[Sent – 10
November 2018 to the 170+ surgeons et al of our Surgical Ethics (Education) Consortium]
Good evening. For my ‘Surgical Ethics Education Resources’ #8 communication, I have inserted below a brief fictional narrative of a young practicing surgeon (with two accompanying language matrices). The brief fictional narrative is a compressed presentation of the conclusions from my attempt – as an anthropologist doing field research – to understand the ethical resolve and the ethical vulnerabilities of the physicians and surgeons with whom I have been privileged to live/work for the past 30+ years. I did the first draft of the narrative and language matrices as the heart of a grand rounds presentation I was invited to deliver in 2000 for the Johns Hopkins Department of Obstetrics and Gynecology honoring their colleague and my close friend Tom Elkins, MD, the department’s recently deceased chief of gynecologic surgery. I have frequently revised the narrative and language matrices incorporating the critical feedback from numerous medical students, residents, teaching faculty, and practicing physicians/surgeons. I welcome your questions and observations. You are free to use the narrative and accompanying language matrices as you think might be helpful in your surgical ethics education efforts. Doug
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What does it mean for a practicing surgeon to be ‘ethical’?
Douglas Brown, PhD
Consider the intentions and the struggles of a young surgeon in her first years of practice after residency. Let’s call her Stephanie. Stephanie is the youngest and newest member of a team of surgeons whose practice is administered by a for-profit management company. She joined this practice with the assurance she would be fully supported in her deeply-rooted resolve to care for her patients in the most beneficial and cost-effective way, with special attention to socio-economically disadvantaged patients. She quickly discovers that numerous competing interests and expectations – some professional, others personal – pressure her to shift her focus away from her patients and their interests.
Stephanie begins most days poised to be empathetic. She is prepared to give disproportionate attention to her more vulnerable patients. She is ready to open herself to her patients’ suffering to the point of risking burnout. She intends to be meaningfully present with her patients. She grips firmly her integrity. She gauges her capacity to tolerate the moral dissonance she experiences from value clashes with some of her patients. She seeks to grow professionally for patient benefit as much as for personal security. She feels a nagging tension between her lifestyle interests and her accountability to her patients.
Stephanie would violate her integrity if she refused to look beyond each patient’s presenting problem. She has already seen far too much. However, she accepts that she is not yet one of those rare surgeons who seem capable of saying “yes” to every deeply pained patient and enter yet another broken story. Fatigue, accountability to her other patients, administrative obligations, research protocols, teaching assignments, family responsibilities, reimbursement pressures, personal interests apart from medicine, and a host of other considerations force her to limit many patients’ access to her time, her energy, her heart. Instead, Stephanie triages her patients carefully to sift out the encounters in which she will enter more deeply into the patient’s story, in which she will make and impose on others the sacrifices to be fully present with the patient.
Especially on her most exhausting days, Stephanie might glance enviously toward the many flourishing surgeons for whom the medical environment is most fertile. For these surgeons, a patient encounter is a sale; the patient, a consumer. Some are entrepreneurs. Lifestyle incentives motivate them. Others are researchers. Innovation and publication motivate them. Stephanie knows these surgeons subtly sift out difficult patients from their panel of patients. They stay sufficiently detached from patient suffering to avoid any risk of being burned out. They have learned to make patients think they are present and care. They turn professional advancements into marketing tools. They lead unreflective lives. They have an easy conscience about at-risk patient groups. But Stephanie is not seriously tempted to join their number.
However, Stephanie is troubled by how often she ends the day wearily thinking of the next patient as one more demand; thinking of herself as a mechanic. She ends many days numb toward patients and tired of confronting the healthcare delivery system. She feels acutely the loss of important family experiences as she does her job. She often sees little evidence that she is making a difference in the lives of vulnerable patients. She finds herself becoming apathetic to patient suffering as the day’s paperwork drains her. She feels ambivalent toward patients for whom she has a dimming vision. She senses that her struggle to stay current with advancements in her specialty is posing subtle risks to patients. She is haunted by the look in her child’s eyes, a look that asks, “Mom, do you care more for your patients than you do for me?” She can sound defensive. She can look disheartened.
Surgical ethics addresses the vulnerability of surgeons such as Stephanie and the many other surgeons who finish residency without such a deeply-rooted, well-grounded resolve to care for all patients – including the most difficult patients -- in a respectful, beneficial, fair, and cost-effective way. Once in practice, they too often yield – some with initial remorse – to incentives to practice surgery in a comfortable and an entrepreneurial way that actually – if subtly – discourages them from being genuinely present with patients. They too often compromise their integrity. They too often lose any initial qualms with hedging their fiduciary responsibilities to patients. They too often are easy targets.
Most medical students who choose to pursue a surgical career are confident they will be ethically exemplary surgeons, humane with a resilient social conscience. However, they quickly feel they are being herded through year after grinding year of preparation. They are being trained, but not necessarily educated. They are under intense supervision as they expand/strengthen their knowledge base, as they become efficient in examining patients, as they learn to do procedures. From one stage to the next, they accommodate standards for identifying ‘good performance’ that may have little to do with valuing patients as individuals. They finish residency still feeling the effects of chronic fatigue, but anxious finally to be focusing on their own patients. Instead, for several more years -- among new colleagues and under smothering fiscal scrutiny – they struggle to find their own practice style, to get out from under enormous debt, to publish, to catch up on a long-delayed personal life. Do they receive sufficient incentives to give of themselves . . . to care deeply . . . to be truly present with their patients . . . to concentrate on the disadvantaged . . . to be reflective?
Ethics education for these surgeons is analogous to an irrigation system delivering nourishment to plants that would otherwise wither.
(See below a language matrix that differentiates four common professional identities found on a spectrum with “I could not care less” at one end and “I could not care more” at the other end followed by a language matrix that probes the struggle to retain integrity.)
Matrix 1
Matrix 2
