September 23, 2011

The Mind of a Surgeon

(and yup, that ones actually me - in my lead suit to protect me from x-rays! - can you tell I'm smiling?) 

today in the OR I was talking with the PA who was first assisting about the Whipple procedure we (really she and the attending) were working on.  A Whipple is a procedure most often done for pancreatic cancer, but because the pancreas is sort of hidden within all the folds of the intestines it's often hard to see on imaging and therefore hard to figure out if there is a tumor there.  This means that in the beginning-middle of the procedure, the surgeon takes biopsies of the pancreas and sends them to the lab to be quickly assessed by a pathologist.  This usually takes anywhere from 10-20 minutes and then the pathologist calls the OR and tells the surgeon: cancer or not cancer (and a few more details).  This pathology report along with the surgeon's own view of that patient's abdomen (to see how far the cancer has spread, if there is any) determine if the operation will continue.  

so anyways, while the surgeon was on the phone talking with the pathologist, I asked the PA what we would do differently if the biopsy came back negative for cancer. Our suspicion of cancer was high in this particular patient and I was really wondering if we would a) do more biopsies to see if we just missed the cancer, b) proceed with the operation anyways because we were pretty sure he had cancer and NOT treating pancreatic cancer has a <1year survival prognosis, or c) wait and not do the procedure because of the risks.  

she said she didn't know.  That even though she knew the technique of the procedure and had done it many times, she had no clue about the clinical decision-making involved and didn't seem very curious about it.  So I asked the surgeon who explained the intricacies of how we decide what to do - and how sometimes it's each of the decisions above, depending on the patient and the cancer.  Which is when I realized, that's why I went to medical school (and not PA or NP school, which I also considered) - because I want to know all the WHY we do things in medicine - not just the HOW.  To clarify, I'm not saying that all PAs do not care about the WHYs; actually there's a lot of the WHY involved in really knowing the HOW.  But it was affirming for me because when people ask me why I went to med school - and not PA or NP programs - I tell them that I wanted to be calling the shots.  Not all of them, and not always by myself, but I wanted to strive to be able to practice medicine in line with my own clinical knowledge and decision-making.  So it's cool to realize that this clinical decision making is what makes doctor training different and that I am being taught how to do it.

"When it's over I want to say: all of my life I was a bride married to amazement, 
a bridgegroom taking the world into my arms"
- Mary Oliver (one of my most favorite poets)

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