Embarrassing question/I think there's something wrong with me

[addy]

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Hi guys.

I'm a MS-3 and I will be doing my surgery rotation but I recently finished IM and I came to an odd realization while I was on the Heme/Onc floor--I love working with terribly/terminally ill patients and, probably the most messed up admission I have coming out of this, I love giving bad news. Sure, the first time I sat in on a "family meeting" I started crying like a baby, but I realized that if someone HAD to give bad news to a family, I wanted to be that guy. Unfortunately, I think I've become obsessed with having this aspect of medicine in my career.

So, I have a really messed up and sadistic question to ask: are there any surgical fields like Heme/Onc with regards to the "death is a colleague" aspect of medicine? I have always been interested in neurosurgery or CT surgery. I've never really considered Surg/Onc, but now I am starting to--do any of these fields have those types of conversations with the patient and/or their families?

Thanks.

And I hope this doesn't make me come off as a sociopath.

 

[SouthernSurgeon]

Acute care surgery/trauma surgery. Walk in the door with a patient/family you've just met, and you often are the one left to tell it like it is.

In all seriousness, this is actually I think a really important aspect of surgery. We very often have to have difficult conversations with families. We come in when things are bad, and often the primary care provider/oncologist/hospitalist either hasn't told them the full scope of things yet or doesn't understand it.

Surgeons can be blunt, but often times we end up being the first ones having these conversations.

Personally I know I'm good at these conversations, and have saved a couple of patients from an unnecessary pre-mortem by explaining to the family what was really going on. I don't know that I "love" doing it, but I'm willing to and do get some emotional energy out of engaging with and getting to know families in these times.

With regards to surg/onc - obviously depends on what area of oncology you choose to focus on. But for solid tumors/HPB/etc? There will be a lot of new patient consultations where you have to deliver the news to the patient that their disease is not resectable. And often you'll get consults for end-stage disease and have to deal with palliative operations for things like malignant bowel obstruction.

Plus, have you heard the old joke: why do they put nails on coffins?

Spoiler

To keep the oncologist from giving another round of chemo.

 

[stevesteve123]

hem/onc

had a family friend in her early 20's who was recently diagnosed with a non-hodgkins lymphoma and was called in to the hospital to be given the diagnosis. she was obviously oblivious to the fact that she might have cancer since cancer is usually regarded as something that older people get. so yea she was a naturally joyous and optimistic person and as she was making her way through the chemo ward she was jokingly like "omg look at all these sick people around me, i dont belong here i wonder why they called me to tell me to come to this place".

then the doc comes out and went on with his spew and whatever routine bs they do during the the disclosure conversation. She didnt even fully comprehend whatever the doc said, all she asked was : "so does that mean I have cancer?". and the doc just simply nodded his head. in that exact instant u could pretty much see all the hopes and optimism and sparkles flee her body like air being let out a balloon and her soul being crushed

u'd f'ing love it i guarantee it

 

[addy]

hem/onc

had a family friend in her early 20's who was recently diagnosed with a non-hodgkins lymphoma and was called in to the hospital to be given the diagnosis. she was obviously oblivious to the fact that she might have cancer since cancer is usually regarded as something that older people get. so yea she was a naturally joyous and optimistic person and as she was making her way through the chemo ward she was jokingly like "omg look at all these sick people around me, i dont belong here i wonder why they called me to tell me to come to this place".

then the doc comes out and went on with his spew and whatever routine bs they do during the the disclosure conversation. She didnt even fully comprehend whatever the doc said, all she asked was : "so does that mean I have cancer?". and the doc just simply nodded his head. in that exact instant u could pretty much see all the hopes and optimism and sparkles flee her body like air being let out a balloon and her soul being crushed

u'd f'ing love it i guarantee it

I know heme/onc does plenty, I guess I was curious about the surgical side of it, If there are any surgical fields with a comparable experience

 

[stevesteve123]

I know heme/onc does plenty, I guess I was curious about the surgical side of it, If there are any surgical fields with a comparable experience

thats tough bro since your skills and levels of competency would inherently be inversely related to your job satisfaction

 

[addy]

thats tough bro since your skills and levels of competency would inherently be inversely related to your job satisfaction

I'm not following, can you elaborate more?

 

[Pir8DeacDoc]

A good surgeon doesn't necessarily want to be handing out bad news, it means your surgery wasn't successful.

 

[deleted547339]

This is almost comical. Our oncologists never give bad news. "You have stage IV rare untreatable cancer that has a 0% 6 month survival. Don't worry, we can cure this....we'll put you on our new trial that will definitely work."

That's roughly how I imagine the conversations go in our heme/onc department.

 

[TraumaLlamaMD]

From what I've seen, general surgery even without specialization has its fair share of bad news and tough conversations. General surgeons frequently deal with colon cancer and breast cancer, not to mention lots and lots of elderly folks with things like mesenteric ischemia and terrible vascular disease.

I think a lot of times, the tough choice - and the hardest conversation to have - is not so much "can we operate on it" as "should we?" As in, even if the surgery is technically a success, it may not restore quality of life and may in fact prolong life beyond what the patient might wish. The skill to have this kind of talk with a patient and/or family is remarkable to watch.

On my liver oncology service we had many patients for whom we could only prolong life for a short time, or for whom an operation would probably cause more morbidity than it could prevent. That was a tough few months for the psyche but something to consider if you like being with patients going through their hardest times.

