E75 Peter Angelos On Surgical Ethics, Informed Consent, Paternalism, And The Limits Of Disclosure

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Chad Ball  00:12

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been brought in range, whether clinical, social or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:13

Dr. Peter Angelos is an endocrine surgeon at the University of Chicago and is really one of the founders of the field of surgical ethics. We asked him to define for us the term “surgical ethics” and then get his thoughts about a number of important and intriguing ethical issues such as informed consent, paternalism, and the limits of disclosure. Dr. Angelos, it’s an absolute pleasure and an honor to have you on the show today, it really truly is such a pleasure to speak to someone who’s had such an impact on the field of surgical ethics. Can you tell us just before we get started about where you grew up, and your training pathway?

 

Peter Angelos  01:49

Absolutely. And thank you for inviting me. And it truly is always wonderful for me to have the chance to talk to surgeons. And it’s always great to have surgeons who are interested in thinking about and talking about these things. So I appreciate the opportunity. I grew up in a small town in very northern New York State very close to the Canadian border. It’s a small town called Plattsburgh, New York. And my father was a small town general surgeon. And so I grew up knowing a fair amount about what it was like to practice surgery, at least from the perspective of a kid watching his father.

Ameer Farooq  02:40

Yeah, I think it’s pretty neat, you know, as someone who has a father, as a surgeon as well, certainly does have an impact on your career decisions. And I could imagine it could go both ways. You know, you could you can look at your father and say, wow, that guy is way too busy, he has no time. Or you know, I suspect in your case, and in my case, you look at your father and say, wow, this person is really fulfilled, and they love doing what they’re doing. So maybe there’s something to their career. Is that sort of how you felt about things to Dr. Angelos?

Peter Angelos  03:07

Yeah, I think that’s absolutely true. And I have to say, you know, my father, for much of the time that I was growing up, he was in a small group with three surgeons total. And it was a small community hospital. And in those days, there were no, there were certainly no residents. And there were no PAs. And so the way it worked is my father was either on call, which meant, you know, he dealt with everything, or he was on second call, which meant that he would just come in to assist the on call surgeon with cases. Or one night in three, he was completely off. And so growing up, it was not an unusual thing that, you know, we would get up and he would have been up all night or no, there were there were certainly holidays where he had to go to the hospital and take care of a patient. But I have to say growing up as a kid, I didn’t realize that general surgeons had a terrible life. When I went to medical school, everybody said, oh, my gosh, how sad your dad was a general surgeon, you must have had a terrible life. And I felt quite the contrary, I felt like he was always very interested in us and what we were doing and would always try to be there. But it was also clear that as you said he did love his job, and he took a great deal, he had a great amount of professional satisfaction and taking care of patients. And I think that part of it is just the idea that you know, he was practicing surgery in the town that he grew up in, and he felt like he was providing a service to the community. And that was a really very fulfilling thing for him. And so for me, I guess I was very much drawn to the, the consistent way in which he was able to help the community take care of patients, and he was certainly loved being a surgeon.

Chad Ball  05:15

I’m curious, in particular, how did your pathway navigate towards ethics? How did that initial interest spark itself in your in your voyage?

Peter Angelos  05:24

Well, thanks, thanks for asking. It’s, it was kind of just fortuitous. When I was in high school, it was a small high school, and there were no AP courses. And so if someone was a good student, instead of having the opportunity to take an AP course, or take honors courses, or something like that, we had the ability to apply to a program that let us take college courses for high school credit. And so just down the street from my high school was State University of New York College at Plattsburgh, SUNY Plattsburgh. And so I applied for this program and, and I ended up taking a course in ethics as a high school student. And I was just intrigued by the course, and I loved the idea that you could study right and wrong. And the idea that somehow someone could be an expert in thinking about those things was really very appealing. And without question, my parents, both my mother and my father very much encouraged me to take this course in ethics. I took it, I really enjoyed it. And then as I was finishing high school, I had decided I wanted to go to medical school. And I was ultimately accepted into a six-year BA MD program at Boston University. And so with this accelerated program, we had the chance of doing, you know, a little bit of undergraduate work. So we did two years of undergraduate and then we started medical school. And during those two years, we were in school all 12 months of the year. And then after the first year of medical school, we went back and finished our undergraduate work. And so during that time, I took a number of philosophy courses, I really enjoyed it, I ended up double majoring in philosophy. And all along I had this idea that one of the nice things about this six-year medical program was that it seemed like I was saving time. And when I was in my second year of medical school, so that’s now four years out of high school, my parents again, sort of suggested to me, well, what is the rush to finish medical school, and I was really interested in ethics. And so I decided that I would apply for a PhD program in philosophy. And so I applied at Boston University, and I was accepted. And so the plan was that either I was going to take a leave of absence from medical school to pursue this PhD, or I had the idea, maybe they would let me be an MD PhD student having a PhD in philosophy. And so I was fortunate, I went to the people in charge at Boston University, and after a little bit of consideration, they gave me permission to be an MD PhD student, they apparent I guess it was the first time they had done that with someone getting a PhD outside of the sciences.

