She was in her late thirties when her medical oncologist asked me to see her. Five years before, one of our community surgeons had removed part of her colon for cancer. She also had a recognized, single metastatic tumor in her liver at the time of that original surgery.
The contemporary standard of practice was to treat for a prescribed period of time with chemotherapy and then re-evaluate for the appearance of other tumors. If there were none, the patient would be a candidate for surgical removal of the liver metastasis.
She completed the chemotherapy protocol, and she had no further lesions. She was deemed not to be a candidate for liver surgery, however, because the metastatic tumor had invaded the right hepatic vein and the inferior vena cava, just below the junction of the vena cava and the right heart. At the time, that judgment was current and correct.
Surgically stymied, her oncologist continued to treat her with chemotherapy, and in those five years her metastatic tumor neither grew nor shrank, and no other tumors appeared. Her surgeon had retired in the interim, and her oncologist, knowing my interest in liver surgery, asked me to evaluate her.
Timing is everything. Two months or so before I met her, I read a report by a French surgical group on “total hepatic vascular exclusion” (THVE) as a technique for safely removing tumors like hers. THVE entailed controlling all blood vessels leading into and out of the liver, and I had managed all the elements of the procedure multiple times, with the exception of the junction of the vena cava and the heart and the partial removal and repair of the vena cava.
I had the good fortune to serve on the surgery faculty for several years, and during that time I worked with a man from his medical school days through his general surgery and cardiothoracic surgery residencies. I knew him to be a talented surgeon, but more importantly a judicious one, one to whom I would entrust my family and myself. We discussed the patient’s circumstances and THVE.
When I met the patient, I explained the anatomy and the technique, the risks and the fact that my co-surgeon and I had never combined all the elements of THVE for the removal of a tumor like hers. She understood and asked that we perform the operation.
We collaborated with the anesthesia team on potential consequences of and remedies for the sudden interruption of blood return from the lower body to the heart. The day came for the procedure, and it went perfectly. She was stable throughout, even during the cessation of vena cava flow to the heart. We achieved a clean removal of the tumor, along with the right liver and a section of the vena cava. The latter was reconstructed by my co-surgeon with a more than sufficient residual caliber. She recovered rapidly and completely, and she continued to do well during follow-up.
It is no small matter for a surgeon to stop operating. Despite all the very wise advice against being defined by your work, surgery is an absorbing passion and becomes in large part what you are rather than merely what you do.
When I was a young surgeon, I saw too many fine surgeons continue beyond the limits imposed by age. What would have been admirable careers were tainted by their staying too long, and I vowed that I would stop operating at my best.
I don’t really know what “best” is. You might even convince me with little effort that there is no such thing. I do know this, though: throughout my career I always had the sensation of getting better, more able, and more knowledgeable. The operation we performed for that young woman was not the most difficult, demanding or dangerous one in my career, not by a very long shot. In its aftermath, however, I realized that the years of study, repetition, teaching, and discipline had produced a moment in which we were able to offer her something valuable and novel. I also realized that I had hit a plateau, much like that experienced by runners. Unlike a runner, I saw no way to change my training regimen and resume an ascendant arc. The effort I had always put into improving my capacity would now be consumed in maintaining it, with the inevitable and ultimate slide downward.
Quitting the operating room was probably less difficult for me than for most of my peers. For one thing, I always felt a bit odd during training. I never experienced the obvious zeal my co-residents had when the chief resident assigned them a case (“Oh man, I’ve got a gallbladder tomorrow!”). Surgery attracted me for its emphasis on defining the problem, devising the solution, and then making the solution a reality through technical proficiency. It was not the surgical act alone that compelled me. I therefore could not miss the adrenaline rush I had never known.
Early in my career, I was also very fortunate in becoming involved in management of the scarce resources we had to care for patients in our safety-net hospital. I came to appreciate that improving the systems and processes of patient care was just as valuable as providing the hands-on care, and I knew that at some point I would devote more and more of my time to the former rather than the latter. I was emotionally and mentally prepared, therefore, to make the move when given the opportunity to be the first chief medical officer for my hospital. This new work is challenging and rewarding, and I have never regretted my decision, although I do miss the intimacy of the patient-doctor relationship.
There is one shadow on the matter. Many people and many resources contributed to making me a surgeon, and I had more than several years of useful service left in me when I made the transition to non-clinical work. Should I have stayed the course to more fully repay those investments, was my decision overly selfish? I can only reconcile the debt by leveraging all I learned as a surgeon and all I am learning as an administrator to help advance the ball.
Richard Patterson is a surgeon who blogs at DailyDudley.
