The Secret Language of Doctors

by Brian Goldman

  One woman who knows a great deal about medical education is Dr. Renee Fox, one of the pioneers of medical sociology. In the 1950s, Fox was associated with the “medical school project,” a long-term study of the sociology of the medical education of students at Columbia University in New York City. As part of her four-year research in the field, Fox observed second-year medical students at Columbia as they attended their first autopsies as part of a course in general pathology.

  In her essay “The Autopsy: Its Place in the Attitude-Learning of Second-Year Medical Students” (first published in 1979), Fox wrote that the autopsy was regarded by students as one of the “landmark” or “milestone” experiences of their training in medical school. She emphasized that the experience was not simply about advancing the students’ intellectual development; but that the students “also describe participation in an autopsy as ‘an emotionally important experience . . . one of the hurdles you have to get over along the way to becoming a doctor.’”

  Fox was struck most by the notion that the ritual of the first autopsy helps teach budding physicians how to demonstrate “detached concern,” a process by which “students gradually learn to combine the counter attitudes of detachment and concern to attain the balance between objectivity and empathy expected of mature physicians in the various kinds of professional situations they encounter.”

  She emphasized the ritualistic aspect of the experience of the first autopsy as helping to prepare students to develop a sense of detached concern. The first autopsy itself was invested with a sense of occasion in which the students experienced a number of firsts—the first time being on call and literally waiting for a patient to die, and the first time students don scrub suits.

  Fox examined an aspect of the culture of modern medicine—first articulated by Osler—that continues to this day: peer pressure to deny the emotional impact of such experiences. “Students share the unspoken conviction that ‘admitting you had qualms about the autopsy’ or that ‘it made you feel queasy’ is not in keeping with standards of professional objectivity,” Fox wrote. She also noted that the students themselves limited the extent to which they discussed the autopsy among themselves so as to “avert an excessively emotional response to it.”

  Fox captured clearly the dilemma faced by the students—and, I would argue, physicians like me; that is, how to look at the work we do objectively while still being able to feel things emotionally.

  Fox’s study of medical students predates my own experience by a quarter of a century. In my first year of medical school, my classmate Eric Deigan (now an OBGYN in North Carolina) and I dissected a cadaver as part of our anatomy class. I recall that there were six to eight cadavers in each seminar room arranged in two rows of three or four each. For an entire semester, we dissected parts of the cadavers to illustrate what we had learned in the lecture hall.

  I remember the strong smell of formaldehyde, the preservative used to keep the bodies from rotting. It filled my nostrils and so covered my hands that it would take hours after each dissection to regain my appetite. Most of the time, I was in awe of the man who donated his body so that I could learn about human anatomy.

  The first incision my partner and I made into the cadaver’s body made me feel physically sick. To ease my squeamishness, I remember making lots of jokes about it. I nicknamed my cadaver Ernest so that if anyone outside of medicine asked how I spent my time, I could reply: “I’m working in dead Ernest.”

  In her research from the 1950s, Fox noted that students made jokes about the dissection.

  “Gallows humor flourished in the anatomy laboratory, where the students were literally faced with cutting into dead human persons,” said Fox in an interview. “That was their first encounter with death in that rather special form.”

  However, Fox said, there were occasions while dissecting cadavers when the gallows humour was put away. “I was also struck by the fact that they didn’t make jokes during the particular high emotional points in the dissection, which were not only working on the genitalia of the cadaver, but even more so on the hands and on the face, where the humanness of the body lying on the table asserted itself.”

  For me, the most difficult moment came the day Eric and I dissected our cadaver’s face. As we cut away the layers of skin and fascia underneath, the cadaver lost its humanness. When I went home that day, I looked at myself in the mirror and realized that what separated me from him were three layers of cells—the thickness of which is roughly the diameter of a pin.

  The connection to a recently living human being—what Morgan Jones Phillips alluded to when he described the body of the man that he and his partner lifted from the subway tracks—is what connects us to the cadaver in the anatomy class and the autopsy room.

  Fox concluded that the first autopsy plays an important role in medical students’ development of detached concern for patients. But the autopsy rate in the U.S. has been in steep decline since 1972. In 2011, the Centers for Disease Control’s National Center for Health Statistics reported that the percentage of deaths for which autopsies were performed dropped by more than 50 percent—from 19.3 percent in 1972 to just 8.5 percent a quarter of a century later. Other countries—including Canada, Australia and Denmark—have also seen sharp declines in autopsy rates.

  Several reasons account for this. In the U.S., Medicaid and health insurers don’t pay for autopsies. In 1971, the Joint Commission dropped its requirement that hospitals have an autopsy rate of 20 to 25 percent of the deaths that occur in them. Some have suggested that doctors are less likely to ask the family to agree to an autopsy out of the belief that MRIs and other modern diagnostic imaging techniques obviate their need. Studies have suggested physicians are reluctant to ask for autopsies for fear of triggering a lawsuit. Others believe doctors are trying to respect religions and cultures that prohibit or frown on autopsies.

