Understanding Our Limitations

Abstract

Surgical thought and action are frequently regulated by an attitude of confidence, self-reliance, and believing in yourself. These qualities are usually promoted by the surgeon's unspoken and unwritten code of conduct. Confidence has often being praised as an important attribute in the surgeon's world.

In this writing I say that as surgeons we are not required to show our enhanced values all the time but rather to exercise prudence, humility, and, above all, the “understanding of our own limitations.” Our surgical profession has matured to the point that accepts certain doubts and occasional lack of confidence, if the “understanding of our limitations” is clear and the patient is not at risk. It is possible, then, and desirable, to show self-assurance by defining the limitations of our art, everything oriented at protecting the patient's health.

KEYWORDS:

• surgery
• limitations
• education

Why is it so hard to understand that we should place some value in determining the extent of our knowledge and its applications? In no other field of medicine, more than surgery, the value of understanding our limitations is of paramount importance. Let me explain how I see it from my own perspective.

BEGINNING OUR EDUCATION

As we begin our education in the early stages of elementary and high school years, our teachers praise and improve our knowledge, even though we do not hear the appreciation to the level in which we should remain cognizant of our limitations.

The years of college offer a great deal of knowledge and new experiences that prepare us for a rich life ahead. It is almost as if someone were saying, “Go to school and your aspirations will be met.” But where is the teaching for defining and understanding our limitations? Perhaps we do not see it because aspirations and limitations do not fit in the same room, do not belong to the same class, and are considered opposites with no common ground of agreement. That is the truth!

MORE EDUCATION

In advancing to higher years of professional school, if we have the opportunity, we realize that the accumulation of knowledge continues, though perhaps not in the same way as before. This time is more intentional and views more complex, anticipating a new world of compromise. In my case, higher education was medical school at the National Autonomous University of Mexico (UNAM) in Mexico City. Teachers, who were excellent educators and highly committed to their art and function, taught us great things. What a distinguished group of medical and surgical teachers we had. They offered the best that was ever possible!

In my academic evolution through medical school, goals and aspirations never included a certain dose of limitations; they were not in the regular scheme of things. Such an approach was not different from other medical schools around the world. The emphasis was in conquering and not in limiting yourself. The objectives centered around lofty goals and not diminished possibilities. How, then, to teach professional advancement and simultaneously to recognize the perils of limitations? That remains a puzzling paradigm.

EVEN MORE EDUCATION AHEAD

The ambition of continuing with more knowledge and training took me to the confines of internal medicine at the National Institute of Nutrition in Mexico City, a respected and venerable institution dedicated to preparing medical specialists of the highest caliber. Their teachings were aimed at reaching the top of the profession and not at decreasing the scope of our intended dreams. Salvador Zubiran, renowned mentor of many generations, was responsible for establishing the rules of this outstanding house of knowledge, and he created an exemplary educational institute of great prestige.

After all this educational experience, where could limitations be included? How could limitations be treated as part of the normal evolution of a medical career? How could we enhance our lives by adding the reality of understanding our limitations? Not a simple task, since aspirations and unfulfilled desires could not be easily counteracted with thoughts of limitations and unrealized expectations.

MORE EDUCATION … THIS TIME IN SURGERY

Next came the surgical sciences at the University of Minnesota in Minneapolis, a formidable academic medical center where surgery had shone in years past and continues to offer the best [[1], [2], [3], [4], [5]]. Surgical masters of the fame of Owen Wangensteen and then John Najarian were in command of the Minnesota Surgical School for more than 50 years. They contributed to assembling a group of surgical professionals unlike any seen before [[1], [2], [3], [4], [5]]. Their school was one of advancement and surgical intellectual ambition. I received a competitive surgical education, with a strong desire to find answers to well-known problems of the profession. The atmosphere was one of improvement and innovation, where everyone was searching for responses to challenging and difficult questions.

How, under the conditions mentioned above, does one look for the understanding of our limitations? How is it possible to amalgamate great possibilities with practical limitations? At what point can we establish a curriculum for the understanding of our limitations? How can we at the same time be fearless and cautious in taking risks? I believe we can, but let's examine the argument more closely.

