Larry Zaroff, MD, PhD
Stanford University, California, United States (Summer 2009)
I once made a technical error that injured a patient. An error of commission. Distressed, I wrote to several cardiac surgeons with whom I was acquainted through training or practice. I asked if they had made similar mistakes and how they were dealing with their mistakes. Were they embarrassed, ashamed? Did they feel guilty? Had they lost confidence? How did they manage to go on to the next case? Did they simply accept errors as part of life, whether in cooking or driving or operating? Some might say “that’s cardiac surgery,” and move on. Others, I suspected, would bleed and then go on. I recall one famous general surgeon, no longer young, but quite capable, who divided the blood supply and biliary drainage to the liver with a single slash. The patient died. He walked out of the operating suite never to return. Every mistake would, must, leave some sort of mark. The mark might be acceptance as a lesson, never to be repeated. Or the mark might be erased by blaming the error on a resident or nurse or the patient. Over time the mark might fade. Or the scar might deepen, or persist, as in my case.
Surgical training, even in the present era of an eighty-hour work week—rather than the previous unlimited toil—remains robust. The surgical resident must make rounds early, often starting at 5 am, review x-rays and lab results, then escort the attending surgeons on his inspection of patients. He, now more frequently a woman, would then spend most of the day in the operating room. The evening work becomes a repeat of the morning, plus the chore of admitting new patients and dealing with emergencies. On-call duty might mean more trips to the operating room. The physical strain, even to the young, is real, cumulative, leaving little time for relaxation, family, or study. The mental pressure to please the senior surgeons, the chief, the nurses, and the patients is greater. At an academic center or university hospital, residents are expected to be productive, writing papers and presenting data at meetings. Moving up the residency ladder to become a chief resident depends on performance. No mistakes are forgiven; they are noted, never hidden. Communication is swift among doctors, especially referring doctors. Like a bad meal in a restaurant, revisits are unlikely. Mistakes, even small ones, can cause great harm to patients and to a reputation. Forgiving is not, never.
Surgery at good institutions with well-established training programs, which are approved by accrediting agencies, and which provide sufficient cases to allow a young surgeon to eventually operate safely and independently are demanding. The programs at such institutions teach more than surgical technique. Preoperative and postoperative care are discussed; complications are studied; and laboratories develop new knowledge. Statistics are maintained and analyzed. Weekly morbidity and mortality conferences are conducted in which the entire surgical staff is present. The cases are discussed openly for both teaching and chastising. Alternatives in approach, evaluation of pathology, surgical maneuvers, and use of consultants are mentioned. Was the error unavoidable or due to bad judgment? No surgeon admits to tiredness. Everything else possible to improve surgical results and care is given light. Praise is not prevalent. Excellent results are expected, even demanded. A heroic operation that rescued a patient with a ruptured heart following an auto accident is not mentioned. Approval and praise is to come from patients and families, not from other surgeons. It is considered unseemly to give kudos for a good result. Satisfactory outcomes are expected.
What is never mentioned, never considered, never thought of: the feelings of the doctor who made an error. The wounded surgeon, like a wounded patient, sits in pain. The remorse is increased. What is the gain? Theoretically the punishment of humiliation is designed to mark the surgeon and the others in the room so that they never make the same mistake. But any reasonable person or surgeon does not forget serious errors–the consequences are too great.
Compassion and empathy and forgiveness are neither mentioned nor taught. They are not given voice publicly or privately, directly or by example. How can we expect our surgeons to be compassionate and empathic to their patients if they are not treated so, if they see no examples, no value, no time spent? How to explain this lack? I suspect we surgeons regard ourselves as macho, powerful, god-like. Caring, generosity, and compassion to each other are regarded as weaknesses. The public, too, enhances our identity as superior, extraordinary. And we like the feeling until we make a mistake.