 

[dienekes88]

Interesting. Most people who like that sort of thing don't seem to like operating. The thing that attracts me to surgery is that it is a definitive fix. A chance to cut is a chance to cure. When you bring someone to the OR for a lung resection, it's because you think you have a reasonable chance of curing them. Otherwise, what the heck is the point of cutting someone open?

It's a tautological argument, but bad outcomes are bad. Sometimes patient families understand that the cases are high risk. Sometimes they don't and wonder why you couldn't save grandma.

 

[Dares Dareson]

Hi guys.

I love working with terribly/terminally ill patients and, probably the most messed up admission I have coming out of this, I love giving bad news.

And I hope this doesn't make me come off as a sociopath.

 

[Dr.LeoSpaceman]

There is definitely room for this in surgical oncologist. And to be honest, I actually think it's actually a necessary skill since I think the stereotype that a surgical oncologist has a single-track mind to find all cancer and cut it out is outdated.

The way I conceptualize the role of a surgical oncologist (and why I like it), is to help formulate the course of therapy which best aligns with the patient's disease and ultimate goals of care. Yes, that may often include surgery...but it's also going to include talking to patients about why surgery may not be appropriate. The problem is that this skill, in the era of procedure-based reimbursement, can hurt your bottom line. I think (or at least, I hope) that will change in the future, but who knows.

 

[Winged Scapula]

There is definitely room for this in surgical oncologist. And to be honest, I actually think it's actually a necessary skill since I think the stereotype that a surgical oncologist has a single-track mind to find all cancer and cut it out is outdated.

The way I conceptualize the role of a surgical oncologist (and why I like it), is to help formulate the course of therapy which best aligns with the patient's disease and ultimate goals of care. Yes, that may often include surgery...but it's also going to include talking to patients about why surgery may not be appropriate. The problem is that this skill, in the era of procedure-based reimbursement, can hurt your bottom line. I think (or at least, I hope) that will change in the future, but who knows.

This is a reasonable way of approaching an oncologic practice. Since patients will often see you first, either for consultation and/or biopsy, you are in the position of "driving the bus". To further that analogy, you may not take the patient all the way to their final destination but it is your job to see that they get to where they need to be next - whether that be surgery, neoadjuvant chemo/radiation or palliation. Not all patients with malignancies are surgical candidates and not all malignancies are best treated with surgery.

While I wouldn't say that I "enjoy" giving bad news (and I suspect our OP misused the term - if you enjoy hurting other people, then that is a psychopathology), I'm good at it and would rather they hear it from me than any number of other providers that aren't as comfortable and/or skilled at it as I am.

 

[addy]

While I wouldn't say that I "enjoy" giving bad news (and I suspect our OP misused the term - if you enjoy hurting other people, then that is a psychopathology), I'm good at it and would rather they hear it from me than any number of other providers that aren't as comfortable and/or skilled at it as I am.

I did phrase it poorly, the bolded part is what I meant.

 

[Winged Scapula]

There's one of our trauma staff who is just terrible at it. I always know the morning after they are on call I or someone else is gonna have to undo some damage...

Yeah, I think we've all had someone like that in our training.

When I was in fellowship the Pre-Op nurses would ask me to come early and consent the patients of a certain attending who was so bad at it; focusing on the "you could die during surgery" part. His APN would also tell me how she hated walking in the room after he was done with "the talk" because they were usually shattered; he just didn't possess the "there, there" gene. One of the smartest men I know but skilled at bad news he was not.

 

[tiedyeddog]

I want to add neurosurgery as a surgical field that has very morbid experiences with patients and their families. It is one of the reasons I became intrigued with the field in the first place. Most hospitals have a dedicated neuro-ICU, indicating how tenuous our patients can be. Hell, our bread and butter bedside procedure, the EVD, is usually only placed once immense cerebral damage has been done. On the other hand, less morbid spine surgery is an option and predominant in the private practice world if the death and poor outcomes gets too heavy.

It's not the human suffering and pain that I enjoy, trust me on that. I enjoy the idea of helping patients and families through the worst moments of their lives. You aren't going to cure their glioblastoma, nor are you going to make someone with a complete spinal cord injury of the c7 level walk again, but you can help them with the suffering as they begin their new lives. I like this quote from Hippocrates: “To cure sometimes, to relieve often, to comfort always”.

 

[Kahreek]

...

 

[JayDoc06]

It is easy to feel deeply and be moved by the gravity of a situation as a med student. You wil either tire of it, become numb to it (dangerous), or co-exist with it (which I think is your question). Seems odd to pick a specialty based on desiring to "have death as a colleague". It is very different to be the only one in the room and other physicians have sent the patient and all of their hopes to you to see if you can help.

As surgeons, I think we are very reasonable at knowing when we can help a patient or not. I call sub specialty surgery " life at the end of the algorithm", if we can't get someone out of a tough spot, that's often it- cancer and benign disease alike. Other people might be able to drag it out, often times painfully. Getting great surg onc training in residency, covering a call group with a busy surg oncologist and doing a lot colorectal cancer, I think surgical oncology is something to look at. I bet your feelings change though.

 

[thedrjojo]

There is an up and coming surgical specialization (usually for surgical critical care) in palliative care (3 of our intesivits are palliative care certified/boarded/trained, including one of the pioneers) and it's a huge part of surgical critical care. They actually precouncil the big surg onc cases to establish long term goals in case when things go wrong