Gloomy Surgeon

One of my attendings in residency told me: “Every complication that can happen in surgery will eventually happen to you. If not, you’re either a liar or haven’t done enough surgery.” Seven years into private practice, I appreciate how true that statement is. It doesn’t matter how amazing of a surgeon you are, sh*# happens to all of us.

As physicians and surgeons, not only are we a paranoid bunch, but also a proud one. No one really likes to openly share their worst beats in the operating room. Most of us don’t even like to discuss poor outcomes that occur despite everything being done correctly. Obviously, it’s even harder to talk about the cases where we just plain f*&k up. Believe me, everyone has surgical skeletons in their closet. Most of the time, when bad things happen, it’s usually from a combination of bad luck and poor judgment. In retrospect, it’s often difficult attribute exactly what part of the complication was from inevitable misfortune or from bad decisions. What makes it especially more difficult is the fog of surgery that the adrenaline, panic, denial, and anger creates in the heat of the moment.

It’s a vicious cycle. Because no one likes to talk about their surgical demons, it looks like complications don’t happen to anyone. Because of this fact, people are reluctant to talk about their own complications when they do happen. We fear looking incompetent and embarrassing ourselves. Hence, we just internalize our anguish and try to sweep it all under the rug. Not the healthiest way to deal with grief.

Every time a case ends suboptimally or unfavorably, I can’t help but play back the surgery in my head, and wonder what I could have done differently. Looking back, there’s almost always something I could have done differently. I usually feel like I could have and should have handled things better. Pure 20/20 hindsight.

When you experience a devastating outcome, it can be an insurmountable struggle to get out of your rut. Especially when there’s no one else to commiserate your sorrows, it can be quite depressing. And all the while, you have to do your best to not let your personal distress get in the way of the care of all your other patients. It feels very much like Maverick being asked to run a successful combat mission immediately after Goose dies in Top Gun.

In 2014, one of my patients got endophthalmitis and eventually lost the eye. It was the first time ever that a devastating event had happened to one of my patients. It took me months to recover, and I still have flashbacks to this day. For a while, every time I saw him on my schedule for a follow up, I dreaded the moments leading up to his appointment time. Our relationship is still very good, and he thinks positively of me, but I still have difficulty overcoming the guilt of having been a vehicle to his loss. Even now, I still replay the case in my head every now and then, and wonder what I could have done differently intraoperatively and postoperatively to prevent this sad outcome. Clearly, I’m not the same surgeon I was back then. I have developed an unrealistic fear of operating, and dread the worst case scenario when a case doesn’t go perfectly. I swear that I have some level of PTSD from surgery.

I absolutely hate the night after a complicated case. Because I have the least amount of information regarding the uncertain outcome, my mind can go to such dark places. I just wish I could fast forward to the next morning where I see my postop, so that I can have a bit more clarity toward the prognosis of the patient’s recovery, regardless of it being good or bad.

Of course, I have great support from my family and closest friends. They always try to console me, telling me that I did the best I could, and others probably would have run into the same type of complication in similar situations. They also remind me that for every person that has experienced harm through me, countless others have benefited from my care. These comments are all so true, and I agree with them. However, I still can’t let go of the fact that even one patient had to suffer because of my actions. Even if there were no way to have prevented a poor outcome, I still can’t get over the fact that I was the vehicle of destruction and pain. I feel very much like an executioner. I didn’t carry out the sentence, but I saw it through.

I think these two scenes from Schindler’s List and Rounders sum everything up nicely.

Don’t get me wrong by the way. I am confident in my surgical skills, and feel like I’m at least an above average surgeon, if not better. I have close to 1,000 cataract surgeries (including residency) behind my belt now. My cases are usually 15 minutes long. I’ve broken the posterior capsule under 10 times in routine cases, and an additional 5 to 10 times on LP/HM cataracts. I dropped nucleus only twice in my entire career, of which one was yesterday. Yet, these are the haunting thoughts that preoccupy my mind. Although, I suppose my unreasonable fear of the worst case scenario encourages me to strive to become the best surgeon I can.

As a young ophthalmologist, just learning to become your own surgeon is daunting in itself. To have to do it in solo practice with no real professional or emotional support is even more intimidating. Especially when your initial surgical volume will be low, and you might operate maybe once a month or so. My first time ever operating alone without a mentor was 9 months after I had graduated from residency. Although it ended up feeling like riding a bicycle, the lead up to surgery was scary. Solo practice has way more merits than disadvantages. However, it is a lonely road. Thankfully, the open community on the internet makes it feel like you’re not walking it alone.

I believe that almost everyone goes through the same soul-searching growing pains that I have, but probably to differing extents. Although the hurt you feel from poor outcomes and complications is unavoidable, knowing that everyone else goes through the same struggle definitely helps decrease the burden we surgeons must suffer through.

One thought on “Gloomy Surgeon

  1. I empathize with you totally. Being a Gastroenterologist, the most risky procedure I do is ERCP and God knows how I spent sleepless sweaty nights when a couple of complications happened and patients had to undergo surgery. I went through the exact same feelings you described. I was trying to contact my friends as well and develop an emotional support network. However, as you said they would be inevitable with high volumes and in a way I am glad I had the worst possible experience early in career so now I am more wise and a better operator!! Loved your post.

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