Ankwari Humanism Podcast 1_3.28.24_edits

Hello, and thanks for listening. This is Patrick Georgoff. As always, we appreciate you tuning in to Behind the Knife. If you haven't already, be sure to download our app for easy access to all the great content on Behind the Knife, including how to videos, board review, and our new trauma surgery video atlas.

Today, we've got something brand new for you. We are taking a deep dive into the extremes of humanity within the field of surgery, the times we as surgeons have felt most human, and the times we have felt like we have lost our humanity. So these experiences definitely impact us immensely and it shapes our outlook on life and our careers.

Perhaps it is time that some of these stories are told. Some are sad and profound, some are funny, some frankly maddening, but they are most definitely all distinctly human. So if any of you have heard NPR before and many of our fans out there, think of this as story core for surgery. And today I'm joined by my colleagues at Duke University's Dr.

Tamara

Fitzgerald and Dr. Ted Pappas. So Dr. Fitzgerald is an Associate Professor of Pediatric Surgery with an academic interest in global surgery, specifically surgical capacity building. And Dr. Pappas is Professor of Surgery and Vice Dean of Medical Affairs at the Duke University School of Medicine. So Tamara, how did this idea to explore the humanity of surgeons come to be?

Thanks Patrick. The idea originated within the Aquarius Society here at Duke, Dr. Anya Aquari was the first black surgeon at Duke University, and the Aquari Society has been started in his honor to promote a surgical community that places humanity at the center of our practice. So in these podcasts, we'll be exploring the lives of surgeons as humans.

Yes, indeed. And today we're very privileged to be joined by Dr. Pappas, who's been on faculty at Duke University for his entire career. He's a well recognized expert in pancreatic and laparoscopic surgery. And in 2018, received the honor of being recognized as

a Master Surgeon at Duke. He has served in numerous leadership roles and as mentioned, currently serves as the Vice Dean for Medical Affairs.

Dr. Pappas, thank you for meeting with us today. Absolutely. My pleasure. Thank you. And I should say as a newbie to Duke, I wasn't quite sure what the master surgeon title was. And this is a title bestowed on very few folks. And these are individuals who shown their true mastery of surgery and clinical care of patients over time at Duke.

And so there's not very many of them and Dr. Pappas, who are one of them. And I've learned now why that is the case. So again, we're happy to have you on today. Thank you. All right. Well, as surgeons, we all experience challenging cases and interactions with patients, some of which can really test the limits of our own humanity.

These stories have a deep impact us and some we will never forget. We recently have been talking about some of these stories from your career and we're looking forward to hearing one of those stories from you now. Yeah, I'm happy to share one. I

could share many but there's one that I remember.

And we'll always remember. And it goes back 30 some years, so I was junior faculty. And at the time I did a lot of abdominal, upper abdominal surgery. And I had a patient who was, gosh, he was in his fifties. Pretty healthy guy, but he had a liver cyst. And it was a symptomatic liver cyst. On imaging, it looked like it had some blood in it.

And so we thought it may have bled and was symptomatic, so we decided to resect it. This was back in a time we admitted patients prior to the operation. So we were doing an operation on Friday and so I'm rounding on him Thursday night. He's in the house, talk to him and the family, explain the operation.

This is before laparoscopy. So this is a full laparotomy. And so, we talked about the operation and after, I came out of the room, his brother follows me out of the room, and his brother then spends 15 minutes with me outside the room telling me how special this man is. On and on about how everybody at the church loves him and his

family adores him and he volunteers every place.

He's the kindest man on the planet. I have to take care of him. Sure. And it was. Even today now, 30 years later, it was the most astonishing thing I've felt then and now. That's how different it was that they were, he was relaying how important this family member was. in an extraordinary way. Had a big impact on me at the time.

But, I thought, gosh, he must be a special guy and we operated. So the next day we do the laparotomy. It goes fine. It's a sort of a hockey stick upper abdominal incision. It was hanging off Segment 2 and 3, relatively straightforward to our operation. Resected it. We spilled some of the cis fluid, washed it out but otherwise the operation very uneventful.

He develops a little ileus post op. You still remember fully to this day, this, the clarity of that operation? Well, absolutely, because, again, because of as we're going to talk about the story, the things that imprint in your brain he had a little ileus, probably

because of the fluid we spilled. He was fine.

So I'm rounding. This is back. We used to round seven days a week, by the way. And so rounding on Saturday and eight days post op. I round on him in the morning. He looks great. He's already started a diet. Probably gonna go home in a couple days. And then an hour later as I'm finishing round, he codes. He got up to the bathroom and died and We ran back to the room, coded him for 30 minutes, and he died.

