Complications

[filter07]

Hoping to get some real talk here.

I'm an attending surgeon in the first few years of practice. All I can think about is early retirement. Not became I don't like work - I like it. Not because I want to spend more time doing hobbies - I do, but I have plenty of time right now for them. I want to retire early because I want to live without having to harm people. This is irrational, I fully understand this. I help many people, and society invested a ton of resources into training me. I help far more people than I harm.

Everyone has complications, there are no guarantees. Yet as an attending surgeon, I sign people up for surgery. And even though I tell them the risks, nobody cares about percentages. All they care about is whether they trust me. Most of them do great, but I never think about those cases. The cases that haunt me are the ones who don't do as well. It's not even about them dying or having a major complication. I think about the SFA CTO I treated. I extended a dissection to the popliteal artery. I treated it fine, but that will potentially compromise a fem-above knee pop bypass in the future. There hasn't been actual harm, but I did maybe burn a bridge.

Intellectually I know that I am being unreasonable. I obsess about having the best possible outcome. When I have a bad outcome I think about constantly thinking about what I could have done differently or better. I do my best and I know that I will never have a 0% complication rate. But emotionally it bothers me. I just want to help, I never want to harm. It's irrational but at the same time it affects what I do.

Is this an anxiety issue? Part of being an attending and assuming all of the responsibility? It just seems like there was an exponential jump in anxiety from being fellow to being attending.

How did others deal with the emotional/visceral aspect of harm?

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[SLUser11]

Is this an anxiety issue? Part of being an attending and assuming all of the responsibility? It just seems like there was an exponential jump in anxiety from being fellow to being attending.
How did others deal with the emotional/visceral aspect of harm?

What you are going through is 100% normal and 100% necessary in your growth as a young attending surgeon. We certainly claim to worry and suffer as residents/fellows, but there is a very dramatic increase in your worrying and suffering when there's nobody upstream to rely upon for reassurance/confirmation during difficult decisions, and nobody upstream to share the weight of the blame when things go wrong.

I suggest that you continue to discuss cases with your mentors. Most of them will happily take your call, and their experience is priceless.

I have talked about this at length in the past, and I will post some old comments below, but in general the way that I cope with this is to read more and work harder than everybody else, allowing me to feel (regardless of accuracy) that I'm truly the best for the job.

Once again, this is normal and necessary, and I'd be scared if you DIDN'T feel it.

From this thread: How do you cope...

"You will become slightly calloused over time. However, I promise that the burden of complications becomes much heavier once you become the attending.

Honestly, I think that some surgeons cannot handle it, and gravitate toward cases where the complications are fewer or perhaps less severe. Within my own field, some surgeons will concentrate on endoscopy and outpatient anorectal cases, only doing occasional abdominal cases. They make better money, and sleep well at night, so it's hard to blame them.

I have plenty of complications, and what I tell myself is that it's the price of doing business. If I'm going to be in the big leagues, and be doing large complex surgeries on complicated patients, then I'm going to have some bad outcomes. This doesn't stop me from sleeping bad on some nights though."

From this thread: GS PGY3 burning out. Is decent work/life balance possible once BE/BC Attending?

"Last week I had 3 very difficult laparoscopic cases that tested my patience, my resilience, and my confidence, but ultimately ended well. That same week I was privileged to tell 3 cancer patients that their pathology was favorable and their prognoses are excellent. I love the ups, and I am strong enough to handle the downs. The weight of my patients' complications, liability, unpredictability, and sadness is heavy, but I am willing to carry it because I know that's the price of being in the big leagues....high cost, high reward. I want the responsibility, I want the glory, I want it all. It takes sacrifices on all levels, but the patients come to my hospital to see me because they've been told that I'm the best.....which is debatable, but still....and I value that trust.

I made that paragraph self-aggrandizing on purpose, BTW. I think surgeons develop gargantuan egos because it's a necessary defense mechanism. How else can we justify the sacrifice? More importantly, how else can we stomach the complications? The only way I can sleep at night after a leak...or a stroke...or a death....is if I truly believe that I was the best man for the job. So the patients come to the hospital for me, and they meet you in preop and give you little regard, and that is not fair because your contribution, like that of many other faceless physicians, is priceless....but I want to be the face of their cancer journey.

OP: that was my motivation. Others want something to do between 8 and 5, and they are happy with their choices. My motivations are trite and perhaps still a bit naïve, but they are mine. You should find your own, and use them to make a very tough decision. Your feelings are normal, and it's acceptable to switch specialties. It's also acceptable to grind it out, and ultimately take a less grandiose approach to your own surgical career. Good luck, and feel free to PM me if I can help in any way."

