Gray Matter

by Kilpatrick, Joel;Levy,David

  But this day was entirely different for me. Pre-op was as busy as ever when I walked into Mrs. Jones’s area. She was lying on her gurney, the rolling stretcher that would transport her to surgery. The attending nurse looked up as I entered. If you’ve ever been in surgery or attended someone about to undergo it, you may already know that in pre-op there are not rooms as such, but bays separated by thin curtains hanging from shower-style ceiling tracks. You can hear everything that’s going on in the neighboring bay, including the blather from the televisions hanging from the ceiling in each stall and all but the quietest conversations. Privacy is minimal and mostly imagined.

  “Good morning. How are you today?” I asked Mrs. Jones as I stood next to her gurney.

  “A little nervous, I guess,” she said, her smile clearly tinged with anxiety. Her two young adult daughters stood nearby, saying nothing and observing me intently, arms folded. One of them smiled faintly in my direction.

  I began to go through the brief presentation I give to patients on their way to surgery, reviewing her case, the possible outcomes from the procedure, and our desired outcome. Yet inside my chest, my heart was hammering so hard that, at least in my ears, it competed with the general din of pre-op and the sound of my own voice. Now that I was here, in the room with an actual patient, the idea of introducing prayer and spiritual matters seemed far-fetched and even dangerous. There was no telling how Mrs. Jones or her daughters would react. I continued on, working hard to make sure my feelings weren’t noticeable as I went over my notes with her one last time. As I spoke, Mrs. Jones nodded that she understood. Thankfully, she didn’t seem to notice my inner agitation.

  Strangely for a perfectionist like me, I had not thought about when or how I would add prayer to my routine. Somehow I figured I would do it on the fly or perhaps feel inspired at a certain moment to offer to pray. This lack of planning now struck me as a major mistake, like going onstage without ever looking at a script. I had checked her admission form and seen that her religion was listed as “Protestant.” That gave me a bit of a safety net if I jumped off this cliff. She would at least be familiar with prayer. If I had seen “None,” I might have canceled my plans. That would have been too much risk for my first time. I was also concerned that the nurse, who was still preparing Mrs. Jones for an intravenous drip, was not leaving. I had made a firm decision that I was not going to pray with anyone else around. To be honest, I was scared of letting anyone else in the hospital know what I was about to do. I would wait until I was alone with Mrs. Jones and her daughters. Only then would I perhaps be able to summon the courage to ask her.

  “We’ve already talked about the risks of the operation,” I continued. “You will have a small puncture site in the artery when we finish. I’ll be going up into the brain to repair this aneurysm . . .”

  As I spoke, I drew out the explanation and spoke more slowly than usual, hoping that in the meantime the nurse would leave so I could carry out my plan. But the nurse seemed in no hurry. She was well occupied with her checklist, taking Mrs. Jones’s blood pressure and temperature, hooking her up to a vital signs monitor, and recording her medications. Nurses in pre-op always have checklists of tasks to carry out. The list can vary in content and length depending on the surgeon, the procedure, and the anesthesiologist. It usually includes such tasks as checking the patient’s belongings, making sure the patient is not wearing false teeth, eyeglasses, or jewelry when he or she goes to surgery. They ask if the patient is pregnant, has had the flu recently, or is allergic to any medications. They might even draw blood for labwork or get an electrocardiogram (an EKG) to check for any problems with the heart before we put it under stress. Today, this nurse slowly moved from one task to another with no sign of finishing. I kept glancing over at her, waiting for her to wrap it up, but it almost seemed that she was working against me.

  Mrs. Jones nodded after my presentation was finished. None of this was new to her, or to me. I tried to think of something else to say to extend the conversation. All I could come up with was the typical capper: “Do you have any more questions?”

  I looked at her daughters hopefully. Doctors often hate getting questions in the rushed moments before surgery, but this time I was soliciting them as best I could with my open expression.

  “How long will it take?” one daughter blessedly asked.

  “That’s a good question,” I said, preparing to give a lengthy answer. I shot a brief look again at the nurse, who tapped obliviously on her keyboard, entering more data into Mrs. Jones’s computer records. It was as if we were competing to see who could outlast the other.

  When I had finished my explanation, managing to consume several minutes with a vague answer that explained the various factors preventing me from making a firm declaration about the surgery’s duration, still the nurse was not finished. My heart was nearly in my throat now. In addition, I felt the distress of having failed to carry out my purpose to pray. But I now had no other reason to be in the room. If I overstayed, Mrs. Jones and her daughters would begin to wonder what was wrong.

  I smiled with disappointed finality.

  “Great. If there are no more questions, I’ll see you after the procedure,” I said.

  “Thank you, Doctor,” Mrs. Jones said. I turned to go and glimpsed the nurse slowly rubbing alcohol on Mrs. Jones’s arm in preparation for the IV. I felt momentarily like ordering the nurse out of the room—I was, after all, the senior medical professional. I wouldn’t even have to give an explanation. This action would have been too disruptive and unusual, though, and would call too much attention to what I was doing. Instead, I admitted defeat and ducked through the curtains. Frustrated, I stepped back into the main pre-op room.

