Looking forward – June 2018

David B. Hoyt

David B. Hoyt, MD, FACS

As Fellows of the American College of Surgeons, we hold ourselves to exceptionally high standards and strive to do what is best for our patients. Most surgeons, cancer surgeons in particular, often see patients when they are most vulnerable and frightened. As a result, surgeons work hard to develop trusting, caring relationships with their patients.

In his book, In My Hands: Compelling Stories from a Surgeon and His Patients Fighting Cancer,* Steven A. Curley, MD, FACS, professor of surgery, chief of surgical oncology, and Olga Keith Weiss Chair of Surgery, Michael E. DeBakey Department of Surgery; and associate director for clinical affairs, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, provides a vivid glimpse into the bond that cancer patients, their families, and health care professionals inevitably form. He shares many patients’ stories. These vignettes serve as the basis for making a larger point about what ACS President Barbara L. Bass, MD, FACS, FRCS(Hon), so eloquently described in her Presidential Address as the joy and privilege of being a surgeon. He also spotlights some key activities in which surgeons should engage to improve quality of care.

Establishing the patient-surgeon relationship

In My HandsThe patient-surgeon relationship is established during the preoperative consultation and evaluation. At this stage of care, it is crucial that the surgeon explain exactly what will occur, the risks associated with the procedure, what the patient needs to do to prepare for the operation, any potential complications, and the benefits of surgery; they also should receive informed consent. Equally, if not more, important, however, are two intangibles—validating the trust the patients and their families place in us and offering hope.

After all of the discussion and tests are over and the paperwork completed, patients commonly tell us they are putting their lives in our hands. Think about that statement for a minute. What patients are telling us is that they have faith that we will take every precaution and apply all of our skills, knowledge, and best judgment to keep them alive and, hopefully, enjoy a higher quality of life than they have known for some time. When patients undergo elective procedures, allowing one person to cut them, they are displaying the highest level of trust. It is their gift to us.

As Dr. Curley writes, “Trust is not something to take lightly or dismiss. It is an honor and a tremendous responsibility for surgeons to be granted such faith in their abilities and care.”

In return, we offer them hope. As a case in point, Dr. Curley describes the preoperative consultation he had with a 69-year-old minister with colon cancer that had metastasized to his liver. The patient had undergone chemotherapy to treat several large tumors in his liver, but this approach wasn’t working. His oncologist told the patient that he probably had six months at best to live, but referred him to Dr. Curley nonetheless. Dr. Curley told him there was a chance that the tumors could be resected, but he would be left with a “sliver of a liver.” The patient’s mood brightened upon learning that there was a chance, albeit small, that he would survive. ‘“Never deny someone hope, Doctor, no matter how hopeless you know the situation to be,’” the patient said. ‘“Humans need hope. Without it there is depression, despair, and death.’” This man survived for 11 years after his liver operation. His cancer never recurred.

Our responsibility to our patients and our colleagues

Unquestionably, the relationships we build with patients can take an emotional toll on many surgeons. It, therefore, comes as no surprise that surgeons suffer from high rates of depression, burnout, substance abuse, and suicide. Some of us avoid these issues by compartmentalizing our professional and personal lives. Others try to detach from their patients. One way they depersonalize their cases is by referring to the body part that is being operated on—that is, the pancreatic cancer or cirrhotic liver—rather than say they operated on a human being with those conditions. Dr. Curley points to the irony of this tendency when operations are such highly personal experiences and the dangers this habit poses for patient-surgeon relations. “What I have learned is that patients don’t want to be abandoned. They want to know that someone will be present and will provide assistance when they have symptoms or fears or need support,” he notes.

“We need to support our own as well,” Dr. Curley adds, stating that we should support our physician, nurse, trainee, and all other caregivers who appear despondent or overwhelmed in the face of caring for patients who are confronting frightening and potentially lethal disease.

Quality improvement activities

In addition, Dr. Curley emphasizes the importance of participating in opportunities to improve the quality of care that our patients receive through collaboration, attendance at morbidity and mortality (M&M) conferences, and tracking both short- and long-term outcomes.

Most surgeons today are accustomed to working as part of multidisciplinary teams and of collaborating not only with clinicians and researchers within our own institutions, but also with health care professionals far and wide. Dr. Curley notes that whenever he visits other institutions, he asks about the problems they are facing and the research they are performing. These conversations often lead to identifying common ground and synergistic approaches to research.

Sometimes collaboration with professionals in other fields can lead to advances in care. Dr. Curley recounts that he was once at a national surgical meeting when two engineers approached him to discuss a new device that might be effective in treating liver cancer. It was a type of needle electrode that would be placed into a tumor and could kill the tumor by heating it. After multiple refinements, this encounter led to the development of radiofrequency ablation of unresectable liver tumors. “Through all this, I learned a marvelous lesson: Always listen to ideas; always look for new opportunities,” Dr. Curley writes.

He describes the important role of M&M conferences and how these meetings should encourage an open, honest disclosure to our surgical peers, trainees, and students of any complication or death that occurred during an operation. It should be an educational opportunity for all present to learn from forthright discussions on improving patient care and surgical outcomes.

Dr. Curley also discusses the importance of tracking patients after surgery. He notes a unique aspect of surgical oncology is that surgeons follow their patients for years, if not their lifetime, watching for the success of the operation, evidence of recurrent or new metastatic disease, and treating symptoms or problems related to the therapies provided.

“Once diagnosed with cancer, patients and their physicians must remain ever vigilant because cancer couldn’t care less about statistics and probabilities. We must persevere and redouble research efforts to improve the survival time and quality of life of ever more of our cancer patients,” he writes.

A celebration of the human spirit

Dr. Curley’s book enlightens the reader on how we serve each other as human beings, professionals, and surgeons. Each story has a message for living life and for recommitting to our values as surgical professionals. And mostly, it is a celebration of the true heroes in the battle against surgical disease—our patients. “They endure the scars, complications, and impairments imposed by the blades of surgical oncologists,” he writes. “I respect the effort, the invincible spirit, and the patients who don’t give a damn about the odds or probabilities; they are going out swinging.”

If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at lookingforward@facs.org.


*Curley SA. My Hands: Compelling Stories from a Surgeon and His Patients Fighting Cancer. New York, NY: Center Street. 2018.

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