And and so I get on the phone, and I call the patient's wife, and had a very sad conversation with her. And then she says, Oh, my daughter, our, his favorite daughter, he had three daughters, his favorite daughter is actually on her way there. And I said, Well, what This is before cell phones. And so, I said, Well, how long is it going to take her?

It's going to be about 4 hours. She just left about 20 minutes. And so, it was a long drive. And I said, and the mother said, You're going to have to talk to her when she gets

there. Oh yeah. So, I sat down and thought about it. And waited four hours. And that, the fact that we're talking about it today is that memory of me sitting there as a pretty young surgeon in my late thirties, thinking about what I'm gonna tell this young lady about her dad.

She's the favorite daughter. And what I'm gonna say. So what did go through your mind? Well, there's good and, there's always good and bad news. I mean, at the end of the day I learned a ton about that because I learned to compose myself before I took, gave serious stuff to families. And I still do it today, so I always now, When I ever have to go into a room talking to families about something tragic that's happened or terrible or bad news, I always pause, and I always collect myself.

And that came from that day, because I had four hours to do it. And so it was an unhappy four hours, and a very sad thirty minutes of both of us crying as I told the daughter when she got there.

But I learned a lot about, again, my own humanity about thinking to myself, what am I going to tell them? And this daughter who's driven all this way by herself, she was in her early 20s.

It just gave, it was like way too much time to think about it. But there was time to think about it and I did collect myself. And again, I learned a bunch that day and I'm a better deliverer of sad news because of it. It was the hard way to learn it. Any recommendations to younger surgeons?

about how to approach a family with bad news. We've talked about some on different podcast episodes previously, and had some recommendations, but it's always hard, and each situation is unique. Yeah, I mean, I think, again, the pause is incredibly important, because when we're in the moment, and our emotions are high, we may not be great communicators.

And so, and shifting from directing an operation, directing a trauma, directing whatever, an open throat economy in the ER, that

energy is totally different than the scaled down empathic energy you're getting to live with the family. Totally different energy. And so, pausing and collecting and thinking, alright, what am I going to say?

And rehearsing, in my mind, what am I going to say, is incredibly important. It seems a little bit artificial, but it's incredibly important. Because what you tell that person, on what may be the worst day of their life, will always be remembered. And you want to deliver something that is empathic, and carefully thought and really, making sure you deliver the message you have to deliver, but in the kindest ways you possibly can.

Yeah. So I think the thing that strikes me is you still remember this interaction after 30 years and it clearly made a big impact on you. Talk to us a little bit about empathy and the role that empathy plays in our lives as surgeons. How do we manage that? Well, I talk about this all the time, often to junior faculty members because I've had several junior faculty members have their first

operative death.

Yeah. And it can be a very traumatic thing for surgeons. And I've had them call me and say, What do I do? And I, and it's quite uncanny. You get very attached to families, and they die, and sometimes they invite you to the funeral. And I always use that as an example, and I always say you should never go.

And the and it's a marker of cutting off your empathy when you have to, otherwise you drag yourself down into this abyss that you can't get out of. Because tomorrow, you're doing the same case on somebody else. Tomorrow. Literally. And if you are, Your empathy has put you in a position that you can't get back up and look at the portal vein the next day.

Or do a trauma laparotomy for massive bleeding. Then you've done that patient, the next patient a disservice. So you've got to separate yourself. And so we I believe we all have to manage our empathy and truncate it when we have to. And not going to the funeral was just the question. The classic example of you can't go there.

You can't share

that empathy. Your empathy has to stop. And again we as surgeons sometimes get labeled as no empathy because of that. We, we have this barrier we'll put up sometimes. But I've often seen it as protection. We're managing ourselves. And you don't want to minimize empathy because empathy makes you a great doctor.

It truly does. But you have to manage your empathy. Yeah, I think sometimes managing that, it can sometimes create a stereotype that people think of surgeons as being disconnected from our patients, but I think in reality we're some of the most compassionate people on the planet and we give so much of ourselves to this job every day and we're deeply moved by what happens with our patients.

So why do you think that stereotype exists and do you think it's changing at all? I don't think it's changing. I think it will always exist. Part of it is because we deal in an episodic fashion with patients as opposed to doctors who will

continuing primary care doctors and others who are just on a continuum of care.