And finally, my discussion of the weight: Tell me about your weight during residency/fellowship, SDN

"I've been thinking about this thread a lot over the last couple weeks. There's a much bigger weight that you carry after graduation that I didn't mention, and that's the weight of your complications, your deaths, your failures....even if your success:failure ratio is excellent, your failures will still be quite heavy, and your success will be "rewarded" with more responsibilities and obligations ("opportunities"). Outside of the hospital, as you age and mature you also carry the weight of your family, your health, finances, aging, illness, etc. Many of us felt this prior to graduation, but it really starts to get heavy as you get farther along. When in training, you are allowed to focus almost entirely on work. You can submerge yourself in training, and essentially defer most other responsibilities. Many (but not all) residents are young, and have few obligations outside the hospital. Residents often benefit from the "lightness" of having a surgeon upstream to consult when they need help, and blame when things go bad.

Depending on your grit and your previous failures, you may be able to carry on, or you might crushed under this increasing weight. Retrospectively, I'm shocked that we become experts in such complex medical situations, but we remain novices in how to run a business, how to manage money, how to support a lonely spouse, how to be supportive to your children, how to remain active and healthy, how to avoid drinking too much booze, etc. It's really no surprise to me now that the burnout rates are so high among surgeons.

Anyway, you should all be thinking now about how you're going to handle this weight, as it is a necessary component of being in the big leagues. Honestly, I welcome it. I feel like it's a reward. Still, the legs tire from time to time."

 

[filter07]

Thank you for posting that discussion. Reading the posts from all those posters - many of whom I've followed from residents/fellows to attendings - have been so comforting.

Your statement that some people shy away from complications rings true. I find myself wanting to avoid the most complex patients and cases. Maybe it's good that I don't really have that option though, and to my surprise they have generally done well. I keep fantasizing about the chip shot private practice cases, but I've realized that that complicated patients exist everywhere, and unless you are extremely liberal with referring out, you gotta put on your big boy pants.

 

[vhawk]

Thanks for the OP. This is a topic that has been weighing extremely heavily on my mind lately as well. I'm still in my first year of being an attending, but in contrast to the more typical situation of slowly building a practice and starting out with smaller cases, my group had been recruiting for a while and desperately needed someone, and I was thrown into the deep end from practically day one (first whipple was morbidly obese woman who had gotten extensive neoadjuvant chemo and rads and required a complete SMV resection with interposition reconstruction, first liver case was extended right hepatectomy with tumor abutting IVC), and I echo basically all of the things you say in your OP. It is shocking to me the change in mindset that I've undergone in 6 months of being the attending on these cases. Even in fellowship, I moonlighted as a general surgeon, such that I was ultimately 100% responsible for decisions and operations, and was operating entirely independently, in the middle of the night, with no residents and no partners. But it felt nothing like this. I feel that every decision I make is potentially a target for scrutiny and second-guessing. I feel that every case I do is potential to do something stupid.

And shockingly, despite the case load and the absurd complexity, I've actually been extremely fortunate so far that I haven't even really had any bad complications. I've had some DGE, a wound infection or two, some readmissions, but basically I'm massively overperforming my expectation (I dont mean that I personally am doing anything well, just that I'm "running hot" in terms of outcomes).

Nonetheless, I dont sleep. I wake up at 1am in a panic that I left a sponge in that guy and cant go back to sleep, trying to come up with any justification to order an xray to make sure that I'm just being paranoid (so far I have not left anything in anyone!) I have never had a panic attack in my life, have never suffered from anxiety or depression, if anything I would almost certainly be described by those who know me as sort of a callous, cocky, arrogant person who may or may not be dead inside. But I feel that at least 2 or 3 times a week I am seconds away from a fullblown panic attack, it gets hard to breathe, my heart rate shoots up. So far this has never happened in the OR (and in fact, the time in the OR is for the most part the only time that I am actually happy and focused and confident. I do not feel that any of this has bled into my operative performance, but I dread the cases even in the preop area).

I appreciate SLUsers responses as well. I also felt like I wanted the big cases, I was good enough to handle them, I was the best man for the job. To some extent I do still feel those things. But I'm just not sure that I want every single case, every single day, to be the hardest most complicated most perilous case of my entire life. I have to believe that this will get better as I gain some experience, but I cant imagine doing this for another 30 WEEKS, much less another 30 years.

 

[filter07]

I have a pretty similar experience. My first few cases were pretty intense. Even though we are private practice, our hospital is a tertiary referral center so we still have tough cases to do.

The cases that give me the most anxiety are the ones where my senior partners can't really help. In vascular surgery the youngest guys generally have the most endo training so the most difficult cases (complicated aortic dissection, thoracic aneurysms, juxtarenal aneurysms) are given to me. It's me and the device reps trying to figure out if something will work, except I'm not playing with Legos, I'm operating on a human being with families who love them.

