The patient, in her late 50s with failing kidneys, had come to the hospital for what she and her doctors thought would be a simple procedure preparing her for dialysis. But instead of returning home the next day, the woman ended up in the hospital for nearly half of my internship. Her procedure went awry, she landed in the intensive care unit, and over the course of the next six months she returned at least a dozen more times to the operating room, all failed attempts to right what had gone so terribly wrong.
Her bed in the I.C.U. was in plain view to any doctor or nurse walking by. Even today, I can recall the sickeningly sweet odor of what had become chronic open wounds, the sounds of the bells and whistles of the small army of machines that kept her alive and the increasingly rancorous discussions between the lead surgeon and other clinicians as the months dragged on. The surgeon, ever more haggard, pressed on, convinced that one day he'd send her home. But the others — nurses, consultants and eventually the hospital ethics committee too — began demanding that her care plan be changed. They wanted to cease all life support interventions and begin comfort care.
One morning, I found the room empty; the woman had died. "She finally did it on her own, without any help from you-know-who," one of the nurses said grimly, a look of disdain flashing across her face. "That's the problem with surgeons," she continued. "Sometimes you guys do the most amazing things for your patients, and sometimes you just won't let them go."
That belief — that surgeons can be both Dr. Jekyll and Mr. Hyde when it comes to the doctor-patient relationship — has been embraced for generations by more than a few nonsurgical doctors, nurses and patients. Heroic in their devotion to patients when they are at their best, surgeons inexplicably seem to transform when they are at their worst. That worst usually comes on the heels of a high-risk operation and a complicated and protracted postoperative course. The nurses, other doctors and sometimes even the patient and family request palliation only; in response, the surgeon often stalls, hesitates or simply refuses.
Since the late 1970s, ethicists and social scientists have tried explain what they viewed as surgeons' paradoxical behavior with postoperative patients. One of the earliest researchers attributed to self-protection the surgical imperative to "do everything possible." Inevitably, this medical sociologist reasoned, all surgeons commit a technical error over the course of their careers. By doing everything possible "for the patient," surgeons protected themselves against the emotional distress of failure. The rationale behind this common-sense theory was straightforward: At least I did all that I could possibly do.
More recent researchers, however, have suggested a more high-minded, almost theological explanation. With unintended irony, they propose that the surgeon's view of the doctor-patient relationship is similar to biblical covenants formed between God and his people. I will not abandon you — this theory contends — and I will battle to the death for you.
All of these allusions are intriguing, but none of the research has ever focused on the surgeon-patient relationship before the operation, on the period of time when the commitment is actually forged. By overlooking these critical moments, the earlier studies fail to address what is perhaps the most perplexing question of all: how could any doctor, surgeon or otherwise, be so confident about pushing for more when the patient and the patient's family seem to be calling for less?
A study published this year offers an interesting possible answer.
With support from the Greenwall Foundation, researchers from the University of Wisconsin in Madison and the Medical College of Wisconsin in Milwaukee asked a small group of doctors involved in high-risk elective operations about withdrawal of life support, advance directives and informed consent and presented clinical scenarios that involved withdrawing care.
In interview after interview, the surgeons referred to a negotiation and agreement — what the researchers called "surgical buy-in" — that occurred during the consent process, long before these doctors and their patients ever entered the operating room. The surgeons believed that patients not only consented to the operation itself but also committed themselves to any care after the operation necessary for successful outcomes. They talked about the operation and postoperative care as being a "package deal" and about a tacit "two-way agreement" that included even well-articulated and well-defined numbers of postoperative days.
"Clearly, surgeons believe something significant is happening during the consent process," said Dr. Margaret L. Schwarze, lead author of the study and an assistant professor of surgery and bioethics at the University of Wisconsin in Madison. For many of the surgeons, dealing with complications was an important part of their work, and they wanted their patients to have a full understanding of all the challenges involved before the operation.
"All of the postoperative challenges are tied in with the operation," said Dr. Karen J. Brasel, senior author and a professor of surgery and bioethics at the Medical College of Wisconsin. "Surgeons don't want to invest themselves in a relationship and a technical tour de force, then have to walk away."
But while the surgeons believed they conveyed this information clearly during preoperative conversations, the patients probably heard only part of the story. "It's entirely possible that patients are missing this part of their early interaction with surgeons," Dr. Schwarze noted. Patients may be overwhelmed at the prospect of a high-risk operation and focused solely on getting through the operation alive. "The operation is already a lot for patients to take in. I don't know how much it occurs to them that there may be something worse than survival."
The result, unfortunately, is the familiar, and potentially devastating, misalignment of surgeon and patient expectations.
While the researchers concede that their current work is based on a small sampling of surgeons, their findings have garnered the attention of palliative care experts. Over the next few months, they hope to complete analysis of a survey involving more than 900 surgeons across the country and begin a second study focused exclusively on the perspectives of surgical patients.
"Surgical buy-in is a real phenomenon," Dr. Brasel said. "It is not inherently bad, and it may even be ethically necessary for surgeons to do what they need to do. But it doesn't preclude patient autonomy, and it doesn't preclude palliative care."
She added, "It just has to be understood from the context of a two-sided relationship, as all relationships are."