  In spite of being tempted to breeze out as I had so many times before, I decided not to give up. To buy time, I wandered slowly over to the central nurses’ station, the vibrant hub of the pre-op area. I took in the computers, stacks of papers, charts, wheeled carts, long desks, cabinets full of records and various other administrative paraphernalia. Nurses came and went on their various assignments. I felt awkward being there without any clear purpose, but I had made up my mind—today was not going to be a normal day. I was going to at least ask Mrs. Jones if I could pray for her. I would conquer my anxiety. Somehow, against all my fears and all practical obstacles, I was going to make it happen.

  * * *

  For years the idea of praying for patients before surgery had hounded me. I’m not even sure when it first occurred to me to try, but over time the feeling swelled from a ripple to a tidal wave. I had prayed privately during difficult moments at surgery, usually under my breath, as many doctors do. I had even prayed for cases in private, before surgery. But to pray audibly and in the presence of a patient was something very different. I had no point of reference for doing this and could not imagine what prayer would look like in a medical practice. At what point in the process would I bring up the patient’s spiritual journey? Where would it happen? What would it look like? How would I initiate it? What would I say? The logistics escaped me. Textbooks never addressed it. Nobody I knew modeled it. For me, this was completely uncharted territory.

  In all my training and in practice, I had never seen a physician pray for a patient or acknowledge God in any way, unless you count the “Oh God” muttered when bleeding shot out from a totally unexpected source or could not be stopped quickly during surgery. Surgeons are generally not, by nature or reputation, spiritual people. Even beyond their spirituality, or lack of it, surgeons pride themselves in being scientific, not touchy-feely. It is almost as if the medical training shapes us into the same mold, and when we receive our license, we also don new personalities that fit the standards of our breed. The surgeon’s motto is “heal with steel.” The subject of God or religion comes with a certain tension when it is merely brought up in the hospital, let alone associated with outcomes. Surgeons dislike the mystical. I felt that broaching the subject with patients would seem as bizarre to my colleagues as m
y bringing a crystal ball into the room and recommending that we all consult it before surgery.

  To say that praying out loud with a patient before surgery would put me out on a limb is putting it too mildly. It would catapult me out of the tree.

  * * *

  During my many years of medical school, residency, fellowship training, and then out in practice, I have observed that many of my colleagues viewed people with religious beliefs as simpleminded. As for me, I was captivated by the power of surgery; compared to that power, faith seemed quaint at best, necessary only if there were no surgical options. When we had to delay surgery until a priest or rabbi arrived, we felt inconvenienced. When religious beliefs limited our options, such as the refusal of a blood transfusion on religious grounds, we saw it as a menace, a silly superstition.

  In medical school we had talked a little about what was called the “art of medicine.” This included the creativity to elicit the correct history, the insight to ask the right questions, and the meticulous attention to detail that would lead us to order the right test and thus lead us to the correct diagnosis. This method of diagnosis, which occasionally touched on areas of spirituality or emotion, was used much more in the days before CT and MRI scans. I had always approached this area of “study” with the idea that spirituality and medicine were weakly connected and could be explained by the placebo effect: if some people thought their faith would help them, then they would improve merely because they believed it. It was the same power I believed many alternative medicines had: the power of positive thinking.

  As I began treating my own patients instead of hypothetical patients in a classroom, I began to see my own carefully honed surgical skills fail to produce the outcomes I expected. I had faith in surgery and had given many years of my life to acquiring the skills necessary to do the most difficult operations. I had thought that if I could do a procedure perfectly, I would get a perfect result every time. I was wrong.

  It was out of the disappointment over bad outcomes—any bad outcomes—that I began to appreciate the connection between our physical and spiritual lives. I was growing in my knowledge of God and beginning to respect the spiritual world in my personal life. Though I still insisted that there was no place for it in the hospital, my opinion on that, too, slowly began to change. The line between the two areas blurred; my reasons for separating them began to crumble.

  Empirical evidence confirms the connection. Studies have shown that approximately one in five patients (19 percent) want their physicians to pray with them on a routine office visit;4 29–48 percent of hospitalized patients want prayer from their physicians;5 40 percent of patients welcome physicians’ exploring religious or spiritual issues with them; and only 7 percent do not believe in the power of prayer.6 An article in one medical journal states, “A large proportion of published empirical data suggests that religious commitment may play a beneficial role in preventing mental and physical illness, improving how people cope with mental and physical illness and facilitating recovery from illness.”7 Another journal article concludes, “Over 35 systematic reviews have all concluded that in the vast majority of patients, the apparent benefits of intrinsic religious belief and practice outweigh the risks.”8

  I could no longer ignore my impulse to offer patients more than just physical care, when there was much more to them than their bodies.

  Then the pivotal moment arrived. I found myself in a dentist’s chair on a Saturday preparing to have a filling replaced. My dentist friend, who had come into the office on his day off just to do this procedure on me, had the novocaine syringe with the long needle in his hand. Like most surgeons, I hate having the needle or scalpel turned on me. I don’t mind wielding it on others, but I’ll go to great lengths to avoid being on the receiving end of a sharp point. My dentist friend sensed my apprehension, put his other hand on my shoulder, and said a short prayer asking God to guide his hands during the procedure. A sense of peace washed over me, and I relaxed. The needle didn’t hurt as I had thought it would, the procedure went fine, and I went home feeling not just fixed but encouraged.