I have seen some cases where new hot shots come in and do multi-vessel debranching in the chest and lay stent grafts into the ascending aortic arch. I have no idea how people have the cojones to do that fresh out of training. To top it off there was a type 1 endoleak.

 

[SLUser11]

And shockingly, despite the case load and the absurd complexity, I've actually been extremely fortunate so far that I haven't even really had any bad complications. I've had some DGE, a wound infection or two, some readmissions, but basically I'm massively overperforming my expectation (I dont mean that I personally am doing anything well, just that I'm "running hot" in terms of outcomes).

The difficult part is that eventually, no matter how good you are, you will have some bad outcomes, and sometimes they come in a wave where you aren't really equipped to cope with it. That's when it's really important to stay in close contact with your mentors, especially in your situation where you're the only one doing a certain type of case locally.

The operative stuff is always a focus, i.e. how much we struggle in the OR, or how calm and composed we can be...but I've really come to believe that the operative part is not nearly as difficult as the decision-making, which is where you're going to have the most middle-of-the-night rumination.

I agree with you that every practice needs balance. I work at a quaternary referral center, so I get a large volume of referrals for complex things (e.g. recurrent rectal CAs, hostile abdomens, complex comorbidities/liver failure/transplants, etc)...but I make sure that I maintain a healthy practice of elective colectomies, anorectal surgeries, and colonoscopies. Without it, I would be miserable and my back would be wrecked. Also, my residents would have a much less useful experience on the rotation, as most of them will never need the skillset for the complex redo-redo pelvic surgery. I do have some good friends in other prominent academic centers whose CRS practice has become almost entirely abdominal, with very little anorectal surgery and no endoscopy, and I simply wouldn't be happy in that scenario.

For you both, though, you are in a situation where you have to say "yes" to whatever comes through the door, so the only encouraging thing I can say is that the referrals get more desirable with time.

 

[doc05]

Interesting to hear all of this. I don't know that it ever gets better. Maybe why so many surgeons tone down their practices after a few years.

 

[deleted859535]

I'm an EM attending just passing through, but I respect the outlook. For whatever it's worth, I'm in my first few years out and have had the same healthy respect for avoiding any outcome less than perfect in my own specialty. I became much more comfortable after the first year.

Not the same specialty, not the same training, and not the same hands-on care, but maybe something that goes to show that it's more reflective of being a new, appropriately conscientious attending despite the specialty.

 

[TypeADissection]

Thank you to OP, SLUser, vhawk and filter for your replies. This has been an incredibly insightful thread to read. It's so easy to be the chief resident right now and crank out some elective and emergent cases while making it look easy. Because I know I can always call someone who can fix my f**k ups. But I know there is a day soon where it will be just me, and where every decision I make for even the simple things will make me second guess. This has been a nice reminder to keep reading, learning and most of all, staying humble. Cheers.

 

[anonperson]

Hoping to get some real talk here.

I'm an attending surgeon in the first few years of practice. All I can think about is early retirement. Not became I don't like work - I like it. Not because I want to spend more time doing hobbies - I do, but I have plenty of time right now for them. I want to retire early because I want to live without having to harm people. This is irrational, I fully understand this. I help many people, and society invested a ton of resources into training me. I help far more people than I harm.

Everyone has complications, there are no guarantees. Yet as an attending surgeon, I sign people up for surgery. And even though I tell them the risks, nobody cares about percentages. All they care about is whether they trust me. Most of them do great, but I never think about those cases. The cases that haunt me are the ones who don't do as well. It's not even about them dying or having a major complication. I think about the SFA CTO I treated. I extended a dissection to the popliteal artery. I treated it fine, but that will potentially compromise a fem-above knee pop bypass in the future. There hasn't been actual harm, but I did maybe burn a bridge.

Intellectually I know that I am being unreasonable. I obsess about having the best possible outcome. When I have a bad outcome I think about constantly thinking about what I could have done differently or better. I do my best and I know that I will never have a 0% complication rate. But emotionally it bothers me. I just want to help, I never want to harm. It's irrational but at the same time it affects what I do.

Is this an anxiety issue? Part of being an attending and assuming all of the responsibility? It just seems like there was an exponential jump in anxiety from being fellow to being attending.

How did others deal with the emotional/visceral aspect of harm?

A few months out of OB GYN and urogynecology fellowship. Am doing a mix of everything right now.

There is a decent amount of stress and you are not alone. I'm hyper paranoid in the OR double checking things that I took for granted in my training as I always had that attending backup.