Ameer Farooq  09:06

That’s so fascinating. It’s lucky that you had your parents sort of sober second opinion, because when you’re in that stage, you kind of just want to go go go and just get everything done. And obviously doing that PhD in philosophy was so critical, obviously, to your entire career. What do you think were the big highlights from doing your PhD in philosophy? You know, you were immersed in doing medical school that sort of the, if I could call it the hard sciences of learning about medicine and physiology, then you take this step away from medicine and do your PhD in philosophy? What was that like? And what did you really get out of the those couple of years doing your PhD?

Peter Angelos  09:47

Sure. It was, it was really a very different way of thinking. And for me, I felt like so much of so much of pre-medical education, when it came to the sciences was was very much like, you know, here are the right answers. And here are the things that you need to know. And especially in the first couple years in medical school, you know, anatomy and physiology. It’s a lot of, you know, these are the facts, and you need to learn those facts, you need to memorize anatomy, those were things that, you know, it was a lot of fun learning. But it was also interesting in the sense that once I started studying graduate school in philosophy, there’s not so many facts, there’s a lot more of, on the one hand, this and on the other hand, that there was a lot of sort of arguments about what is the, you know, what’s the more important thing to take into consideration when you’re making a decision about this or that. And so I felt as though it was almost like a refreshing refreshing change from those first couple years of medical school. And, and I have to say that in some ways, although the third year of medical school and fourth year of medical school, we’re, you know, you’re taking care of patients. It’s it is based in science, but those interactions, I think, have much more to do with the the thinking that is related to things like philosophy, because in interacting with other people, we do have to learn what’s important to them. And the facts sometimes matter a little bit less, when values play, necessarily have to play a big role. And so, so it was this, it was kind of a fun ability to sort of switch between the world of medicine which was much more scientific based and the world of philosophy, which was much more non non-scientific and clearly, where there’s a lot more subjectivity.

Ameer Farooq  12:27

Well, in one of your addresses, you talk about, then coming back from your PhD, and then going on to, to match or try to apply for surgery residencies and you express your desire to pursue surgical ethics. And I love the line that you say it says, the level of interest was about as much as if I had said I was interested in in modern dance. So I have sort of two a two pronged question. I mean, one is, if you’ll indulge my little bit of psychoanalysis here, surgeons are often drawn to surgery, because of it being a bit more clear cut less and less ambiguous, you know, we have to cut or not to cut. And so I’m curious how sort of that part of your brain works. And maybe why it has traditionally been a bit difficult for surgeons to kind of get interested in the in the topic of ethics, although I you know, as we were talking about before the start of the show show, I think that’s changed. And the second question is, how did you convince the program directors of your vision and your career plans for surgical ethics?

