I am a surgeon. I am not an orthopaedic surgeon. I recently returned from ten days in my hometown, helping my eighty-year-old mother through a total knee replacement. The first three days of this experience were dreadful. I knew that they would be difficult medically, but I was not prepared for the impotence and rage that I experienced in attempting to obtain information and support from her surgeon.
Despite the fact that I am as medically sophisticated as my mother's surgeon, I was unable to get him to talk to me. He stood in the family waiting room ten feet away from me and said, "We're finished. She's fine and going to the recovery room." I tried to ask questions as he edged toward the door. I wanted to know about the operation, postoperative management, and pain control. His demeanor clearly said, "I have no time for you. My job is done. Don't bother me." He would say nothing else. Perhaps my mother received some of that information before the operation, but how likely was it that an eighty-year-old, immediate postoperative patient in pain was going to be able to transmit all that information to me, her out-of-town designated caretaker for the next ten days?
I had what I considered a surgically sophisticated concern about removal of the skin closure over a joint on the third postoperative day. I wondered whether this was a matter of convenience or medically indicated. Clearly, I was worried about wound dehiscence. He would not explain why he thought that this wound would stay together. Rather, on the first day after the operation (the last time that we saw him before my mother was discharged from the hospital) he said, with obvious irritation, "Sometimes we leave sutures in for a month; sometimes I just Steri-Strip the wound." Not a very scientific response. Finally, the fellow explained that the subcuticular closure was very tight and, although he did not know the surgeon well, he assumed it would probably be fine.
The major reason a patient elects to have a joint replacement is pain, and that also is the patient's primary concern in the first two or three days after the operation. When we asked about pain control, the surgeon said, "I don't worry about pain. If the patient has pain he or she will take a pill." He could have said, "I care very much about your pain, and I will do everything I can to keep it to a minimum. Pain cannot be eliminated totally, but the anesthesia pain service and I will do everything possible to help you."
On the first postoperative day, we asked how long the acute pain from the spasms in the quadriceps muscle would last. He said, "Nine months." He could have said, "Your acute pain will decrease dramatically every day. You may have pulling in the muscle, but this severe pain will be short-lived and we will see what we can do to ease it."
My mother's surgeon was treating a joint and an incision. He was behaving like a technician. We needed a physician. I, another surgeon, was uncomfortable with the information that I was given and was distressed at the information that I was not given; the situation would have been worse for a medically unsophisticated family.
A prominent cardiovascular surgeon who works at my institution said to me, "Parents bring their children to me for my surgical skill. If I do not relate to them well, they don't mind." He is wrong. Healing takes more than surgical skill. The heart muscle or valve may heal, but scars from an emotionally difficult recovery, unsupported by the surgeon, may never heal.
In contrast, I spent a day in a family waiting room with a friend whose mother was having a craniotomy for a tumor. The neurosurgeon came in with news of an aggressive incurable tumor. He was warm and willing to answer questions. He was able to hug a tearful daughter. When he left, the diagnosis was still bad, but there was healing in the room and a sense that there would be support for the difficult journey ahead.
Healing is different than fixing. Healing is a complex process that has many components. The patient is not alone in his or her need for healing. The patient's family, and we surgeons, are also in need of healing. Through the relationship that we form with our patients, we can create an environment in which healing takes place for the patient, the family, and the physician. Let's start with the patient.
There is an abundance of evidence that attitude affects healing4. Anxiety and depression have a negative effect on healing. In primitive societies, belief systems can lead to illness and even death without any apparent medical cause2,3. A patient who feels supported and cared for is in the best possible condition for healing. In the history of medicine, before modern technology, the laying on of hands was an important part of healing. It still is. The physician who is able to hold a patient's hand, to touch a shoulder, to hug a grateful or sad patient creates a healing environment.
Family is an essential part of the healing process. Few of us live in a vacuum, and most patients have someone who is concerned and whose state of mind will have an impact on his or her healing. This is more noticeable with children and elderly patients. Patients may not be able to understand explanations and instructions in the postoperative period and may need a great deal of family support in the healing process. A physician who communicates well with the family has an advocate and an assistant in the patient's recovery. A concerned family member who understands the medical issues can keep a disoriented patient from climbing out of bed, prevent a patient who is supposed to have nothing by mouth from eating, and ensure that postoperative medications are taken correctly. A family member who is considered an irritant and a waste of the surgeon's time is less likely to be an adjuvant to healing.
When a patient has an operation, the family is wounded. With even the simplest, shortest operation, the family hurts. Their worry about their child, parent, spouse, or friend is draining. A caring physician who is able to listen to a family's concerns will help that family to heal, and the family can then help the patient to heal. An anxious family dealing with an impatient surgeon remains anxious. This anxiety is transmitted to the patient, and healing is impaired.
Although physicians rarely acknowledge it, we can also be wounded. We work in a high-stress profession. Measurements of surgeons' vital signs during operations show that we undergo substantial stress even during the most routine procedures1. Even more difficult are the stresses of an untoward result, a rocky recovery, an intraoperative disaster. Surgeons too must heal.
When we create a healing environment for the patient and the family, we create one for ourselves as well. When we let them know that we are hurt by a bad result and that we find joy in a good one, when we give them the opportunity to tell us how much our concern means to them, when we accept the hugs that they offer, when we indicate—by not distancing ourselves—that we want to hear from them, we allow them to help us to heal.
My mother's surgeon understood none of this. He saw a joint and an incision instead of a person and a family in need of healing. I am sure that he left his encounters with us angry and frustrated, as we were clearly not happy with him. He was having a bad week, just starting to operate in a newly acquired hospital, running between locations. I am not unfamiliar with those stresses. Had he stopped for a few moments and shared himself as a person, his week would have been better. Had he treated the people and not just the knee, he would have left us feeling supported, if not free of pain and anxiety. Everyone would have been in a state of healing, including him. It is the healing relationship with our patients that makes the tough weeks bearable.
I believe that giving the patient and the family a space in which to express their concerns, their needs, and their gratitude, and responding as a compassionate human being, is an essential part of our role. When we, as surgeons, show patients and their families that we hurt when they are in pain, that we rejoice with them when the results are good and grieve with them when the results are bad, we create a healing environment and everyone benefits.
Perhaps my mother's surgeon will read this and recognize his words. Perhaps he will recognize my name and choose not to read this. Perhaps he believes that detachment is necessary. I believe that we are wounded further by detachment and that it is time to grow beyond the notion that it is bad for a surgeon to feel for his or her patients. I think we know better today. I believe that some of the popularity of alternative therapies reflects a need for the humanity and concern offered by the practitioner.
We do not have to provide repairs alone. We can provide healing. As a surgeon, I understand well the stresses and demands of a busy practice. I also understand the rewards of the personal relationships, however brief, with patients and their families. This editorial is a call for those who are still detached and focused on the repair alone to try a different approach and focus on healing. The rewards are immediate and dramatic. The difference is real. I know. I've been there.
Carol Roberts Gerson, M.D., F.A.A.P.
Pediatric ENT, Limited
2308 North Lincoln Avenue
Chicago, Illinois 60614