  That experience confirmed the growing feeling in my heart that God wanted me to pray with my patients before surgery and transmit that same kind of peace to them. Still, I remained skeptical and opposed to the idea of prayer before surgery, having many good reasons to think it was a bad one. I reviewed these on my ride home:

  To call on a higher power would be to admit weakness or lack of control. Prayer, I thought, would be seen as an admission that I was lacking in confidence, ease, or skill in the procedure I was about to perform. This was exactly the opposite of what any doctor wishes to convey to anyone else—patient, nurse, or colleague. It could very well alarm a patient at a critical moment and cause him or her to doubt my abilities.

  Patients may be offended. How many of them would think I was trying to convert them or badger them with religion? Was it even appropriate in this context? It seemed to violate the professionalism inherent in good medicine. I didn’t want to cause offense, and I didn’t want any complaints.

  If I prayed and things went badly, it could ruin patients’ faith. What if that happened? Would it shake their faith or make it less likely that they would ever want to know God? Would they be angry with me or with God?

  I still believed in the separation of the physical and the spiritual. Even though I was growing as a follower of Jesus, I was trained to respect the gulf between medicine and religion. Doctors are science based. Chaplains and certain alternative medicine practitioners are not, and they are therefore free to use anecdotal and unproven methods. They are also less respected by many because their training is less demanding. Only for them is prayer the “standard of care.”

  I would lose my reputation in the medical community. My colleagues simply would not accept or respect someone who introduced spiritual matters, or what they might term “superstition,” into the practice of medicine. They would have more sympathy if I were to confess to alcoholism or mental illness or even attempt suicide. Appealing to a divine being would be akin to using incantations or good-luck charms. By praying—and relying on something other than science—I would be admitting that science did not have all the answers, and I would in effect be giving up my exalted position in the scientific community.

  I wanted to be credited for my successes. I was trained to believe that success in surgery is always the result of applied knowledge and expert technical skills. I believed that the intellectual acumen needed to correctly diagnose a problem and the ability to technically execute a plan comprised the real healing power; I had worked diligently to obtain and apply this expertise. To suggest that knowledge and skills were inadequate would be to challenge not only my own sense of self-worth but the very way in which medicine is practiced.

  I was introducing an unnecessary variable. Performing surgery is about controlling variables—that is, minimizing the number of unquantifiable risks. The fewer the variables, the better. Prayer would introduce an unnecessary variable into an already stressful and difficult situation. It would create a condition in which I didn’t know what might happen or whether it would upset the patient or the family.

  In addition to these reasons, one other thing disconcerted me a great deal: Praying would alter the typical doctor-patient relationship. That relationship usually puts the surgeon in the superior position. Surgery is the doctor’s show to run. The patient is often a passive participant, not a partner. I am seen as the one with all the answers. Prayer would make patients equal partners with me. In fact, I would need to ask permission to pray. This didn’t feel familiar to me. They were in the position of asking me for my services; would I now ask them for permission to pray? Would that be desirable? Would it even be proper? Would I lose respect? Or worse?

  In truth, the doctor-patient relationship is based on something more than hierarchy—it’s at least partially based on fear. Doctors fear being sued; patients fear a bad outcome. This is the overriding dynamic of the relationship,
especially when it involves a high-risk surgery, which includes every brain surgery. Because of the fear of being sued, doctors are very careful not to let their humanity turn into any sort of vulnerability. The questions in the back, or front, of their minds are always, How could this relationship go bad? What might turn this happy scene into a lawsuit? The questions in patients’ minds are, The doctor seems nice, but is he or she competent? What if something goes wrong? What will happen to me?

  Being sued is one of the few possibilities that make doctors feel vulnerable. It is the worst possible scenario for a medical professional, because it means someone has broken through the protective barrier of your life and threatens your personal and professional well-being. A patient is calling into question the thing that sits at the core of your self-image—your competence. This person is accusing you of something that you never intended to happen and perhaps wasn’t even your fault. Once you’ve been through that, the pain lingers for a long time, so to protect yourself, you start to worry only about dotting the i’s and crossing the t’s. It’s no longer entirely about a patient’s health or well-being; it is also about getting you, the doctor, through the procedure with the best possible result and without a lawsuit. In that sense, you are united in purpose with the patient, but for many physicians, a significant motivation is self-preservation—to avoid becoming personally or professionally vulnerable to the patient.

  It is easy to understand the vulnerability of the patients. They long to hear good news, and I can sense that longing as soon as I walk into the room. Most doctors I know try to be upbeat and friendly, and this, I think, is because doctors have incredible power to impart feelings—confidence or anxiety, peace or stress. I often want to say with a big smile, “This is going to go perfectly,” because that is what patients want to hear to put them at ease. But it goes both ways: surgeons can be affected by the feelings of their patients, too. In this way, the dynamic of fear also occasionally works against successful outcomes.