Have been in a couple of hairy situations (repeat c section times 3) that i had the pleasure of doing number 4. Of course belly was a mess. I thought everything was dry when i closed but post op she developed tachycardia and decreased urine output. Almost took her back but was able to chase her with blood. Was scary and a close call.

Another time i was assisting some old guy on a vaginal hysterectomy. He gets a big cystotomy by the ureters/trigone and looked at me to fix it. Gee thanks bro. Was worried she was going to end up with a fistula but thankfully she is ok.

I know in my training and in my short career I have caused patient harm unintentionally but i do know i have saved more people and improved their quality of life.

I think the thing to remember is we are human and we are doing our best in jobs that are stressful and difficult. That gets lost on plenty of patients, admins, and lawyers unfortunately

 

[dynx]

Brave post.
I think what you’re feeling is normal but maybe at the far end of normal.
I’m <5 years out and noticed that for the first couple of years yeah, every complication weighs on your concience and further you feel like you’re being scrutinized for every bad outcome. That somebody is gonna come along and say “whoa! A stroke! This guy sucks!”.
I would (and still do) turn complications over and over in my mind wondering what I could have done different or did wrong. It can be maddening if you let it. Then 2 things happened:
1. A 52 year old guy had a dissection with extrav from the underside of his arch. Long case, full debranching and TEVAR. Did great, except a tiny little stroke (I mean tiny measurement wise) but took out his left side. Frankly, it was a miracle he wasn’t dead. And I realized even with crap like that he’s better off having had me around.
2. Shortly after a very nice lady...83 with pulm fibrosis had a dissection. She said she was a fighter and wanted everything done. She would have had a horrible outcome regardless. As soon as I said we’re going to the OR she coded and died.
Those cases drove home some points.
You can do an amazing job and get robbed. You can be the best option that patient has and still have a “bad” outcome that’s still better than the alternative.
You are fixing real problems and filling a need to give people a chance with terrible diseases.
I’ve got more but my 3 year old is hanging off my neck.

 

[boogaaloo]

What you are going through is 100% normal and 100% necessary in your growth as a young attending surgeon. We certainly claim to worry and suffer as residents/fellows, but there is a very dramatic increase in your worrying and suffering when there's nobody upstream to rely upon for reassurance/confirmation during difficult decisions, and nobody upstream to share the weight of the blame when things go wrong.

I suggest that you continue to discuss cases with your mentors. Most of them will happily take your call, and their experience is priceless.

I have talked about this at length in the past, and I will post some old comments below, but in general the way that I cope with this is to read more and work harder than everybody else, allowing me to feel (regardless of accuracy) that I'm truly the best for the job.

Once again, this is normal and necessary, and I'd be scared if you DIDN'T feel it.

From this thread: How do you cope...

"You will become slightly calloused over time. However, I promise that the burden of complications becomes much heavier once you become the attending.

Honestly, I think that some surgeons cannot handle it, and gravitate toward cases where the complications are fewer or perhaps less severe. Within my own field, some surgeons will concentrate on endoscopy and outpatient anorectal cases, only doing occasional abdominal cases. They make better money, and sleep well at night, so it's hard to blame them.

I have plenty of complications, and what I tell myself is that it's the price of doing business. If I'm going to be in the big leagues, and be doing large complex surgeries on complicated patients, then I'm going to have some bad outcomes. This doesn't stop me from sleeping bad on some nights though."

From this thread: GS PGY3 burning out. Is decent work/life balance possible once BE/BC Attending?

"Last week I had 3 very difficult laparoscopic cases that tested my patience, my resilience, and my confidence, but ultimately ended well. That same week I was privileged to tell 3 cancer patients that their pathology was favorable and their prognoses are excellent. I love the ups, and I am strong enough to handle the downs. The weight of my patients' complications, liability, unpredictability, and sadness is heavy, but I am willing to carry it because I know that's the price of being in the big leagues....high cost, high reward. I want the responsibility, I want the glory, I want it all. It takes sacrifices on all levels, but the patients come to my hospital to see me because they've been told that I'm the best.....which is debatable, but still....and I value that trust.

I made that paragraph self-aggrandizing on purpose, BTW. I think surgeons develop gargantuan egos because it's a necessary defense mechanism. How else can we justify the sacrifice? More importantly, how else can we stomach the complications? The only way I can sleep at night after a leak...or a stroke...or a death....is if I truly believe that I was the best man for the job. So the patients come to the hospital for me, and they meet you in preop and give you little regard, and that is not fair because your contribution, like that of many other faceless physicians, is priceless....but I want to be the face of their cancer journey.