My training at two great institutions of surgical practice—known for their high standards and their excellent results, famous for their doctors—over a period of seven years did not teach me compassion or forgiveness toward neither other doctors nor patients. When I made a mistake, at best my standing was silently lowered, or worse, I was admonished, sometimes in front of colleagues. I brought this attitude with me after completing training and entering private practice. I was critical of all, nurses, administrators, and other doctors out of their hearing, anyone who did not do things right, my way. I was a prisoner of my training.
In my first week in my new practice, I was called to the intensive care unit to supervise a resuscitation of a cardiac arrest. No one was doing anything the way I was taught. I yelled at anyone trying to help.
When the emergency ended, unable to restore a heartbeat, I listed all the mistakes the staff had made. I was not adored for many months after that episode. Years later, the nurse whom I had worked with that day referred her father to me for a lung resection. He did well, and the nurse and I became friends. Only then did she tell me what an ass I had been. She said, “I had the intravenous bottle, glass then, in my hand, held over your head. I was restrained only by the patient’s welfare.” I treated the staff the way I was treated. Cooperation was harder to come by after that day. I learned, eventually, that nurses are the most important workers in a hospital, the most caring, the ones who first notice faltering of patients. The nurses are the first to initiate therapy and notify the doctor.
That was an early lesson—never embarrass or criticize those with whom you work, no matter their status. However, I remained insensitive to the needs of my associates, unconsciously thinking they too were powerful, not in need of my support. I certainly did not need their assistance to prop me up if I had lost a patient or had a bad result. Nor did they ever offer me comfort. Only many years later, after studying outside of the surgical literature, entering a program in the humanities and reading widely, did I come to understand how I had failed my partners.
The senior partner in our group was well trained, a bright and conscientious surgeon with a superb record. He was, however, like most of us, cool and controlled. In the fifteen years we had worked together, he never asked me for anything, certainly not for advice or commiseration. This changed once and for the only time, when he walked out of the operating room to talk to me. I hear the slow drum of his voice now. He was walking down a new path, entering an unknown grotto as he said, “I was doing a pneumonectomy on a young woman for an extensive cancer of the lung. I did what I always do, placed two ties around the pulmonary artery (the major artery supplying the lung) before dividing it. After I cut through the artery, freeing the lung, both ties slipped off the artery. Within seconds she bled out. Died on the table.” My response, the words more vivid in my memory than his, was, “I never settle for two ties. I also put two sutures through the artery so the ties don’t slip off.” He looked up at me and said, twice, “I was hoping for sympathy.” I turned away, thinking that sort of error does not deserve sympathy. We, after that event, never talked of our personal lives, just the profession, just business. When I finally realized my failure, he was ill, dying. I missed my chance.
I have tried through my teaching for redemption. I believe through narratives—from the words of perceptive writers—compassion and empathy can be learned. Essays, plays, novels, my own experiences help students to see the importance of empathy and compassion and caring and generosity in medical care. Much harder to pass on to students are the lessons of forgiveness: to others first, and then, even more difficult, to ourselves. We can forgive ourselves if we admit to our mistakes, are honest with our patients, learn from our errors. We can forgive ourselves if we do everything possible to avoid injury to patients, don’t proceed beyond our training, communicate with patients. Then we can, over time, forgive ourselves.
has had five careers following his residency and two years in the U.S. Army Surgical Research Unit. He focused for 29 years on cardiac surgery, including a stint as director of the cardiac surgical research laboratory at Harvard. There his work centered on the development of the demand pacemaker. He spent the next 10 years concentrating on climbing and did a first ascent of Chulu West, a 22,000-foot peak on the Nepal-Tibet border. His third life has been at Stanford, where he received a PhD in 2000, and where he teaches courses in medical humanities. His fourth career has been as a writer for the NYT science section. He now works one day a week as a volunteer family doctor. He has received awards as the outstanding faculty advisor for the Human Biology program and in 2006 was honored as Stanford’s Teacher of the Year.