Following Minnesota, my surgical educational voyage took me to the University of Chicago for one year. Vascular and thoracic surgery occupied my attention. The clinical questions, as expected, related to understanding the essentials of these subspecialties but never to focusing on the limitations emanating from the practice of the profession.

By now, questions of surgical limitations were not completely clear in my mind, but they became more apparent as I moved from surgical resident to staff surgeon. It was a period of definitive transition in my career and one that would allow me to clarify the depth of my knowledge and permit me to be more precise about the scope of my expertise.

NOW A FULL-TIME SURGEON

For full-time staff surgeons, the question is how to define the purview of your expertise or, in other words, the extent of your limitations? No answer is immediately evident, so intense consideration is in order.

When I started doing clinical kidney transplantation as staff surgeon at Henry Ford Hospital in Detroit, I quickly realized the magnitude of my job and the implications of my clinical involvement. Two years later, when I moved to Detroit's Mount Carmel Mercy Hospital, new surgical responsibilities included pancreas transplantation in its various technical representations, islet cell transplantation, and kidney transplantation as well. I promptly determined how my clinic would be shaped based on the encounters with my surgical cases, knowing full well that obvious clinical results would be the main determinant of my practice.

After 10 years at Mount Carmel, it was time for a new move, this time to Kalamazoo's Borgess Medical Center, where kidney transplantation was the main focus of my attention. Understanding how to cope with the specific particulars of a new mix of cases represented my main concern. High-risk candidates constituted a frequent source of evaluation and discussion. During this period, a strong association with Western Michigan University and Michigan State University in East Lansing and Kalamazoo was built. Practicing the concept of “understanding our limitations” was a frequent and welcome occurrence.

FINAL COMMENTS

As a surgeon and student of surgery and its historical implications, I support the notion that “understanding our limitations,” whether in the operating room, in the hospital wards, or in the clinic is an important concept we need to uphold to the highest standards. The idea of limiting ourselves in terms of surgery, patient care, and/or patient selection has not been a frequent way of proceeding in our surgical practice, and therefore, we need to change this paradigm. It is as if we have been told to go ahead and not to stop at anything, at any time, and under any conditions. That is not entirely right and let me tell you why.

I believe the surgeon, whether just beginning or with extensive experience, needs to know the value of his/her participation, the strength of his/her convictions, and his/her overall response before these pressing issues arise. The surgeon should be a judge, a master, and a fair and just professional. The surgeon should be committed to accepting his/her limitations as far as they might go, as special as they might be, and as difficult as they might appear.

There is no written statement as to how we need to limit ourselves in surgery. Criticism is not usually spared in training programs, but that differs from common sense and a deliberate approach in recognizing and advancing our position when facing the “understanding of our limitations.”

One of the real questions for a young or mature surgeon is: How would you handle a case in which you realize intraoperatively that matters are more difficult than you imagined and it is taking longer than predicted? Would you stick to your principles of knowledge and determination, or would you use commonsense and request the help of an associate? Speaking from personal experience, and having faced both of these situations, I would recommend either solution, depending on the case. Whether the surgeon is young or mature does not matter. What matters is believing in yourself [[6]], accepting the value of “understanding our limitations,” and having the personal courage to call someone else to help with the case. There is absolutely nothing wrong, and in fact it is extremely wise and prudent, in having the needed assistance at the right time. In fact, since our fundamental concern is to improve the health of our patients at all costs and at all times, it is not hard to accept that we need to immediately request the sought-after assistance whenever necessary.

The topic of this writing can be very well summarized in a recent discussion I had with John McKee, a colleague transplant surgeon and a friend from the University of Michigan. When I asked him what advice would he give to a new faculty transplant surgeon, without hesitation, he said, “Not to be afraid to ask for help,” Those words are quite telling and of enormous wisdom, since they reflect, among other things, the importance of “understanding our limitations.” At the end of the conversation I thanked John for characterizing this important topic so well.

In conclusion, it takes determination and personal maturity to recognize our personal capabilities when evaluating ourselves within the framework of our surgical expertise. “Understanding our limitations” should be a well-attended process, inasmuch as we always pursue the betterment of our patients. Having patient well-being at the forefront of our surgical thoughts would permit us to readily accept why it is so crucial to live by the concept of “understanding our limitations.”