OP: that was my motivation. Others want something to do between 8 and 5, and they are happy with their choices. My motivations are trite and perhaps still a bit naïve, but they are mine. You should find your own, and use them to make a very tough decision. Your feelings are normal, and it's acceptable to switch specialties. It's also acceptable to grind it out, and ultimately take a less grandiose approach to your own surgical career. Good luck, and feel free to PM me if I can help in any way."

And finally, my discussion of the weight: Tell me about your weight during residency/fellowship, SDN

"I've been thinking about this thread a lot over the last couple weeks. There's a much bigger weight that you carry after graduation that I didn't mention, and that's the weight of your complications, your deaths, your failures....even if your success:failure ratio is excellent, your failures will still be quite heavy, and your success will be "rewarded" with more responsibilities and obligations ("opportunities"). Outside of the hospital, as you age and mature you also carry the weight of your family, your health, finances, aging, illness, etc. Many of us felt this prior to graduation, but it really starts to get heavy as you get farther along. When in training, you are allowed to focus almost entirely on work. You can submerge yourself in training, and essentially defer most other responsibilities. Many (but not all) residents are young, and have few obligations outside the hospital. Residents often benefit from the "lightness" of having a surgeon upstream to consult when they need help, and blame when things go bad.

Depending on your grit and your previous failures, you may be able to carry on, or you might crushed under this increasing weight. Retrospectively, I'm shocked that we become experts in such complex medical situations, but we remain novices in how to run a business, how to manage money, how to support a lonely spouse, how to be supportive to your children, how to remain active and healthy, how to avoid drinking too much booze, etc. It's really no surprise to me now that the burnout rates are so high among surgeons.

Anyway, you should all be thinking now about how you're going to handle this weight, as it is a necessary component of being in the big leagues. Honestly, I welcome it. I feel like it's a reward. Still, the legs tire from time to time."

This post deserves a prize.

 

[vhawk]

Thanks for the OP. This is a topic that has been weighing extremely heavily on my mind lately as well. I'm still in my first year of being an attending, but in contrast to the more typical situation of slowly building a practice and starting out with smaller cases, my group had been recruiting for a while and desperately needed someone, and I was thrown into the deep end from practically day one (first whipple was morbidly obese woman who had gotten extensive neoadjuvant chemo and rads and required a complete SMV resection with interposition reconstruction, first liver case was extended right hepatectomy with tumor abutting IVC), and I echo basically all of the things you say in your OP. It is shocking to me the change in mindset that I've undergone in 6 months of being the attending on these cases. Even in fellowship, I moonlighted as a general surgeon, such that I was ultimately 100% responsible for decisions and operations, and was operating entirely independently, in the middle of the night, with no residents and no partners. But it felt nothing like this. I feel that every decision I make is potentially a target for scrutiny and second-guessing. I feel that every case I do is potential to do something stupid.

And shockingly, despite the case load and the absurd complexity, I've actually been extremely fortunate so far that I haven't even really had any bad complications. I've had some DGE, a wound infection or two, some readmissions, but basically I'm massively overperforming my expectation (I dont mean that I personally am doing anything well, just that I'm "running hot" in terms of outcomes).

Nonetheless, I dont sleep. I wake up at 1am in a panic that I left a sponge in that guy and cant go back to sleep, trying to come up with any justification to order an xray to make sure that I'm just being paranoid (so far I have not left anything in anyone!) I have never had a panic attack in my life, have never suffered from anxiety or depression, if anything I would almost certainly be described by those who know me as sort of a callous, cocky, arrogant person who may or may not be dead inside. But I feel that at least 2 or 3 times a week I am seconds away from a fullblown panic attack, it gets hard to breathe, my heart rate shoots up. So far this has never happened in the OR (and in fact, the time in the OR is for the most part the only time that I am actually happy and focused and confident. I do not feel that any of this has bled into my operative performance, but I dread the cases even in the preop area).

I appreciate SLUsers responses as well. I also felt like I wanted the big cases, I was good enough to handle them, I was the best man for the job. To some extent I do still feel those things. But I'm just not sure that I want every single case, every single day, to be the hardest most complicated most perilous case of my entire life. I have to believe that this will get better as I gain some experience, but I cant imagine doing this for another 30 WEEKS, much less another 30 years.

So just to give an update to this, about 1+ month later and none of this has improved, if anything its worse. Had a long meeting with my division chair about it today, he was very supportive and the meeting was definitely helpful to me, but not really sure that there are any "solutions" per se. Also spoke with a coworker who went through a similar thing and ended up changing her practice dramatically, and is much happier for it. I'm really on the fence about this. I dont know if my current employer would really have a role for me if I wasnt doing what I'm doing now so that means I would have to find a new job, but the main reason I took this job was to do these cases, I dont have any particular ties to this area or anything. Its hard for me to really have true perspective on how much of this is just growing pains and new attending stuff, stuff that I would be feeling no matter what, and how much is stuff specific to what I do. Sure it could all just be temporary stuff, but it could also be that I hate this and am not cut out for it....how can I tell the difference, other than wait and suffer more, and if it gets better, it was the former?

