevin, MD, in a post entitled, Are Female Surgeons Happier than their Male Counterparts? provides a link to a MedPage Today report. Happiness is hard to quantify, but female surgeons are significantly more enthusiastic in recommending surgery as a specialty to students. The study also confirms the huge impact that specialty choice has on lifestyle and family. 

The New York Times Health Blog, Well, has a post and a link to a wonderful essay by surgeon Pauline Chen, MD. Dr. Chen tells the story of a woman who pursued alternative breast cancer treatment for two years before presenting with a large, painful mass. She writes, "I find myself wondering when it comes to patients like Marla or others whose diagnoses are delayed for various personal, social and economic reasons, how responsible am I as the physician and are they as the patients?" I have had several similar experiences.

Dr. Jon at Unbounded Medicine presents some amazing (and a bit  disturbing) photos of Rectal Prolapse. Thank goodness for colorectal surgeons! 

In my own blog, Reflections in a Head Mirror, I describe how, in the operating room, not everything the patient tries to hide stays hidden.

Sometimes, the life of the surgeon has unpleasant challenges. Jeffrey Leow provided a link to a story about plastic surgeons in Australasia being stalked by unhappy customers.

A medical student, MedZag, writes a moving post about the loss of a patient in The Bee Gees, Storage Closets, and Medical Education. It is another essay that resonated with me. (His current post is about his initiation on the surgical service. Hang in there!)


Candidates for the "THIS MAKES IT ALL WORTHWHILE" Trophy:

QuietusLeo, an Israeli anesthesiologist who writes The Sandman, has a beautiful essay entitled The Gift where he reflects on the gratitude of a young patient and his family. "He who saves one soul - saves an entire world."

Sid Schwab at Surgeonsblog writes about how a patient and a gift had a long-term effect on him in a post entitled Kung Fu Surgeon. 

South African surgeon and blogger bongi writes about his surprise when he learns that Americans are not all the same in a post entitled "gracious." 

In a post entitled "difficulties," bongi writes about how hard, yet rewarding, it is to keep visiting patients for which we have little to offer. He remarks, "i just kept on visiting her, usually just to say hello so that she would know she was not totally alone."

In another great piece, bongi reflects on the concept that "Only the Good Die Young" in a post entitled, "who actually wants to live forever?"

SeaSpray, an eloquent patient-blogger, writes about the final moments before surgery. She writes, "I do believe it ... but there is always that ... last glance around the room or up to the ceiling, knowing that I am right then ... at that moment in time ... surrendering my mind and body to them." Powerful stuff. 


Candidate for the "BAD DOG!" Trophy:

In a story entitled Plastic Surgeon Botches 28 Operations, we learn that there is value in checking to see if your physician is board-certified. Tragic outcome.





Candidates for the "GET READY FOR THE FUTURE" Trophy:

Surgery in the future will have new tools. MedGadget tells of research at MIT that will lead to the development of tissue-specific adhesives.  

Is social networking coming the the operating room? Kevin, MD reviews some of the potential uses for Twitter in medical practice. Two of our local hospitals recently used social networking for surgical procedures. One live-twittered a bilateral knee replacement with 250 tweets. (Can you sterilize your BlackBerry???) Another local hospital used Twitter, Facebook, and YouTube to follow a patient through prostate surgery. A bioethicist and colleague, Art Derse, MD, JD was interviewed on our local NPR affiliate about the Twittering Dilemma in the operating room. (Spoiler: Social networking has potential pitfalls, but is not inherently unethical.)

Can we afford the future? Buckeye Surgeon discusses the future of medical innovation in the midst of healthcare and world financial crises. He notes, "At some point in time (like when health care in America isn't in full crisis mode) it may be advisable, even desirable, to see innovation...gather momentum as acceptable alternatives to the standard of care. But we aren't there yet." MedGadget includes a post with a photo of President Obama at the controls of a DaVinci Surgical Robot, one of the world's most expensive medical innovations at $1.75 million apiece. Paul Levy, at Running a Hospital explains why every medical center feels pressured to spend the millions of dollars the devices cost just to stay competitive.  

AND FINALLY ...

The winner of the "BEST IN SHOW" Trophy:

Rusty, who lives at Suture for a Living, is one of the medical blogosphere's beloved mascots (along with a certain lobster and some llamas). Rusty is a contestant in the Top Dog in Arkansas Contest! You can vote for him (registration required) at the Arkansas Democrat-Gazette's website from now until August 26. Go, Rusty!




Thanks for visiting! If you would like to host a future edition of SurgeXperiences, contact Jeffrey (our fearless leader) here. Be sure to submit for SurgeXperience #304 using the carnival submission form. Past posts and future hosts can be found on our SurgeXperiences index page.

Technorati tags: SurgeXperiences, blog carnival.

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The following is feedback received for this blog: I think it is terrific the way in which you used the opportunity to teach additional non textbook info. Also..that you are nonjudgmental and compassionate. Having lost Mom this past April.. I sincerely appreciate this comment from your previous commentator "Previous family deaths have taught me that the intense pain does diminish but it never diminishes the love for your loved one. As time progresses, memories will come in stages as painful, then bittersweet, then as soothing and delightful. " If it is alright with her I may quote her. Certainly I am putting it in my drafts. :) - SeaSpray seaspray-itsawonderfullife.blogspot.com Thank you for allowing my submission and your kind words Dr Campbell. You did a great job with Surgxperiences! Quite clever using the *dog* days of summer and loved seeing Rusty in the pics. :) I am going to borrow son's lap top so I can kick back and do some reading in comfort. Lots of good reads here! Now I shall link. :) - Seaspray Great edition! Thanks for the vote for Rusty! - rlbates http://rlbatesmd.blogspot.com/

SurgeXperiences 303 (Aug. 9) will be hosted right here! The deadline for submissions is midnight on Friday, Aug. 7.  

SurgeXperiences is a blog carnival of surgical blogs. It is open to all (surgeons, nurses, CRNA's, anesthesiologists, ORT's, patients, etc.) who have a surgical blog or article to submit. 

The last time I hosted, I waxed poetic. I can’t predict what will happen this time.

If you are a blogger, be sure to submit your post via this form.  If you would like to be the host in the future, please contact Jeffrey who runs the show here. To view the catalog of past SurgeXperiences editions, click here.  

Come back next Monday and read the best of the surgical blogosphere for and by people who spend time in the operating room!