Looking forward – August 2015

David B. Hoyt

David B. Hoyt, MD, FACS

I recently had the privilege of serving as a visiting professor at the University of New Mexico (UNM), Albuquerque, at the request of Ashwani Rajput, MD, FACS, chief, division of surgical oncology, and John Russell, MD, FACS, professor of surgery; chair, department of surgery; and dean, graduate medical education. As part of this event, I participated in a memorial service for UNM patients who had recently died. Bridget Fahy, MD, FACS, surgical oncologist and associate professor of surgery, department of surgery, UNM School of Medicine, and Erika Ketteler, MD, FACS, associate professor of surgery and associate program director, residency program, department of surgery, UNM, and a vascular surgeon with the New Mexico Veterans Affairs Health Care System, have led this program for the last two years.

A moving, memorable experience

The memorial service at UNM takes the place of the traditional morbidity and mortality conference once a year and provides an opportunity for faculty and residents to spend an hour remembering the patients whom they have recently lost and revealing how the experience personally affected them. Participation is voluntary, yet all of the residents and faculty from the department attended. A total of nine cases were discussed, and presenters ranged from interns to attendings.

The participants shared their experiences in providing care to dying cancer patients, explained how they used critical decision-making skills to treat trauma patients and, perhaps most movingly, described what it was like to lose pediatric patients whose lives were cut far too short. Particularly noteworthy was the thoughtfulness, introspection, and maturity that the interns and residents displayed when telling their stories. All of us were truly mesmerized as we listened to these young health care professionals convey their personal experiences. The reports were extemporaneous but comprehensive, really cutting to the soul of what it means to be a surgeon and provide care to a patient who is dying.

In fact, these presentations were some of the most honest and emotionally moving discussions of patient outcomes and care that I have had the honor of hearing in 40 years of surgical education, training, and practice. Even the most self-assured residents opened up and articulated their feelings about the grieving process and how they were able to find the resilience to continue caring for critically ill patients.


UNM residents, from left: Eyas Alkhalili, MB, BS; Ana De Oliveira, MD; Jacquelyn Brandenburg, MD; Rebecca Sauerwein, MD; Alissa Greenbaum, MD; Zoe Jones, MD; Lindsay Jinkins, MD; Barkat Ali, MD; Margaret Rigamer, MD; Nova Szoka, MD; and Richard Miskimins, MD.

Building on past experience

The organizers of the event, Dr. Fahy and Dr. Ketteler, are among the only 65 or so U.S. surgeons board-certified in hospice and palliative medicine, and both are members of the American College of Surgeons Palliative Care Committee. Unquestionably, both of these surgeons are deeply concerned about the quality of care that end-of-life patients receive. “With two surgeons with expertise and training in palliative care, our residents have learned that speaking about patient death and the impact that these losses have on our trainees is acceptable and supported,” Dr. Fahy said.

The memorial service program builds upon a quarterly program called Surgery Death Rounds, which Dr. Ketteler has facilitated since her arrival at UNM eight years ago. “These death rounds have been well received by faculty and residents and have contributed to an environment that allows our residents to share their patient death experiences. Since Dr. Fahy’s arrival here two years ago, the discussion that a patient has died—not passed, expired, or some other euphemism—is even more in focus,” Dr. Ketteler added. “Palliative care input for our surgical patients is not taboo at UNM, and the residents participate in providing that care and see such care as just a normal part of being a thorough and competent surgeon.”

Dr. Fahy agreed, adding, “In the [death rounds] program, residents present cases of patients who have died, with an emphasis on the ethical, emotional, and other nonmedical aspects of the case. We believe that having this background has contributed to an environment that allows our residents to share their experiences of patient death.”

The camaraderie and support not only of the faculty for their residents, but also among the residents for each other was palpable and struck me as getting at the essence of developing the peer connections needed to work together effectively in surgical teams. At a time when we are bombarded by demands for greater efficiency in clinical care and education and of increased scrutiny of our outcomes, it was refreshing to see a group of surgeons focused on the human side of surgery. I think that forming these bonds of compassion for one another can have a significant impact on averting feelings of isolation, frustration, burnout, disillusionment, and cynicism.

Getting to the heart of surgery

I left the service feeling both touched and impressed. The empathy that the young surgeons who participated in this event demonstrated for their colleagues, their patients, and their patients’ families left me quite sanguine about the future of our profession. I wanted to share this experience with all of you and to encourage surgical educators to consider starting similar programs at their institutions.

Drs. Fahy and Ketteler are in the process of preparing a manuscript based upon a survey they sent to faculty, residents, and medical students about their responses to patient loss and their impressions of how this important topic should be addressed in surgical training. The Editor-in-Chief of the Bulletin has been in touch with Dr. Fahy about publishing an article based on the results of that study in the near future.

Death is almost always an uncomfortable topic, particularly among surgeons who enter the profession with the goal of saving lives, not watching them end. However, I believe programs like the one at UNM will help the next generation of surgeons attain a broader perspective on death and dying and what quality really means when caring for the end-of-life patient.

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

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