“Action, heroism, certainty and optimism”, are some of the key tenets of surgical culture all across the world. However, in today’s times surgeons have been compelled to cope up with, “inaction, fearfulness, uncertainty and some degree of pessimism”. To say that COVID-19 pandemic has disrupted the very foundation of healthcare would probably be an understatement.
These are uncertain times and “fear” is the dominant emotion, ruling the minds of people across the world. In the absence of a precedent and adequate data to rely on, decision making is one of the most challenging tasks today. Most governments across the world chose to freeze, as did most of the big businesses. However, the only profession, where decisions cannot be deferred is medicine. As doctors we do not have the luxury to defer and have to take split second decisions all the time. Decision making during Covid 19 pandemic is probably one of the biggest tests that all of us have had to face.
At the beginning of the pandemic, surgical associations across the world were quick to act. Guidelines were drawn and circulated at a lightening pace. However, at the ground level, each of us have had to grapple with taking decisions on a daily basis and it has been a lonely exercise. Along with clinical dilemmas we have also had to deal with moral and ethical dilemmas. Should we be focusing on what could go wrong or refocus on what could go right? Would it be smarter to be pessimistic at this time than being optimistic? Could being optimistic be a liability at this time? How should we think about the future? What are the implications for patients and for surgeons? I have personally struggled with many of these questions over the last few months.
Taking a decision to get a surgery done is not an easy one. Patients and their families derive a lot of clues from the surgeon’s demeanour and body language which helps them to take these decisions. As I mentioned earlier, even the smallest of surgical procedures can lead to grave complications and rarely can even lead to mortality. As the complexity of the operation increases, so does the chance of having complications. Most patients and their families suffer from optimism bias and despite being informed about complications during a consultation, they tend to filter the information related to bad news. Hence the onus is on the surgeon to drive the point home. In an increasingly litigious environment, surgeons have to tread carefully on the fine line between being optimistic and being brutally honest.
Well, the solution to this conundrum may probably be found in realistic optimism. I have always believed that surgery is a very humbling branch. While surgeons may be vested with the power to cure many diseases, all of us are well aware that however skilled and experienced we may be, we can never get to a hundred percent. We all know that failure can strike us at anytime. Sometimes it could be because of an unintentional mistake and at other times we just lose to the forces of nature. Law of averages eventually catches up with all of us some day. Despite this awareness, most of us choose to go on. We take all risks into account and perform new operations every day. Should we attribute this to heroism? I guess our non-surgical colleagues may agree to that. However, being a Bariatric Surgeon myself, I know that what drives us is not heroism, but optimism. Not just optimism, I would say that it is actually realistic optimism that drives most surgeons.
So, what is realistic optimism and how do we apply it to the surgical practice? How is it even more relevant in today’s times?
Optimism is a necessity. However, unrealistic optimism can sometimes be misconstrued as having a non challant and uncaring attitude. In worst case scenarios, unrealistic optimists may be treading on waters of denial. When it comes to surgery or taking surgical decisions this would translate into ignoring possible risks and complications and focusing only on the positives. In a scenario where things may not go our way, it comes as a shock to the patient and their family. Despite the good intent of the doctor/surgeon, this forms for a perfect setting for a litigation. During the Covid-19 pandemic not taking the added risk into account would border onto sheer foolhardiness.
On the other end of the spectrum is unrealistic pessimism. Unrealistic pessimists would go on to highlight the negatives much more than the positives. They would downplay the possible benefits of a particular procedure and focus a lot more on the side effects and complications. While it is important to keep our patients informed, it is also necessary to have some perspective. Treatments and surgical operations only come into common practice when their benefits are significantly more than the risks. No doctor deliberately wants to harm their patients but sometimes in trying to be honest we may tip over the scales to being too pessimistic. An over defensive doctor may unknowingly take away hope and push the patient into denying treatment. I would not shy away from saying that during this pandemic many of us have veered into the realm of unrealistic pessimism which may have unknowingly affected the disease outcomes for our patients. Only time will tell whether this was for good or bad.
This finally brings me to the middle ground and we all have to ultimately choose between being realistically pessimistic and realistically optimistic. Being realistically pessimistic is considered as a safe zone for certain professions and surgery is one of them. It is said to prepare patients and their families better for any eventuality. It also takes the onus of liability away from the doctor/surgeon. As surgeons we are an integral part of the tragedies of our patients and their families. Being realistically pessimistic helps us to maintain a certain degree of detachment which is necessary for our own survival. It prevents over involvement and protects surgeons as they venture into the unfamiliar territory of taking high stake decisions. Realistic pessimism is the sentiment which is ruling through the Covid-19 pandemic across all surgical specialties. There can be no arguments against it and in the present times, it is probably the most sensible way to proceed.
All said and done, doctors are human too. What ails the world today, ails us too. However, we also have to move forward and rise to the occasion to do right by our patients. We have to take the risks into account but ultimately, we have to move towards resilience. As we do this, we have to take our patients and their families along with us on the road to realistic optimism. While personal impact of negative outcomes can never be compared to statistics of complications, as doctors/surgeons we cannot take away hope from millions of patients. Just as patients must be made aware of all possible negative outcomes, they must also be made aware of the tangible benefits of the treatment being offered. Risk taking is a part of the journey towards a better life. As surgeons we become a part of this journey alongwith our patients. We have to help them to be able to objectively weigh the pros and cons and reach to a decision taken mutually for their betterment. Being realistically optimistic helps to ease the tension for a patient and their family and clear a partially cloudy disposition. At times carefully chosen words of optimism may be just the ice-breaker that was needed in order to reach to a life-saving decision.
Covid-19 pandemic is being considered as the Black Swan of 2020. Healthcare is at the forefront in this battle. As we wade through these troubled waters the need of the hour is to move away from panic and paranoia. We have to approach this challenge with increasing resilience and realistic optimism. We have no option but to become comfortable with ambiguity. None of us will be a hundred percent right or wrong in our decisions but ultimately whatever happens, in our hearts we must know that whatever we are doing is in the best interest of the people that we are serving.
Author: Dr. Aparna Govil Bhasker; MBBS, MS
Bariatric and laparoscopic surgeon, Mumbai
A guest article contributed for Upsurge- Association of Surgeons, Nagpur.