Peter Angelos  13:31

Yes, thank you. Thank you for asking those great questions. I do think that there, there is something that is definitely appealing for me, and I think probably for many people about surgery, in that you can talk about, you know, the possibilities, and maybe on the one hand, this and on the other hand that and you could talk about differential diagnosis, but ultimately, you do have to make a decision, and then you have to act on that decision. And so in that sense, there is something wonderfully definitive about surgery. The, I think that what is what’s fascinating to me is the extent to which we are often forced to make decisions based on incomplete data. And sometimes, you know, we just don’t know exactly what we’re going to find, for example, you know, someone comes in with an acute abdomen, and we say, I’m not sure what you have, but I know you need to go to the operating room. And that sense of, sort of, it’s, it’s the absolute antithesis of theoretical analysis. It’s sort of like I don’t care what the what the ultimate cause is right now, but I know the ultimate, the next step has to be an operation. And so so I think that to me that it’s almost like the contrast of thinking about thinking in a philosophical way about possibilities and alternatives. But in surgery, there is something refreshingly wonderful about the fact that we do make decisions and act on them. Now, you asked about how I convinced program directors and, and surgery surgery department that, you know, they should take a chance on me, it was actually that I was very fortunate that I applied for a surgical residency at Northwestern University. And the chair and program director at the time, as a gentleman named David Nahrwold. And Dr. Nahrwold, had a huge influence on me, because he was the one who actually was very, very interested in ethics. And I remember vividly of all of the people that I spoke to about my interest in ethics and surgery, he is the one person who said to me, tell me about this interest in ethics and how you think that you could sort of integrate that into an academic surgical career. And, you know, he was someone who was so interested in it, that I do think that that’s probably why I was fortunate enough to match and do my residency at Northwestern because I’m pretty sure that I didn’t have quite the qualifications of most of my colleagues in the residency. But I was very fortunate that Dr. Nahrwold thought that there was something there that he was intrigued by, and then, you know, he continued to have a huge impact on me, because although I had done all of this work for my PhD, my dissertation was ultimately not accepted at the point that I was applying for residencies. And so I was still in the position of having to rewrite my dissertation as I started my residency. And Dr. Nahrwold actually supported my doing research for a year while I rewrote my dissertation. And at one point, I even was disgusted with the whole thing and said to him, you know, I think that we should just cut our losses, and I think I should stop the PhD program, because I really love being a surgeon. And he said, to me, that’s a bad idea, it will have a huge impact on your career, and you really need to stick with it. And in those days, you know, when the chair told you that, that’s what you did. And so that’s what I did. And I am forever grateful to Dr. Nahrwold for that good advice. And then, you know, if it if that wasn’t enough of a huge influence, then he hired me as a faculty member when I finished my training. And so, you know, I really think that it was his vision for what might be that ultimately led to me sort of completing that early decision to get a PhD.

Chad Ball  18:37

How would you describe to our learners, maybe some of the differences between traditional medical ethics and then the more sort of new concept or newer concept that you’ve really championed, and pioneered, that being surgical ethics?

Peter Angelos  18:53

I would say, for me, there are a number of things that make surgical ethics, different from medical ethics in general. And, you know, I’ll just touch on a couple of them. I think that the relationships that surgeons have with their patience is very different from the relationships that most other physicians have with their patients. And I say that because I think there’s an intensity of the relationship that’s different. There’s a time factor in that generally. Obviously, there are exceptions, but generally surgeons don’t know their patients for years before they have surgery. We meet them we have to establish, we have to establish ourselves as trustworthy so that they will put themselves in the ultimately most vulnerable position to let us operate on them. And I think that that’s a that’s a really amazing thing. And I do think that, that this aspect of the surgery, and that is the trust that our patients have in us, the critical nature of our ability to communicate well, such that we are able to engender that trust, that ethical dimension is something that I do think surgeons have largely taken for granted. But is so critical to what we do. And, and I do think that it’s funny, frequently, medical students who will rotate with me and you know, we have great medical students at the University of Chicago, and they’re are a lot of fun, and I and you know, I love having them be in the OR in clinics with us. But occasionally I’ll hear things like, you know, I really like surgery. But you know, I like talking to patients. And so I just don’t think I’d want to go into surgery. And it always makes me laugh, because I feel like communication is absolutely central to successful surgical practice. And so if one is not able to communicate well, if a surgeon cannot explain things to a patient in a way that’s meaningful to them, and also express to the patient, the concern that we have for the patient’s well being, that surgeon is not going to have patients trust him or her. And, and I think that that ability to engender trust, is a huge thing. And I do think that that’s something that, you know, people like my father, you know, I don’t think he thought about that as being sort of like a separate thing that was, you know, part of surgery that was part of surgical practice. And so I don’t think this is in any way new. But I do think that as, as the knowledge of physiology, and as we’ve gained so much more knowledge, and we have so many more critical patients, critically ill patients to deal with, I think that we have to be a little bit more intentional in our focus on this ethical dimension, or we run the risk of becoming too careful, too much boxed into being just technicians. And I really think that that would be a terrible loss for the profession of surgery. And I think it would also be a terrible loss for our patients. Let’s say we’ve got a patient who, maybe there’s consideration whether they should get a tracheostomy. And this person’s had a devastating brain injury as a result of, you know, trauma. So so it seems to me that the conversation about whether it’s appropriate to do a tracheostomy and the risks associated with it, and the patient’s long-term goals, you know, that’s something where I think the surgeon should be involved in that conversation, and we ought not wait outside the room for others to tell us. Yeah, we’ve decided we want you to just do the procedure. So you know, just do the procedure. I think we need to be at the table and engage in the conversation about, you know, what is the appropriate end here? What are the, you know, what are the goals of care for this patient? And what are and is what we are doing helping to facilitate that.

