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Last night I had another one of my weird surgical dreams. I had begun to wonder if I was done having them, as I hadn’t had one for a while. Clearly my subconscious is not done though, as this one was a doozy, and it has stuck with me all day. 

In the dream I have been asked to do a surgery on a patient who vacillates between being an older male awaiting a liver transplant, and two men who are actually acquaintances of mine in real life. I have no idea what that means! The surgery itself is a procedure that would never be done in real life, but in this dream it’s totally legit, and it goes very smoothly. I am assisted by a former surgical colleague of mine, someone who caused me a fair amount of stress in real life, and who tends to be very robotic about patient care. I am in some sort of teaching hospital. It feels like the place I went to medical school. Senior staff (men) who asked me to do the surgery, but did not participate in it, are very critical of me for how it has gone, even though it goes well. I am not a resident, but am being treated like I am. These staff men look for complications, investigate for them, but there are none.  There are no apologies. At least one of the residents is a guy I went to medical school with, and is now an orthopedic surgeon. The surgeon who assists me is not present to defend me while the staff men are looking for problems. 

I recall feeling frustrated that my assistant, who is a surgeon, is someone who is there just to do a job or a “case”, and not care for a specific person. I recall thinking the surgery itself was weird, but I had done it correctly, to the best of my ability. I felt very stressed when the staff men were so openly critical of me, one even calling me stupid or something. Why had they felt that it was unimportant to be involved during the surgery, only seemingly caring for the patient afterwards? The patient hadn’t suffered any complications but I was left with this feeling that complications were going to show up because these men were looking for them. Moreover, these men questioned my training, implying that I was just lucky that there were no complications. It was also stressful when the patient morphed into these two men I know, because then there were a lot of family members and friends around them, asking if things had gone alright. 

The dream left me unsettled, although I recognize that it is just a dream. It was disconcerting enough to wake up realizing that I had performed a truly bizarre surgery that doesn’t exist in real life. Moreover, I was being told that I did not perform it adequately enough. In reality, constructive feedback is beneficial in good patient care, but this was not that. I recall one of the residents saying that I was going to be dragged into an “M and M rounds” (morbidity and mortality rounds, ostensibly to learn from real cases and errors and outcomes, but often fraught with an atmosphere of trepidation and humiliation). 

Ultimately, there is the take home message: medical education and team work is often consistent with the expression “in medicine they eat their young”, or rather, that there is no such thing as positive, constructive feedback. In my country, training in medical school and residency is excellent, and of the highest standard. But some lessons are unbelievably harsh, and, in my opinion, are one of the main contributors to burn out, disengagement and depersonalization experienced by so many physicians today. Basically, you simply cannot absorb the emotions you end up feeling as a result of these episodes, so you ignore them, deny them, and bury them.

When I was a first year surgical resident on my orthopedic surgery rotation I saw a patient in ER, an elderly man who had fallen and broken his hip. My job was to see the patient, look at the xrays, and call my staff person with my plan. So I did just that: I took a history and did a physical exam, saw the fracture on the xray, and told the patient and his son that surgery would be required to fix the fracture. There was one caveat though, and that was I had asked the patient if he had a history of blood clots (no) or new leg swelling (yes, his left leg for about three weeks).  Based on this I suspected that he might have a blood clot which needed to be diagnosed and managed before surgery so that the risks of dying from a blood clot to the lungs during or after the surgery could be minimized. I ordered an ultrasound and it did indeed show a blood clot in this man’s leg. 

What was memorable to me was the next day my staff person paged me and said this: “You saved this man’s life, and I wanted to tell you that you did a good job, and to thank you for taking care of my patient.” Wow. I hadn’t expected that. She then went on to say “I’m joking when I say this, but I contemplated whether or not I should page you and tell you this, because this is positive feedback, you know.” We laughed about that, but she was right. She didn’t have to take the time out of her busy schedule to give me positive feedback and say thank you. And let me tell you, it was an amazing experience to hear it. Don’t get me wrong—I had many staff men and women who were kind, and also generous, buying residents breakfast or lunch or coffee. But although hard work and excellence in patient care was expected, and given to the best of my ability, appreciation and positive feedback was few and far between. It’s just not in the culture of medicine to say kind and appreciative words to each other.