And so they're sharing empathy all the time. We're dealing with episodes where we come and go in patients lives. And so they'll feel it differently. But I, and I again, I think it is, it's largely because of how we deal with our stress. And so you'll see people round and joke about, amongst ourselves we're rounding and we'll move down the hallway after we leave the patient's room and we'll say something that if you objectively look at that comment you think, that's terrible.

Sure. But we make a joke and we're managing ourselves so we can deal with that terrible thing we just left that room. And so if you're an observer, that, you think, what's wrong with those people? But I, we see this all the time as on rounds, you joke about things that you can't imagine as a joke because it's not, but otherwise, how can you not, how can you see the next patient when you realize that catastrophe you just left?

It's terrible. Well, that brings us to another interesting topic, which is

about the culture of surgery. Surgeons can be very direct and at times very blunt. But the way that surgeons communicate in and out of the operating room has changed a lot over time. And you and I were talking about a story before about when you were a resident and what the culture was like.

So tell us a little bit about that. So we're talking a long time ago now. This is 1988. And again You'll have to ask me, why am I talking about this, so it's all old news. But these are the things that you have, that have impacted on you, and you remember. So I was doing a triple A abdominal aortic aneurysm, open.

It was, they were all open at the time. And working with an attending that I loved, and got along great. And we were mobilizing the duodenum up, and encountered the left renal vein, and in the dissection, I took my scissors and cut it in half. And three liters later, when we had got control of the massive bleeding, he stopped, and he looked at me, and he said, That was the stupidest thing I've ever seen a resident do.

Why?

And, as he said it, my, the guy had been in practice for 25 years, and he'd trained hundreds of residents, and I thought, well, that's a significant thing to say. That's like a real deal, if I'm, that's the stupidest thing you've ever seen. And so, the fact that we're talking about it.

It had an impact on me. I mean, I don't think he, he probably never remembered it, but it had an impact on me. Interestingly enough, it didn't have any impact on my resilience. I mean, at the time we were doing 120 hour work weeks and the culture was all that, right? You insulted first and talked later.

That was the culture. And so I was a pretty resilient guy, otherwise I wouldn't have been chief resident, right? And so it didn't. I wasn't going to quit over it, but I remembered it. The sad thing about it is I owned the same culture for many years. I'm better now than I've ever been as far as managing what I say to residents.

But, residents used to make jokes about me all the time. The things that I would say that are completely outrageous when you think about it now. And

it just, you just set it back then. And so, fortunately we do less of that now, but that was the culture back then. So where are we at now with this type of communication?

Certainly there's been improvement in the workplace, but some might argue that we've gone soft. Well, I think it depends on what level of resident you're talking to. Because you can't, I mean interns are, that job is impossible. And so, I've managed myself totally differently when I take an intern through a case and I used to just yell at them the whole time if they were doing it wrong.

And now, what I've done now is I'll pause and I'll switch sides with them. And operate for two minutes and show them what I'm talking about. And then I'll give the case back. And the message is, I'm not stealing this case because you're incompetent. I'm going to show you something and I'm giving it back.

And I think that's an important sign to them. Because they can't, you can't defeat their confidence. Because you can't, it takes years to get it back. And so you have to support their confidence. But

you got to get their message across about what they're doing wrong. So they have to learn. And so sometimes I'll just tie the knot for them.

Or I'll put the stitch in for them. And so, I think it's just a man, managing it. So I don't have to say that's the stupidest thing I've ever seen. Because I can't say that. Now, I think chief residents already have resilience. That doesn't give me the license to yell at them. But I can be even more direct with them, that's, I think that's probably right.

So there's a lot of different elements that we're kind of talking about here. Truth telling, criticism, humor, the desire to be better. How do those things shape us individually and our culture as surgeons over time? Are there things about our current culture that you think should be different? That's a big question,

Yeah. Well, I, I think we have to give feedback all the time. This I laugh all the time about somebody who af after a case asked me, can I have feedback? And I say, I was yelling at you for 20 minutes, didn't you? That was feedback. I'm just joking. But I

think that's my point. I think we as teachers have to be talking continuously.

Yeah. I really agree with that. Yeah. You can't, yeah, you can't teach if you're silent. You have to be talking all the time, non stop. And because presumably I know more than the person I'm teaching, and so every word that comes out of my mouth has a potential to teach them. So I have to teach continuously, talk about anatomy, talk about the diseases, talk about the operation.

And that's it. The rest is about an ounce of human kindness. Again, I always tell the story when my wife, who's a school teacher, So there has definitely been a lot of focus on feedback recently. And despite this effort to improve the quantity and the quality of feedback that trainees receive, some studies suggest that it's still lacking overall.

