A surgeon’s thinking : An algorithm

Surgery is craftsmanship involving the application of manual dexterity with purpose. It is a deliberate infliction of mechanical trauma and/or correction of effects of trauma to a consenting patient for the betterment of the patient.  This blog, I hope, will make you think a lot about how a surgeon (read me) thinks.

At the outset, I want to have a disclaimer that, this blog is not a medical recommendation and no therapeutic/diagnostic/preventive purpose is being served with it. The sole purpose of this blog is to put forth my personal views which obviously are not universally applicable.

If you have a look at the algorithm (see diagram) it involves a lot of decision making and repetition.

If one thinks that information collection is easily done with the help of standard checklists and questionnaires; it is true. It is also true that collection of objective data like pulse, BP, SPO2 and so on can be automated with multiparameter monitors. But collecting information is just one part of the algorithm. There are many places which require selection (where the paths break) . The first such place comes after history and physical examination. It takes a fair amount of training to winnow off the chaff from the kernel. I have noticed, and sure every surgeon must have about them, that as I progressed from a second year MBBS student to a Consultant over a period of a decade and half this ability of discretion was gradually amassed by repeated practice and it goes refining on every year that passes by.

Before committing a patient for surgery, it is important to establish a diagnosis. Fortunately the role of surgery as diagnostic modality has decreased over last half a century. Simultaneously the availability of quality diagnostic modalities has been a revolution. My generation of surgeons has the problem of plenty regarding imaging and investigations. It involves multiple specialists. And again, at this level, a precise and clear communication is required. If you can tell the radiologist/pathologist regarding what exactly you think clinically regarding the patient helps arriving at a precise diagnosis. This power of communication is acquired proportionate to the time a surgeon spent during residency and practice; discussing CT/ X ray and USG with his colleagues, fellow radiologists and bosses. Likewise basic tenets of pathology should be done and dusted if you want to communicate with your pathologist.

Revealing a diagnosis to the patient is not much of a problem, if it is not cancer or stigmatizing (a term I used with dislike) disease. If it is cancer or stigmatizing disease the close relatives have to be taken in the loop and might be a trained counselor has to be roped in.

Now that a diagnosis is established; the next question is whether an operation is needed? Or indeed, any treatment is needed?

The answer is rooted in the much cliched Latin phrase ‘Primum non nocere’ that means “first, do no harm.” All types of surgeries, however minor or major, have some complications. The complications can be minor to life threatening. We surgeons; have been hammered from our surgical infancy; that always assess the risk of surgery against the benefit of surgery and offer surgery only when benefit outweighs the risk unambiguously. This is easier to be typewritten than be practiced. It involves inferences drawn from medical peer reviewed literature (reading journals and learning from other’s experiences good or bad and to know standard complications and their rates). Inferences from your own past experience (We surgeons keep something called a log book and do surgical ‘audit’ both out of the scope of present blog). Doing this tells me that my proposed surgery is fairly safe (or dangerous but has to be done to save life). Also if the surgery is needed but I lack facility to carry it out at my centre it makes sense for me to refer the patient to a higher centre.

The next big question is “Is my patient safe for the surgery?” The answer to this, I get from the most trusted aide of the surgeon in the operation room, the anaesthetist. (A word of caution! They are called anaesthetists in the UK and anesthesiologists in the US. In India it is personal preference of the individual, some dislike being called an anaesthetist). He (more often a she) does a pre-anaesthesia check-up, orders some investigations for the patient safety and if required sometimes asks us to ‘cross-consult’ the patient to a physician/cardiologist.

Now the safety of the surgery towards the patient and the safety of the patient for the surgery is matched and a conclusion is drawn to post the patient for surgery.

Surgery is a very serious endeavour never to be taken lightly. The Listerian principles of asepsis are paramount for us. It involves a team effort of surgeon(s), anaesthetist(s), nurse(s) and technician(s). We use ‘WHO safety checklist’ to ensure we don’t miss a single important thing and make it safe for our patient. A lot many things like blood reservation, antibiotics, emergency drug tray, defibrillators readied are done as a part of preparedness for any untoward incidence.

Follow up after surgery is what truly sets us apart from mere craftsmen to thinking wise craftsmen. It is a loop followed every day by eliciting history, physical signs, and requisite investigations and modulating medical treatment accordingly to a point when the patient does not require any active treatment or is self-sufficient to self-medicate. At that point we discharge them with a reminder to follow-up. A minority of cases, do get some kind of complication for which the same loop is reiterated and if the treatment required is not available then the patient is referred appropriately.

Highlights:

• Surgery is a serious endeavour.
• Surgical decision making is a complex process and not a straight sequence always.
• It involves
  • Points of discretion and selection of one option above another: A process demanding experience, education and adequate training.
  • Multiple reiterations of same things: A process that requires lot of devotion and dedication.
• More often than not it is a craft practiced in a team along with other doctors and para-clinical staff.
• Referral to a higher centre is neither the shrugging off of a responsibility nor a mark of incompetence; it is often a wise decision for benefit of the patient.

There is no shortcut for what it takes to make a surgeon (6 years of pre-residency scientific training. 3 years of blood and sweat in residency to get armed with surgical methods and skills and then many years of a continual process of maturation).

Dr Sudhanwa R. Pathak
MS, FAIS, FIAGES, DNB (GI surgery)
Miraj, India
10 Jan. 18

An algorithm to show how a surgeon thinks