The only thing that has changed from last month is that I can no longer say "and I havent even really had any bad complications..."

 

[doc05]

So just to give an update to this, about 1+ month later and none of this has improved, if anything its worse. Had a long meeting with my division chair about it today, he was very supportive and the meeting was definitely helpful to me, but not really sure that there are any "solutions" per se. Also spoke with a coworker who went through a similar thing and ended up changing her practice dramatically, and is much happier for it. I'm really on the fence about this. I dont know if my current employer would really have a role for me if I wasnt doing what I'm doing now so that means I would have to find a new job, but the main reason I took this job was to do these cases, I dont have any particular ties to this area or anything. Its hard for me to really have true perspective on how much of this is just growing pains and new attending stuff, stuff that I would be feeling no matter what, and how much is stuff specific to what I do. Sure it could all just be temporary stuff, but it could also be that I hate this and am not cut out for it....how can I tell the difference, other than wait and suffer more, and if it gets better, it was the former?

The only thing that has changed from last month is that I can no longer say "and I havent even really had any bad complications..."

Unfortunately, big cases lead to big complications.

The reality is that you're doing high risk operations and maybe don't have good mentoring...a situation I'm familiar with.

A lot of this is growing pains, but it won't get better for a couple years. Try to learn from your bad outcomes and all the cases you wish you hadn't done.

Putting it all together, keep in mind that you'll probably be a better surgeon in the long run if you stay in your current role, but will also lose a lot of sleep, time with friends and family, etc.

Don't rush to make a decision at this point, but do start thinking about what else/ where else you'd be doing if you stop doing your current work.

 

[vhawk]

Thanks appreciate the advice. My rational brain recognizes that, from the outside, this is probably normal, I'm probably doing fine, it's early, it probably gets better. But from the inside my less than rational brain says get out, id rather flip burgers, if I sell enough plasma I can pay of my loans and my kids probably like eating dog food anyway v

 

[VincentAdultman]

Thanks appreciate the advice. My rational brain recognizes that, from the outside, this is probably normal, I'm probably doing fine, it's early, it probably gets better. But from the inside my less than rational brain says get out, id rather flip burgers, if I sell enough plasma I can pay of my loans and my kids probably like eating dog food anyway v

All I can say is that there were multiple times during residency and beyond where I thought that I'd be much happier just being free of this stress and waiting tables at Olive Garden.

I can't say I've ad an experience like yours as an attending but I can say that it took a long time for me to get to a point where certain seemingly routine procedures no longer terrified me. I'm not talking about anything on the level of a Whipple.

Hang in there man.

 

[SLUser11]

Thanks appreciate the advice. My rational brain recognizes that, from the outside, this is probably normal, I'm probably doing fine, it's early, it probably gets better. But from the inside my less than rational brain says get out, id rather flip burgers, if I sell enough plasma I can pay of my loans and my kids probably like eating dog food anyway v

Self-doubt is necessary...it just means you're self-aware. You won't see dramatic changes over short periods of time, e.g. 1 month.

If you are doing the cases you want to do, but finding them more stressful than anticipated, then this is a perfect example of when you need to lean on your mentors, and touch base with them frequently. You need mentorship. Feel free to PM if you have job specifics that you don't want to share.

It's definitely too early to throw in the towel and look for a new, simpler job. It's also still 100% normal to feel the way you do. Right about now, you're seeing all the issues with your job/institution that you didn't recognize when you signed, and it's a surprising underbelly. BUT, all jobs have these unrecognized downsides.

Just on SDN you can go back and see how common the scenario is. However, I agree that such reassurance doesn't really solve the problem when you're IN it, and you're the one not sleeping, etc. It's simple advice, but I would simply say, "hang in there."

 

[vhawk]

Self-doubt is necessary...it just means you're self-aware. You won't see dramatic changes over short periods of time, e.g. 1 month.

If you are doing the cases you want to do, but finding them more stressful than anticipated, then this is a perfect example of when you need to lean on your mentors, and touch base with them frequently. You need mentorship. Feel free to PM if you have job specifics that you don't want to share.

It's definitely too early to throw in the towel and look for a new, simpler job. It's also still 100% normal to feel the way you do. Right about now, you're seeing all the issues with your job/institution that you didn't recognize when you signed, and it's a surprising underbelly. BUT, all jobs have these unrecognized downsides.