Do you believe that's true? And there is some wisdom there. And so, but, having said that, we have to be talking all the time. And we have to be We have to have some compassion about people

we're teaching because they don't know anything compared to what we know. So we have to be careful about what we say.

It's not easy because in stressful times, when the aorta is bleeding, sometimes you say stuff that you regret. There's no question about that. Well, I think we're in a funny spot now because we have a lot of younger people who feel like the words are hurting them. So there's these microaggressions and things like that.

So To my mind, we have to balance making clear that we're teaching and they're learning and we're saying things that are constructive and sometimes it's very direct. Very direct. And in the rest of the world, the rest of the world doesn't do that with direct, like that direct. And so that's why we're uncomfortable with it.

Some people see it as a microaggression when I say you have to do this, not that. Even within medicine, even within the whole world. It is. It is. The whole world of medicine and training and different sub specialties. Yeah, I think that's what we're stuck in right now. So, we have to pay close attention to the fact that

30 percent of our medical students think they're being insulted or hurting their feelings.

I mean, that's a real number. But at the same time, we have to teach. So we have to figure this out. And I think we can do it. We have to do it. But it's not about shutting up. You have to keep talking and manage what we say. So the natural follow up to that relates to autonomy. And this is an area that is heavily debated and is a major focus of contemporary training.

And many worry that residents do not get enough autonomy. So, so will the level of autonomy ever grow to fill what may or may not be a major shortcoming? Well, it's not going to grow. I mean, the expectation of society is that me as an attending, I have to be there all the time doing all things. And that's a sensible expectation.

So we've got to live in that environment. So we get, we've got a couple of things going in our favor. Number one, when I finished my training, I had done my residency, plus I had done a

super chief year and finished with a thousand cases. Well, our regular old residents are finishing with minimum of 1500.

Some of them are going to finish with 2000. Well, we're overwhelming them with volume of cases, which is great, and some of that then seeps into their sense of autonomy, they get a lot more confidence. And the other thing is, 80 percent of them are doing fellowships, too, so they have all this other time to get autonomous.

So I think it's, we can't go back in the day when, you were at the VA and you never saw an attending, for example. Or they were city hospitals in this country. where the trauma services is run by the chief resident, and you never saw him attending. Those days are not coming back, and they shouldn't come back.

But we're replacing it and figuring it out, and so, when I teach, I'm specifically figuring out when I need to horn into their space. If it's an intern, I'm going to have to see that patient no matter what. If it's a chief resident at the VA, for example, I may or may not

see the patient, depending on what the problem is, if they're in the clinic.

So, I think we can do it. And I think if you look at the product we're creating, they're great. And so we're not hurting them by being there all the time. I mean, do you think in some ways autonomy is overrated? When you're a resident, that's really the one chance that you have to get a lot of mentorship and get a lot of feedback.

And once you're launched out into your career, you have as much autonomy as you're, as you want. But you never really have that special relationship again where you have constant feedback. Yeah, no, I think that autonomy has been important and is important because it gives you internal confidence that you're ready.

I think as a resident that's finishing, you're dreading the first day on call, right? That, that you're not going to have somebody there to hold your hand. And so if you've done it a little bit ahead of time, you can get a job and you're ready to go. And I think that it's a confidence builder. Autonomy is all about confidence.

I made the decision. Nobody was looking over my shoulder. For And you build confidence

over time, and I think we build confidence in just different ways. Again, when I look at the chief group we have right now, they're incredible surgeons. They're really talented people who are very good at what they do.

And when I fill out these EPAs, I commonly write, practice ready, because they are. I'm there watching them, and I'm talking, but I always feel I could probably leave and they could finish. I don't, but I could. So how does a seasoned attending like yourself deal with a boneheaded move by a trainee?

Certainly not by saying, that's the stupidest thing I've ever seen. Well, I mean, my advice is always, you've got to turn it into education, you just have to. And so, for example, after I cut that renal vein, the next 48 hours. I knew everything about the left renal vein. I knew when you could take it.

I knew, I read everything about it. I knew what the blood flow back was. I knew what's come from the caver. I knew when you could ligate or not ligate it, whether you should fix it or not. I read about it. So I became an expert on that doggone

vein. And so you can turn misery into education after you get the control of the bleeding.

Again, we appreciate you being on the podcast. And if you will, Our tagline is, dominate the day. So I think you should say it for us on the way out. Absolutely, we have to dominate the day.