Blaming “difficult” patients for lack of informed consent. A case study on surgeon psychology.

Surgeon: Hello, Dr. Wible! I liked your informed consent article! When I was a surgery resident, I saw a a severely ill hospitalized man who needed a leg amputation and our attending surgeon and senior surgery residents never adequately explained to him why he needed surgery. Each morning on rounds, they kept asking him if he was ready for a leg amputation. Our patient would cry and say he didn’t want his leg chopped off. He said he didn’t know why it was necessary. The surgery team treated him with disgust each morning and labeled him as a difficult patient and just walked out of the room. I think it’s extremely dangerous when doctors label patients as difficult or crazy. Everyone was calling him crazy. He was not known to have psych disorders (no psych meds or listed psych history). They said there is no point in even talking with him because he is completely unreasonable. It’s a very normal emotion to be scared about an amputation. Yet calling him difficult and bipolar stopped our team from conversing with him. This label was perpetuated for many days. Either our attending heard this label from our senior resident or our attending started it—out of impatience. I didn’t allow these labels to stop me from relating to him as a human being.

Dr. Wible: So you were the one who had to obtain informed consent?

Surgeon: Yes. Finally he asked me if I could explain why he needed surgery. I promised him I would. I talked to our attending surgeon and told him our patient was open to life-saving surgery; simply that he did not know what the surgery entailed, and that he was refusing because he was scared. I asked if the attending surgeon would talk to him and he said no. He said if I wanted to I could, but then he also reprimanded me for staying in the hospital too long and being an inefficient doctor. At 9 pm, after I was finally done with my tasks, I sat with our patient and brought a copy of his angiogram so I could explain why he needed surgery. It was inappropriate for me as the junior resident to be the one telling him but I did my best. I sat with him and we had a very long detailed conversation. He was so thankful I spent time explaining his condition. When he understood the pros and cons and risks of surgery he decided to proceed with amputation the next morning (he could have died from gangrene otherwise). I told my seniors about my conversation with our patient. I was never thanked for my work. They just kept calling him “bipolar” for supposedly changing his mind. In my extensive interactions with him, spanning many days both before and after surgery, I always found him to be completely reasonable and mentally sound.

Dr. Wible: Can I share your story? I want patients and physicians to understand the impact of lack of informed consent in our training—and how we can make things right. I talk to so many suffering physicians who feel their humanity is stripped away by all the trauma they witness compounded by lack of compassion—and outright abuse—from wounded peers.

Surgeon: Yes, please share! Everyone was overworked and that led to a loss of humanity among our surgeons. Most rushed out of the hospital. I couldn’t see any humanity in them anymore. Rounding and doing surgeries was like just going through the motions. I felt our senior residents acted cocky all the time. I felt there was a lot of groupthink mentality. Surgeons seemed to be influenced by other surgeons’ bad behavior. They made disgusting lewd comments about patients. I never joined in, and even confronted them for their inappropriateness. I was treated as an outcast, and was never invited to hang out after work.

Dr. Wible: I think your co-residents and attendings had lost their humanity due to human rights violations in our medical training. As you know, surgeons are inundated with trauma and physicians may be punished for seeking mental health care, so doctors sadly just go numb and unconsciously pass on their pain to others. My heart breaks for them, for you as the witness of their pain, and for the patients who may have been harmed by lack of informed consent. I commend you for being a beacon of light among your wounded peers who need grief counseling so badly.

Surgeon: Thank you so much, Dr. Wible!! I am worried that patients won’t trust doctors anymore. I’m disappointed in how terrible some doctors are. Major reform is needed. You have done so much as one person for this cause. The truth needs to be known. I really related to your article and respect your work for patients, including hosting informed consent sessions in public libraries!

Dr. Wible: I want you to understand WHY doctors act this way. Since surgical trainees are forced to work in hazardous conditions with no labor law protection (many work 24+hour shifts, 100+hour work weeks) with extreme exposure to vicarious trauma, they go emotionally numb. Self-preservation leads to compassion fatigue—so they skimp on (or skip) informed consent conversations. Exhausted and traumatized, they escape the hospital as soon as possible. Some drink alcohol at night to stay numb. Cut off from their own emotions, they make fun of others who still have emotions as “sensitive” or “crazy.” Since they lack self-compassion, they cannot extend compassion to others, so they ridicule peers who spend time with patients as “inefficient.” Dehumanizing others is their defense mechanism. Projecting psychopathy on peers and patients prevents them from confronting their own disturbed psyche. Ridiculing others distracts them from feeling their own pain. If they truly could feel their own pain, they’d be flooded by a tsunami of tears that would incapacitate them. You were not invited to join social events because you were unwilling to submit to the psychological defense that kept them numb.

Most enter medicine with a desire to help others. I don’t frame doctors as good or bad. I see all doctors as emotionally wounded—and crying for help. Many physicians over the years have told me they’ve lost the ability to cry, so their cries come out as ridicule and an inability to connect with others as humans—leading to lack of meaningful informed consent conversations.

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One comment on “Blaming “difficult” patients for lack of informed consent. A case study on surgeon psychology.
  1. Sharon Klint says:

    I find your comment that most docs go into medicine because they want to help and heal people is not really accurate. I grew up around a lot of docs; some of whom were just plain rude, offensive and insulting. When my brother was at Northwestern University Medical School, I asked him point blank why were most of the students in medical school; obviously, he knew quite a few medical students. His answer was thought about for a minute or two; then, he said, “about 80% are there to have a good income, make money.” I was not surprised because medicine was known to be a pleasantly lucrative career. As I got older and saw more docs, I was surprised at how many smoked and lived very financially comfortable lives. I became rather familiar talking to docs and found my brother’s answer to be very true. My cousin also pursued a medical degree at Temple University. It was very interesting to watch these two men who were cousins and the same age go through their educations, residencies and the military at the same time, my brother at Trippler Hospital in Hawaii and our cousin at Walter Reed. Our cousin was in medicine to help his patients and constantly grow and learn more; he was board certified in 3 specialities and held 3 important jobs at the same time. My brother was board certified in one specialty and later obtained his MPH and went into hospital administration. In the years I have been able to understand the “business” of medicine the biggest and most detrimental change came when hospitals stepped away from being not-for-profit institutions and became regular businesses; this gave the hospitals more freedom in the financial arena. It also changed their goals from medical help and healing to making a profit. Docs did not seem to mind at all. But, medicine changed dramatically! Medicine still suffers because of this change; yes, they are more free to pay higher salaries, but they are also competitive which spreads the hospitals too thin. Between the responsibilities of patients and the horrendous amount of time needed by their career choice, docs are really squeezed! And, because the bottom line is now the driver of the medical business, we have lost a wonderful medical service, which is now a medical business. Docs do not like to discuss these sort of things with people who are not working docs. But, these factors and pressures affect our whole medical system, and docs and nurses have the most pressure.

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