FIVE LESSONS AT FIVE (PART 1)

Sometimes back I was invited by my alma matter to the annual convocation cum freshman dinner. While thinking on what remarks to make, I thought of reflecting on the first five years as a consultant and what life lessons I have learnt that may resonate with a new consultant setting out for work. That speech did not happen, so my thoughts remained as thoughts. In a month or less, I got into a conversation with former schoolmates on the sidelines of a scientific conference. One of the stand out observations was how time was flying since we have been out of training. 

‘ I cannot believe it has been five years!’, I said. 

‘I cannot believe it is already 10!’, another observed. 

I got back from that conversation wondering, what are the lessons I have learned on the surgical streets during those 5 years? 

I christen them five lessons at five, what young consultants would love to hear as they hit the ground running. 

1. IT ALL CHANGES FROM BLACK AND WHITE TO COUNTLESS SHADES OF GREY

This is also known as the middle ground. I was sent into the field to be an evidence based surgeon.That is like an extremist. I hit the ground running. I expected that the other support health departments would do their work to augment the surgical service. I expected an intensivist in the critical care unit and extensive diagnostic support. Then I found myself doing the real critical care: prescribing and adjusting the ventilator settings in the ICU, linking my procurement department with relevant industry players for a commodity supply here and there, making phone calls and sometimes driving to Wells Fargo office in town to pick and return donated surgical power devices to ensure that hospital transport processes did not inconvenience the magnanimous industry donor already pressed to have the gadget in another corner of the country the next morning. Well, I also found myself reading almost all the scans and evening signing off reports under the ‘radiologist’ section for patients medical reports.

I had always hated the rhetoric of answering every clinical question with the disclaimer “In the Ideal setting…..”. That is why I had sought training in a private top of the range facility that is arguably the best around. But here I was, meeting the hostile ground and learning street smartness really first.

You meet a patient  and prescribe what is text book treatment (and surgery) for the confirmed diagnosis. The patient tells you you can go hang, they will only have that surgery over their dead body. You invite them to try the disease and face the wrath of its morbidity and mortality. Sometimes you splash flash cards full of survival curves and other prognosis digits. The patient walks out on you. You close the file and move on to the next patient. Almost certain there is nothing salvageable about them. The patient walks back one year later. But you said they would be dead in 9 months? The disease is still at the same stage, and they are ready for the surgery. You swallow the humble pie and go operate. Then the patient recovers and goes home. Lesson learned: you treat the patient when they land at your door, whether early or late in the disease process. You have got no right to be mad at them for delaying the health seeking behaviour, or seeking alternative medicine.They are the ones to decide which and when treatment is best for them, not you. 

I graduated knowing 5 year survival rates for numerous cancers. Always able to quote what percentage of patients would be alive in five years based on the nature of their cancer. Then I kept encountering worse cancers on paper living for long, and earlier and less aggressive cancers taking the patient sooner than predicted. The same goes for complex operations where the patient recovers impressively quickly and some with simple surgeries suffering complications.

I now cherish the wisdom of my late mentor and teacher when that survival question once arose. It was of a male in his 30s diagnosed with advanced stomach cancer. Him having been adept at asking the question of ‘what does the data say?’, I had expected him to tell the patient that five year survival for metastatic linnitus plastica was less than 5% at 5 years, or 12 to 18 months.  He did not. He embraced perfect vagueness. 

“All we can say is that as it stands now, as doctors we cannot promise to cure the cancer. As for how long he will live, it is up to his body and his god.” 

“Offer a guarantee and disaster threatens” so reads an ancient inscription at the Oracle of Delphi. 

The human body is a complex biological system that surprises us every single day. The frustrating thing is that we only know what we do not know in hind sight. Treatments that we held as best practice years back keep being proven ineffective or even harmful. 

I now say what I know and let the patent still make their free decision. It is not my responsibility that the patient chooses the evidence proven intervention. It is my responsibility to let them know what evidence so far says about what they suffer from and how to help them. If the patient says ‘thank you but I am sorry I will not be taking that option’, I thank them and give them my card. They can always call in case of change of heart. 

The text book teaches how to be an extremist. How to look at the best way to handle the case at hand. But medicine seems to be a delicate diplomatic circus or a tight rope democracy. What I thought were Contingencies in the surgical text book seem to be critical factors in every decision making. The culture, the language barrier, the cost, the taboos. The list goes on and on and on. It looks clear cut until those factors are placed on the table. The middle ground seems the only safe ground.