As a practicing neurosurgeon for approximately 365 days, it has been a roller coaster of wins and losses, small victories and forced adaptability. The annual migration of residents and fellows to attending status is a well-trodden path, overseen and shaped by mentors and colleagues; those who have and are currently walking the same path.
The adjustment to becoming an attending is markedly similar year after year for those entering into practice. However, the stressors of the COVID-19 pandemic have dramatically altered the medical landscape with high rates of burnout, shortages of medical personnel and exceptional delays in treatment.
Last year, I began my first job in Portland, Oregon, after having spent seven years of training in Ohio. The overlapping urban catchment circles that existed in Ohio are non-existent in Oregon. Portland, tucked away in the northwest corner of this sprawling, mostly rural state was the first and last stop for all Oregonians. Many patients I saw in clinic had been waiting upwards of six months for an appointment with any surgeon. Some had driven six hours across the state in their RV campers to appointments at Oregon Health & Science University.
Because of these delays, the psychology behind the patient-physician interaction is particularly vulnerable. Spine patients living with some degree of pain and/or weakness have been forced to endure protracted emotional and financial distress. Calls for earlier appointments go unanswered and disease pathologies continue to worsen.
In a region where patients do not have the option to seek second opinions, or that second opinion is another six-month wait time, there is an unsavory power dynamic. The patient is made vulnerable because of a lack of options. The stability of their psyche rests on the possibility that a surgeon for whom they’ve been waiting to see for months, may be able to provide the opportunity for relief. The longer the wait times, the greater the vulnerability; and the less likely patients and their families are willing to express overtly any skepticism towards a new, young attending. Many had read my bio, but only the boldest asked how many cases I had done. In fact, it seemed that patients’ greatest fear was not that I had done too few cases, but that I could not provide a surgical option. If I hinted at further workups or referrals, partners would speak up more forcibly, relaying the hours and days the patient lives in pain, their despondency, their lost income, their inability to see friends and family; a desire to return to a better life.
For those that did ask how many cases I had performed, I have found transparency to be the best solution. I explained “yes, I’ve done many of these procedures in training, that it is a procedure I am comfortable with, but every surgery has known associated risks and it is important for you to be aware of them.” For those with extreme skepticism, which I have not encountered very often, I more than willingly offer a referral. Ironically, offering a referral for a second opinion, and also not forcing, frightening or cornering a person into surgery, seems to engender trust. An understanding that they have some agency in the situation to seek other care or to say no to surgery seems to empower the patient. I do not want a patient to consent to surgery if they do not understand my experience, the procedure and the alternatives. Educating and providing a patient with choice I do believe elevates the relationship and relieves many of the insecurities for these vulnerable patients.
