Wednesday, July 7, 2010

On surgeons and being nice

"Nice doctors kill people," the surgeon told me, apropos of a question I'd directed elsewhere.

He explained: when doctors spare their patients pain by skipping tests or aspects of the physical exam that are uncomfortable, they end up harming the very people they'd set out to help. And he has a point: If you don't palpate an abdomen because your patient has belly pain, you could miss a surgical abdomen, and your patient could die (this resembles something that happened recently on the pedi ward, although I don't think that death was preventable; but that was the version of events that happened in the responsible resident's head).

But I wondered: can't you be nice and competent at the same time?

Sometimes I think, yes, of course, the best doctors are those who are nice and who listen and explain things clearly and give an encouraging smile before leaving the room. With something as complex as health, in which the power of the mind is startling and patients' outcomes have more than a little to do with their attitudes, being nice may actually heal.

But, I do understand his point. And the more I work with surgeons, the more I get it: being nice doesn't take you very far if it means you skip more tests or spend less time learning about more effective treatments and procedures or pay less attention to the detailed nature of your daily tasks. There's only so much time for learning and teaching in one day. If you're the average patient, you don't want a doctor who will scream at you, but you really don't want a doctor who doesn't know enough to perform procedures well.

So, while you can always be nice, and there's no justification for flat-out aggression, there probably is some trade-off between niceness and competence.

And it might just be that I've spent the last two weeks walking amongst them, but I'm feeling more like an asshole surgeon every day. What do I need to know before walking into the OR-- the name of the patient, or the name of the procedure? Well, it would be nice to know the patient's name, but as a surgical student, what's more important is the procedure. And I kinda like working with assholes: at least you know where you stand, and you know you can push back and have that be perceived as strong rather than pushy.

This probably has a lot to do with my background of being a nice person with a focus on the more behavioro-psycho-social aspects of medicine. Coming from a place in which surgeon is a dirty word (a figurative place, that is; wouldn't want to implicate of my previous places of learning), I can only be pleasantly surprised by the surgeon's perspective as I learn to adopt it. Competence, after all, is what any patient wants more than anything else that his or her physician might offer.

So, another realization in the road to medical knowledge, and another goal: to find the right balance between competent and nice.


Che said...

I wish that the surgeon who I used last winter would be a preceptor - he was SO GREAT at being nice AND competent. He was sort-of abrupt, but not rude. I mean, he certainly didn't have the time to sit and chat like my doctor at the headache clinic does (ha ha... 'cause sitting and chatting is TOTALLY gathering clinical information when you're a neurologist, but not when your a urogyn surgeon!), but he explained the procedure thoroughly, and he calls patients at home after surgery to see how they are, and make sure pain control is good, and all that. He wasn't that old, maybe early 40s, so, you know, it's not like it takes a lifetime to find the balance :P

Rica said...

That's awesome... good to keep in mind that that's possible. Maybe "nice AND competent" should be my new mantra, to be repeated a few times before walking into the patient's room.

D Moo said...

i love this reflection, and something on my mind a lot during training. I don't have an answer, but i have gotten to maybe some similar conclusion (1) it is really important to do the right thing (clinically, ethically, and as a human being who connects to other human beings) (2) some people can do this while being nice, and others by being cantankerous fart faces (3) but point 1 and point 2 appear to operate independently of each other. Some patients even really like cantankerous fart faces! Admirable master clinicians seem to come in lots of flavors. None of them are totally abusive, but its ok to be nice and its also ok to not* be charming. Being authentically dopey smiled/fart faced while working so hard on point 1 is really challenging. the dream is they some day reconcile to be you, future awesome doctor. (for some reason i looooved the surgical culture. although abrupt there is something very romantic in that warrior no-nonsense approach to things. it felt oddly comfortable, maybe bc it was so clear to read everybody)

Rica said...

Ha- you're right, there is something romantic about the "don't worry, I'll fix you [*and whoosh, I'm gone*]" sort of patient interaction.

It's totally baffled me that some people seem to love it when doctors are brusque with them, but, well, the customer is always right.

Let's see how I do with a full 8 weeks of surgery! That post was written after 2 weeks of sub-specialty. Aaaand, go. Hope you're well!