  I think physicians no longer ask for autopsies because they no longer think they’re worthwhile. Likewise, I suspect that physicians no longer believe in the carefully crafted sense of detached concern nurtured in medical students as described by Renee Fox and other medical sociologists.

  Whatever the reason, without the ritualistic structure of the autopsy as a milestone experience, it’s entirely possible that medical students might be learning to be less detached and more concerned about their patients—a cause for celebration.

  * * *

  All doctors struggle to find the balance between detachment and emotional openness; for surgeons, the sweet spot is by far the trickiest. My surgical colleagues spend years developing the technical skill and gathering the experience necessary to put patients under the knife safely.

  “For me, the conduct of an operation is largely about focus and discipline,” says Dr. Marcus Burnstein, a colorectal surgeon at St. Michael’s Hospital in Toronto. “The focus is on the steps of the operation, and the discipline is to ensure that every step is completed without shortcuts or compromises.”

  The technical demands of surgery are obvious. You need unparalleled manual dexterity, stamina and the ability to go patiently through a series of complex steps in order. It also helps if you have prodigious attention to visual detail.

  The thing I find many surgeons fail to appreciate is that an operation is a form of controlled violence on the patient. If surgeons thought about what they do to patients on a daily basis, I suspect many wouldn’t do it. Even the most successful surgery causes severe (albeit manageable) pain. For patients relieved of their condition, post-operative pain is bearable—but not so much when the surgery results in complications or worse.

  “You asked if emotional detachment is necessary, and for me I think the answer is yes,” says Burnstein. “I think I need the separation to facilitate a pure focus on the task.”

  For surgeons, the ability to detach emotionally and focus on the task at hand is especially necessary when dealing with the fallout of surgical mistake
s.

  “Dealing with bad outcomes and errors is extremely difficult, especially in the early years of a surgical career, but not only then,” says Burnstein. “There can be tremendous fallout (I would argue even PTSD in the worst cases) from making errors or even just the perception that you made an error. My personal behaviour has been sleeplessness, anxiety, reliving the decision-making moments, inner voices trying to calm me down with reminders that I am not perfect and that’s okay, that I have to ‘shake it off’ and that I must learn from this.

  “The shake-it-off manoeuvre, easier said than done, is the key to being successful at tomorrow’s tasks. It gets a bit easier as you get older. It really helps if you have a few colleagues with whom you can talk and commiserate.”

  Burnstein, who teaches surgical residents, says surgeons are only just beginning to instruct formally how to deal with mistakes. Much more fundamental is how surgeons balance their focus and discipline for the operation with empathy for the patient.

  “Now and then, I will find myself dealing with something much worse than was expected and the consequences for the patient and her family will certainly enter my mind, accompanied by the emotional response of sadness and anger,” says Burnstein.

  That’s how Dr. Sid Schwab, a retired general surgeon and author and blogger felt the day he lost a teenage girl in the operating room. The teen had been in a sled being towed by her family car, which her parents were driving, when the car went around a corner.

  “She got whiplashed into a concrete culvert,” says Schwab. “She passed out at the scene but they took her home and put her on the couch. Then she had a cardiac arrest. She had a pulse when they brought her in and you do everything you can for a little kid like that.”

  Schwab took the teenager to the operating room, but the accident had caused far too much damage. “It just fractured her liver so badly that there was not much we could do about it. To go out into the waiting room and tell the parents of a 15-year-old girl that you couldn’t save her life and have them pounding on my chest and saying, ‘What do you mean you couldn’t save her?’ That was pretty heavy.”

  Schwab recalls his eyes welling up with tears as he sutured up the dead girl. To surgeons, the operating room is a kind of safe haven from emotional attachment to the patient. It was there that Schwab could concentrate on trying to repair a teenage girl’s mortally wounded liver without thinking about how her parents would feel when he had to tell them the surgery didn’t save her.

  But taking a patient to the operating room and subjecting her to the controlled violence that goes with incising, dissecting and cauterizing human tissue has to involve an emotional bond between surgeon and patient that begins in the surgeon’s consulting room or at the bedside. The surgeon has to invest time in preparing for surgery, and invest emotionally in the patient.

  Surgeons seldom talk about that bond. Still, they must feel it. And, they’ve invented a telling bit of medical slang that addresses perfectly the ambivalence they experience about feeling emotionally attached to their patients.

  As I mentioned briefly at the beginning of the book, surgeons use the phrase peek-and-shriek, which describes taking a patient to the operating room, opening up the belly (peek), realizing the patient has a condition that cannot be fixed (shriek), and then closing the belly without fixing the problem.

  “That is a very commonly used phrase,” says Dr. Christian Jones, a fellow in surgical critical-care at Ohio State University Medical Center in Columbus. Jones learned it during his residency in general surgery at the University of Kansas Medical Center in Kansas City. “We write that down on our patient lists. All of us know what it means.”

  Jones says the worst example of peek-and-shriek he’s ever seen happened with a patient he knew had cancer. “We opened the abdomen, and the entire small intestine was white. The walls of the intestines—every bit of them—were completely covered with tumour. We closed the abdomen. There was nothing we could do.”

