At the End of the Day -- Advice to a Young Surgeon

by: Carol EH Scott-Conner, MD, PhD, MBA

When I finished surgical residency and took my first job as an Assistant Professor, I emerged from a fog of chronic sleep deprivation and became conscious, as if for the first time, of a myriad of new emotions associated with work and home. Over the years that followed, I developed some methods and rituals that served me well. I pass them along to you, in the hopes that some small measure of what follows may be of assistance. As you read these words, remember that for more than three decades I was a general surgeon and it is only in the past four or five years I've concentrated on breast cancer.

As you read these observations, put them into the context of something in your own practice that you might find unutterably sad or difficult. For example, when a critically ill teenager lies up in SICU dying of massive head trauma; or, perhaps, when you have had to perform a “peak and shriek” when you had hoped to do a definitive resection of a tumor.

1. When talking with the patient or family about a bad thing: breathe slowly and deeply, relax all your muscles, and listen. Let them talk. Sometimes that is all you can do to help them. It will help you as well. Repeat your explanation simply and carefully. Be as accurate as you can. Remember that what you say may be different from what they hear. Bring a third party with you – the family clergy, a hospital chaplain, a nurse, social worker – if it seems appropriate. Don’t be afraid to reach out. Human touch is good.
2. End your work day with something good. If you have three patients in hospital to see on evening rounds, and two are critically ill and the third is recovering nicely, see the one who is doing well last. Sit down at that patient’s bedside, breathe and relax, talk and listen. Hold our your hand and nine times out of ten the patient will take your hand and hold onto it. Rejoice in the success. Live in the moment with that patient.
3. When you get home after something bad has happened, cue your “best friend” as to your mood. My “best friend” is my spouse, but it might be your partner, your housemate, or even your dog. Whatever. When I go home, the first thing I say is “I love you and I missed you.” But then, when we are standing side by side and making dinner, I say something very nearly like this, “Something bad happened today,” and I pause. Then I might say, “We admitted a teenager with a bad trauma. I don’t think he’s going to make it.” That’s all I need to say. My husband knows what mindset I’m bringing to the dinner table. My burden lightens almost immediately.
4. If your “best friend” tries to console you (which is a normal human response) don’t shoot back, “you just don’t understand” (another normal human response), even if that is what you feel like saying. Say, “it wasn’t like that, it was…” or, “I’m not ready to talk about it yet…” They don’t understand until you explain it to them. If you are fortunate enough to have a person in your life who has chosen, of all the people in the world, to stand by your side, then you should share your world with them. I don’t necessarily mean all the gory details. My husband was a medic in Vietnam and went on to medical school, but even he doesn’t want to hear it. I am always struck how spouses of soldiers with PTSD say, “he shut me out. He won’t talk about it.” Remember, your “best friend” is attuned to your moods, but isn’t a mind reader. Unless you tell that person why you are moody or depressed, they won’t know.
5. Then, immediately, let it drop. Don’t use your bad day as a cop out or an excuse. Wipe the slate. Have dinner, play with your kids, walk the dog, whatever. Live in the moment with your family (or dog). Later, read, write (journal), think about the incident, talk to colleagues, whatever works for you. But let the naming of the problem be a signal to put it to rest for the evening.
6. Give your “best friend” some follow up, if they wish. A couple of days later, you may be able to say, “that teenager we admitted the other day? He’s starting to wake up. He’s doing a lot better than we expected” or “He died today.”
7. Exercise is good. Get some exercise every day. I like to bicycle to and from work whenever weather permits. On the ride home, I try to concentrate on my surroundings, rather than the day that has passed, or the day ahead of me tomorrow. When bicycling isn’t feasible, I try to swim. Find something that works for you, and concentrate on your body and all of your senses.
8. Drugs and alcohol are bad. I’m not talking about a glass of wine with dinner, I’m talking about stopping at the bar to knock back a couple of stiff ones before you go home.
9. Be a warrior. By that I mean, acknowledge that you have chosen a noble and dangerous path. A path that will take you into daily contact with death and the deepest mysteries of life. Draw strength of that. And always remember that you are not walking the warrior’s path alone.

Dr. Carol Scott-Conner is an Endocrine and Breast Oncology Surgeon and Professor of Surgery  - Surgical Oncology and Endocrine Surgery at University of Iowa Carver School of Medicine.