Sunday, May 23, 2010

Barriers

In the practice of surgery it is necessary to create barriers; obstacles that separate the surgeon from his patient. During any operation the surgeon and his assistants wear gowns, caps, masks and gloves which act as a barrier between the patient and the OR crew. These protective items help prevent contamination of the surgical field; keeping the bacteria that reside on our skin and in our mouths and noses from infecting the surgical wound. Indeed, certain orthopedic procedures, those in which any introduction of bacteria can be a life threatening disaster, take this barrier precaution to the extreme. The orthopedist has adopted an elaborate system of helmets and filters, strictly limits access to the room during the procedure and does everything humanly possible to banish the potentially deadly microorganism from the OR suite.

There is, however, much more to the barrier concept than protection of the patient. Unfortunately, it is a necessity of modern times that the OR crew also be protected; protected from contamination by the patient. It is one of the sad facts of our modern world that chronic infectious diseases exist. It is an almost daily occurrence that medical personnel will be called upon to care for patients with HIV, hepatitis B or C, MRSA and a host of other infectious agents that have the potential to be transmissible from the patient to OR personnel during the course of an operation. Proper barriers, proper technique and appropriate choice of operation protect us from our own patients and allow us the opportunity to live and serve another day.

At the end of most operations the final mechanical barrier is left with the patient, the surgical dressing. I have seen such dressings raised to the level of ritual, the surgeon mandating that only certain materials placed in a certain way be used, instructing the patient to leave the dressing in place for exactly 76 hours and 12 minutes and then remove it at precisely the proper time, unless there is a full moon, in which case it needs to be left until dawn the following day. A bit of an exaggeration, surely, but not as much as you might think. Personally, I think that a simple dressing is best; something that can be removed easily and painlessly in 48 hours.

The surgical dressing certainly is important, particularly for the first few hours. Most wounds, however are probably sealed from the outside world within twenty four hours. As a matter of fact, I instruct my hemorrhoidectomy patients to remove their dressings after only about six hours; for comfort and to begin proper care of the area. It is an extremely rare event for these patients to develop an infection, surprising really, given the location and environment of such surgery. There are reasons why infections in this area are rare which involve an entirely different sort of biological barrier, but that is a subject for another article.

There is another type of barrier that is necessarily built up between patient and physician. This is the psychological barrier; an invisible wall that prevents excessive bonding between a doctor and his patient, thus preserving an appropriate doctor-patient relationship, one that is intimate on a medically therapeutic level only. Medical School, at least my medical school, taught us to maintain an aloof concern for our patients, supposedly for the patient’s well being and to maintain our objectivity.

An excessively close relationship can make the patient too reliant on their doctor, while at the same time potentially cloud the physician’s judgment, leading to decisions based upon feelings, rather than proper objective findings. I carry this concept to its extreme in my upcoming novel Joshua and Aaron, as the doctors are prohibited from actually examining the patients in person. Such a scenario is unlikely, you are thinking, but the trend is already present.

Today, a patient visiting an emergency room is initially seen by a triage nurse, who makes the initial assessment of the severity of the condition and very often orders the indicated tests to help establish a diagnosis. After such tests are completed the emergency room physician will finally see the patient and confirm a diagnosis that has already been established. It won’t be long until the doctor becomes a superfluous intermediary and is completely eliminated from the equation, (Obamacare here we come).

It’s not just in emergency rooms such a scene plays out. The pressures of modern medicine force doctors to spend less and less time with the patient as regulations, paperwork and diminishing reimbursement force the doctor to do more and more in a limited period of time. However, don’t think that the quality of care suffers in such a system, because this definitely is not true. The amazing array of imaging systems and lab tests has made medical diagnosis far more accurate now than it was thirty years ago. What is lost is the personal aspect, the unique doctor-patient relationship.

In my surgical practice we have a physician’s assistant, whose job is to assist us in the operating room. When she first started with us our office manager asked me if I wanted her to help in the office. My answer was no. Surgery today requires much shorter hospital stays and the contact between surgeon and patient is greatly limited. Generally, I will see my patient once in the office; surgery will be scheduled, they’ll be seen again immediately before the operation and then once or twice more in the office afterwards. This is a far cry from years ago when the patient, for a similar operation, would go into the hospital the day before surgery and then stay for one or two weeks afterwards; certainly all this contact strengthened the physician patient relationship and lowered the barriers that existed, but in no way did it actually improve patient care or final outcome.

The current system is more economical and far better for the patient. But, it throws up a barrier of sorts. That is why I refused to have our PA see patients in the office. I am given one chance to create a relationship with my patient before surgery and I do not want anything or anyone to diminish this already limited opportunity.

There is one particular medical condition where I do everything possible to break down the barrier that exists between doctor and patient and that is with breast cancer patients. Of course all patients are important and most every type of cancer is serious, but of all the different diseases I encounter this one creates the greatest emotions and intense feelings for the patient and family and perhaps for the treating physician. I am often the physician called upon to inform a woman (99% of the time it’s a woman) of the diagnosis of breast cancer. Usually I’m the one that has performed the biopsy and often the first therapeutic intervention requires surgery. So, I have to break the news. Most of the time I’ve started to prepare my patient for such bad news even before the biopsy is done.

Probably 98% percent of the time when a woman comes to me with a lump in her breast or an abnormal mammogram or ultrasound it is immediately apparent whether or not the lump is cancerous. At this point I will tell her and her family that the findings are very worrisome for cancer, but that a biopsy is necessary. When I receive the confirmatory biopsy report I always tell her in person and make sure that I am not rushed for time while I explain all the implications and options. After the first explanation I usually explain everything a second and usually a third time, hoping that some of what I say will actually be retained. Even with all this many women hear nothing beyond the two words “breast cancer”. It is very common to get a call a few hours later or the next day asking about all the options again.

In situations like these I do my best to tear down the invisible barrier that exists between doctor and patient. The trust that is built in those moments contributes tremendously to healing for the patient and their family. It isn’t bad for the doctor, either.