Just on SDN you can go back and see how common the scenario is. However, I agree that such reassurance doesn't really solve the problem when you're IN it, and you're the one not sleeping, etc. It's simple advice, but I would simply say, "hang in there."

Thanks. I may PM you at some point.

 

[filter07]

I think one of the common experiences that vhawk and I have is that we are often the only ones doing our complex niche operations/procedures. There is no real benchmark other than abstract mortality/morbidity data in NSQIP or the literature. And those things don't help much. There's no other person in the hospital or group you can look at to say that your outcomes are better/same/worse than someone else. Or at least someone who knows the patient population, disease process, and have the surgical experience to critique or reassure. You're kind of out there on your own and you don't have enough experience to wonder if that death or complication is something you did poorly, patient disease, or just bad luck.

I agree that a mentor would really help. I don't know about you but I'm not one to just shoot the breeze with my old faculty. It's just not how I am. I like them but I don't really look for help, especially if there isn't something specific I'm asking about.

I work with dialysis patients and everyone knows they are some of the sickest people in the hospital. But I am greedy; I want all of them to do well and think my "minimally invasive" procedures are benign. They aren't. The patients aren't the picture of health either. Sometimes s*** happens, it feels terrible, I don't have an answer, it's just how it is.

The thing I struggle with is the guilt I feel. Even if I'm 99% convinced I did everything right and bad outcomes are a necessary part of sick patients and big operations, there is 1% of me that still doubts. I wonder about what the patient and their loved ones think. Maybe in their perspective I killed or maimed them. I go on with my life getting paid well, going on vacations, living comfortably while their lives are changed forever. How do you deal with that guilt even if it's irrational?

 

[vhawk]

The thing I struggle with is the guilt I feel. Even if I'm 99% convinced I did everything right and bad outcomes are a necessary part of sick patients and big operations, there is 1% of me that still doubts. I wonder about what the patient and their loved ones think. Maybe in their perspective I killed or maimed them. I go on with my life getting paid well, going on vacations, living comfortably while their lives are changed forever. How do you deal with that guilt even if it's irrational?

This is exactly how I feel

 

[doc05]

I think one of the common experiences that vhawk and I have is that we are often the only ones doing our complex niche operations/procedures. There is no real benchmark other than abstract mortality/morbidity data in NSQIP or the literature. And those things don't help much. There's no other person in the hospital or group you can look at to say that your outcomes are better/same/worse than someone else. Or at least someone who knows the patient population, disease process, and have the surgical experience to critique or reassure. You're kind of out there on your own and you don't have enough experience to wonder if that death or complication is something you did poorly, patient disease, or just bad luck.

I agree that a mentor would really help. I don't know about you but I'm not one to just shoot the breeze with my old faculty. It's just not how I am. I like them but I don't really look for help, especially if there isn't something specific I'm asking about.

I work with dialysis patients and everyone knows they are some of the sickest people in the hospital. But I am greedy; I want all of them to do well and think my "minimally invasive" procedures are benign. They aren't. The patients aren't the picture of health either. Sometimes s*** happens, it feels terrible, I don't have an answer, it's just how it is.

The thing I struggle with is the guilt I feel. Even if I'm 99% convinced I did everything right and bad outcomes are a necessary part of sick patients and big operations, there is 1% of me that still doubts. I wonder about what the patient and their loved ones think. Maybe in their perspective I killed or maimed them. I go on with my life getting paid well, going on vacations, living comfortably while their lives are changed forever. How do you deal with that guilt even if it's irrational?

Yes, your guilt is irrational. Mostly the bad outcomes are not your fault. Sometimes they are. Even so, feeling "guilty" won't help your patient, or you, or your next patient either. As I wrote earlier, just learn from your mishaps and move on.

Also keep in mind that in your first years in practice, a lot of what you learn is who not to operate on ... some never develop the right judgement, but hopefully you will. Better case selection will yield better outcomes.

 

[IlDestriero]

I work at one of the major Children’s Hospitals and we also get the high acuity, high risk, don’t want to touch that with a 10’ pole kinds of cases all the time, they really do fly in from all over the world. It’s definitely not for everyone. We recently got a new experienced anesthesiologist from another children’s hospital and one of her early comments was, “The acuity here is insane.”
Some love it, thrive on it, and want to be here forever. Many alter their practice in various ways to decrease the acuity after a while. And some head out to places that wouldn’t touch many of those kids with a 10’ pole.
There’s nothing wrong with deciding that you’d rather not be doing the worst of the worst cases/patients day after day and week after week and year after year. I’m out of the main OR about 1/2 the time, and that’s great! I’ve been here for a decade! I’ve earned it. I can still do everything that they can throw at me, and believe me I do, but I’m happy to spare myself the constant stress of a one day old one lung vent thoracotomy or resections of tumors that are 1/2 the size of the baby, etc. I’ll be up in GI, or out at the ASC. I definitely still like being at the tip of the spear, but just not every day.
Do some soul searching and figure out what will make you happy and what options you have. You’ve got a long career ahead of you, so you might as well be happy about it. I can tell you that if you want to change jobs, significant experience at one of the Mecca’s opens a lot of doors, including some that are notoriously hard to open.
And if all else fails, just sell out for the money. I think about that often. 😉 I’ve got a couple irons in the fire just in case I decide that I’ve had enough. And I won’t lose any sleep about leaving Mecca in the rear view mirror.

