Monday, June 24, 2013

Fear of Surgery

As a surgeon, it is difficult to be a patient. Perhaps this is why there are so many comments about doctors and nurses being 'bad' patients. We know too much.  Enough to be scared. We know about risks.  After all, we talk about them everytime we consent a patient for surgery. We review complications and deaths with our colleagues in the attempt to improve care for future patients. And perhaps some of us went into medicine in the hopes of cheating death. But, everyone of us is human and subject to illness and death just like every other living being on the planet.

The fear is not limited to health care professionals. About a year ago, in a Morbidity and Mortality Conference, we discussed a patient who has had a bad outcome.  He seemed to be doing well before a routine surgery, and only hints of the problems to come immediately after.  Everyone on the surgical team agreed the surgery was appropriate and indicated for the problem at hand.  Everyone agreed at the conference today.  But, before the surgery the patient was resistant until his family talked him into it, then he wanted to proceed, and asked that it be done.

Many times I have had patients initially afraid of surgery then change their minds and ask to proceed.  Most of the time things go well, but sometimes not.  It seems reasonable to be a bit afraid to undergo surgery.  I know I was afraid before my knee surgery, but it went well.  I wasn't actually as afraid of the surgery as of the anesthesia.  I was afraid of losing control.   I had some with my appendectomy as well, but fear of a repeated rupture and the associated pain pushed me to proceed. As a General Surgical colleage said, "So pain and fear is what's pushing you to surgery?" I responded, "Absolutely. Is there any other rational reason to have surgery?" With my last surgery, I was even more afraid. Afraid of dying. Either due to the surgery or the disease. I felt that I still had much to accomplish on this planet, but still I was afraid. My children were too young. They weren't ready to be on their own. And, while most things are settled, I hadn't had the time to settle everything.

So some preoperative anxiety is probably normal. Anesthesiologists often premedicate the patient with an anxiolytic (a drug to block anxiety) before they even come to the operating room. This certainly makes sense. Seeing some of the tools we surgeons use might be even more frightening to a patient.

But what of the patient who is so afraid that he is prepared to sign out against medical advice.   What does that mean when things do go bad?  Did the patient have some sort of premonition?  I have seen it often enough that I sometimes wonder.  One place where I worked had the informal policy that a patient who cancels three times needs to see another surgeon before being rescheduled.  I have tended to follow that policy with my own patients since.

Likewise, I have sometimes had a bad feeling before surgery when I am the surgeon.  It doesn't happen often, but when there is a problem, I think afterward about my feelings.  Was I ignoring something that I should have paid attention to?  Or am I simply over thinking the problem?  Remembering my own anxiety in the situation of a less than perfect outcome?  Are premonitions something real?  Something we should pay attention to?  Is intuition just a subconscious processing of an observation that can't easily be described?

When I think of the topic of premonitions, I remember the series of dreams I had for months before my mother's death.  She was not ill, though had some chronic conditions.  And she was well enough to travel and walk for hours on cobblestones.  Hardly, someone I would have thought on the verge of death.  Yet, I had dreams for months before her death of trying to resuscitate a family member.  The dreams stopped immediately after her death.  It was as though I was rehearsing resuscitation techniques in my sleep for when I needed them to try to save my mother.  More of the details are published at:

Yet, as I think about this topic, I am left with more questions than answers.  Premonitions certainly seem real to me at times, yet I cannot come up with a scientific explanation.  The closest I can come is to say that I simply cannot put my observations into words, so get intuitive feelings about something.  Yet this doesn't apply in my mother's case, since she had been living on a different continent for eight months and I did not see her until about a week before her death.  So what kind of subtle observations could have prompted my dreams to begin two months before her death.  Yet, that is when they did.

So what do I do when I feel such a sense about surgery as the surgeon, or when a patient expresses more than the typical anxiety?  I listen.  I recheck everything to see if I am missing something.  I don't rush to the operating room.  But, if I can't find a reason not to proceed, I usually do if I think the procedure is indicated and the patient agrees.  And, most of the time everything is fine.

And, how do I feel as a patient? When it seems to be the best approach and I trust those caring for me, I have gone under the knife. But, still, I do so with some trepidation.

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