  One of the most common peek-and-shrieks is of a woman with ovarian cancer. According to the American Cancer Society, ovarian cancer is the ninth most common cancer among women. This year alone, more than 22,000 American women will be diagnosed with ovarian cancer and more than 15,000 will die of it, making it much more deadly than breast, colon and prostate cancer.

  The reason ovarian cancer is a common cause of peek-and-shrieks is that only about 20 percent are detected early enough to cure. The symptoms of ovarian cancer, which include bloating, pelvic or abdominal pain, trouble eating or feeling full quickly, and having to urinate frequently and urgently, are vague enough to be passed off by both patient and physician until it’s too late for a cure. Or, there may be no symptoms at all.

  “I think peek-and-shriek is a quick way of getting the message across that you encountered a disaster and found yourself to be useless,” says Burnstein. “It’s really damning of our skill set that we looked in and found nothing we could do. To make light of our uselessness, peek-and-shriek covers that.”

  Listening to Marcus Burnstein talk about it, I get the sense that if surgery means diving in with both feet, peek-and-shriek means dipping one’s toe in the water of emotional investment. It’s one thing for the surgeon to take on a critically ill patient knowing the odds of survival—much less recovery—are slim. It’s quite another for the surgeon to take a carefully prepared patient to the OR not knowing what shocking discoveries lie ahead.

  That’s what happened to Dr. Raz Moola, now an OBGYN in Nelson, British Columbia, when he was a resident more than ten years ago. Moola was part of a team looking after a 20-something-year-old woman in her third trimester of pregnancy. The woman complained of abdominal pain, and had been to hospital several times.

  Because of the risk of exposing the unborn child to radiation, a CT scan of the abdomen was out of the question. Several ultrasounds failed to show anything abnormal. Pain undiagnosed, the doctors decided the deliver the baby by Caesarean section and have a look inside the woman’s belly.

  “You open this woman’s abdomen expecting that you are going to find a uterus and a baby,” Moola recalls. “What we found were tumour deposits everywhere. It was clear that she had metastatic gastric cancer. Right then and there, you know what this woman’s future is, you know what this child’s future is—that the child is not going to have a mom. We were in total shock. It was a ‘dear God’ moment.”

  Christian Jones has had similar experiences. He and his colleagues once admitted an elderly man who was vomiting blood. The man had heart and lung disease and was a risky candidate for surgery. Jones says the team devised an audacious plan in which the stomach would be removed, and the esophagus and intestines would be left unattached for several weeks to give the old man’s body a chance to heal. Meanwhile, he would be fed by IV drip.

  “I was excited because I thought we could really help this guy,” says Jones. “But as soon as we got him to the operating room and opened his belly, we saw that his entire small intestine had died. It was black and purple. We were shocked.”

  All Jones and his colleagues could do was close up the abdomen and keep the man as comfortable as possible. He died soon after.

  “I was fully expecting that we were going to fix this guy,” says Jones. “[Instead] we gave the family the worst news possible—not only could we not fix him, but nobody could fix him. I didn’t use the term peek-and-shriek in that case. I don’t know if that’s because I did have that emotional attachment.”

  The therapeutic relationship between patient and surgeon—though shrouded in the mystique of operative procedures and sterile drapes—is as rich and as complex as that between any doctor and patient. Clearly, there are times when surgeons are more concerned than detached—just like the rest of us.

  14. Circling the Drain

  A heart attack is triggered by a sudden and complete blockage of a coronary artery. Starved of oxygen, the heart muscle convulses into a
spasm of chaotic electrical activity called ventricular fibrillation, which causes the heart to stop beating. Without a timely electric shock from a defibrillator, irreversible brain damage ensues six to ten minutes later, followed by death.

  Medical textbooks portray death much like that: in the cold, sterile language of pathophysiology. That’s what we learn in medical school about human demise. It’s only when we arrive on the hospital wards and in the ER that we discover the other side of death—the emotional side, the one that rips apart the hearts of loved ones.

  * * *

  “Brian, do you mind coming over to the resuscitation room for a minute?” a nurse working in my hospital asked me. I told her I’d come over as soon as I finished with a couple of patients in the ambulatory care room where we see cuts and sprains.

  It was nearly three in the morning and I was tired. I’d done my time taking care of patients in the resuscitation (resus) room. If there’s one thing ER physicians hate, it’s getting pulled back into a job, a patient or an assignment you thought you were over and done with for your shift.

  But I already knew that it was going to be different this time.

  Two hours before the nurse asked me to come back to resus, paramedics had brought in an impossibly young Asian man who had suffered cardiac arrest while working the night shift in a factory. He had been complaining of pain in his upper abdomen and lower chest for a day or two, but passed it off as indigestion. During a meal break, he called his mother to say he wasn’t feeling well. Half an hour later, he collapsed.

  The paramedics wheeled him into the first bay in the resuscitation room in full cardiac arrest. One was doing CPR, a second was manually ventilating the man using a bag-valve-mask device. A third medic gave us a report.