-I actually meant one day old one lung vent thoracoscopy. I love it when they go open!
Time for a drink. Happy new year!
--
Il Destriero

 

[Diagnostic Laparotomy]

How did others deal with the emotional/visceral aspect of harm?

Also a new attending here, been in practice for a couple years now out of fellowship.

One of the very worst experiences I had as a resident was seeing the occasional functional human being ruined (or worse) by complications after elective surgery. Intellectually I know that those cases were medically indicated and a net benefit was rendered after a given procedure to a cohort of similar patients, but each case that goes wrong is emotionally draining.

Ironically, this is what helped me make my decision to take care of some of the most critically ill surgical patients that exist. I do trauma/ACS/critical care. I'm a good surgeon and have a good record (knock on wood), but at the end of the day if a trauma patient doesn't make it - it wasn't me who shot the patient.

My cases generally are simply not elective. Many are literally do or die and under those circumstances I try my best but I don't feel the same level of direct responsibility for their outcomes.

They didn't walk in for an elective operation. They are a mess from the moment I meet them.

 

[vhawk]

Also a new attending here, been in practice for a couple years now out of fellowship.

One of the very worst experiences I had as a resident was seeing the occasional functional human being ruined (or worse) by complications after elective surgery. Intellectually I know that those cases were medically indicated and a net benefit was rendered after a given procedure to a cohort of similar patients, but each case that goes wrong is emotionally draining.

Ironically, this is what helped me make my decision to take care of some of the most critically ill surgical patients that exist. I do trauma/ACS/critical care. I'm a good surgeon and have a good record (knock on wood), but at the end of the day if a trauma patient doesn't make it - it wasn't me who shot the patient.

My cases generally are simply not elective. Many are literally do or die and under those circumstances I try my best but I don't feel the same level of direct responsibility for their outcomes.

They didn't walk in for an elective operation. They are a mess from the moment I meet them.

I certainly understand that mindset and the cases that I actually manage to sleep comfortably after are the call cases where someone comes in with dead bowel or free air. That was a do or die situation and if they end up with a hernia or an abscess, great.

None of my cases are really elective, but it isn't quite the same as trauma. Sure, if I don't operate on them, they will die....in 18 months, of which 12 of that will have been spent with their family with reasonable QOL. 3 weeks dying in the SICU is still a lot worse.

Plus despite what the patients and their families think, it isn't like I'm curing a huge number of these people. So even the wins are mostly just delayed losses.

 

[idiot07]

Echo what you guys say. I'm a couple a years out doing general thoracic surgery. Part of the reason I chose it (considered surg onc), is the typical patients (stage I and II lung cancer) do pretty well post operatively and oncologically, especially compared to your average whipple. My esophagectomies have done well postop, but of course it's a more mixed bag with cancer outcomes. I do a fair bit of airway surgery and assorted weird thoracic stuff (which is usually for benign disease and can have some catastrophic complications), and I still don't sleep for two weeks after I do one of these or a goose. There's something about seeing a patient in clinic, counseling them on a huge whack for potential benefit and then having them not do well that just sucks. I still have trouble getting over it, and I don't know if that'll change. Emergency cases and transplants, you expect them to struggle a bit and it's ok. For me it helps to have the smaller cases mixed in too, and I have supremely supportive senior partners. I don't think I could've done cardiac or peds from a psychologic standpoint and remained sane. I think you just have to figure out what you can tolerate and adjust your practice. To quote one of my old bosses when it comes to bad long term cancer outcomes: "Local control and the psychological chance of cure are valuable to patients and undervalued by doctors." and "You ain't treating the sniffles."

 

[Diagnostic Laparotomy]

I certainly understand that mindset and the cases that I actually manage to sleep comfortably after are the call cases where someone comes in with dead bowel or free air. That was a do or die situation and if they end up with a hernia or an abscess, great.

Last week in the OR my residents were getting worked up about this old lady's large ventral hernia that I opened through going after a perforated duodenal ulcer.

I told them that if she lives long enough to get a recurrence I'd call that a win.