Ameer Farooq  23:54

We really wanted to dive deep into this whole issue of informed consent. There were so many topics that, you know, potentially we could have talked with you have on the podcast, you’ve done so much work on the ethics of surgical innovation, for example, but you’ve done a ton of seminal work on the topic of informed consent. And you have this great series on MD Edge where you wrote about a whole bunch of different issues. And in one of those pieces, which is entitled “The personal dimension of informed consent,” you talk about having a medical student in clinic with you, and you’re seeing thyroid patients, and you have two patients that you booked for a thyroidectomy. One, you you spent a lot of time detailing the risks and the other, you don’t really spend much time talking about the risk. So how do you think the personal connection with the patient changes the way that we do our informed consent?

Peter Angelos  24:49

It’s a it’s a great question. I think that there’s this there’s a minimum level of information for example, that every patient for who’s having an operation needs to know. And so, you know, I think that they’ve got to know, they got to know what the risks are, they got to know what the alternatives are, and they’ve got to know why they’re having it, what are the benefits? It strikes me that that in those circumstances where there is more latitude for choice about what’s the best thing to do, that we should be certain that we focus a little bit more carefully on the patient fully understanding what those risks are. And so, you know, I, I appreciate you, you know, noting that that the the column that I had written, and I remember it vividly, because there is one circumstance where, you know, a patient needed a total thyroidectomy, because they have a thyroid cancer, and they’re, you know, that’s the treatment, it’s a big thyroid cancer, we know they’re going to need radioactive iodine. So surgery is really essential, or they could not have surgery, but given the size of the tumor, nobody would recommend that. So in that circumstance, I really feel like okay, so the patient’s got to know what the risks are, they’ve got to know why, why I’m recommending it. And I want to be sure that they know that they understand, you know, that they could have a nerve injury, they could have hyperthyroidism. But the the second patient was a patient with Graves disease, so Graves disease could be treated medically, it could be treated with radioactive iodine, or it could be treated with surgery. And so in that circumstance, it strikes me that a little bit greater emphasis on what those risks are, becomes really important. Because I would hate to have a patient in that circumstance say, well, I never really appreciated how big a deal it would be, if I had a nerve injury. And if I’d known that that was a real possibility, I don’t think I would have done it. So so I do think that knowing so that’s the reason, in my opinion, why informed consent actually has to be sort of an individualized conversation. And so at one point in my career, I thought, you know, I could just save so much time, if I made a video, and on my video, I would just be, I would just explain, you know, this is the risks of a thyroidectomy. And I could just run that video, and then I could be on to the next patient instead of doing it in person individually for each person, each patient, but but it does, it’s really clear to me that there is the the emphasis on these risks, that the nuances of wanting to inform a patient but not scare them in unnecessarily. I think that that is an important thing that requires an individual approach. And so, so I think that, you know, it’s, it would not be enough, it wouldn’t would not be adequate. For example, if there was a website in which you could just send your patient to okay, you’re going to get you know, you need a an adrenalectomy, just go to this website, and you can, you know, learn all about the risks of adrenalectomy. And then, you know, come back and sign the consent form. I think that that would be inadequate. I think that it really does require that personal attention. And in addition, I think that, that interaction of us explaining something to a patient, that is our opportunity to prove to patients that we are worthy of their trust. And so, you know, I think trust is absolutely essential to informed consent. And how do we show our patients that they should trust us? Well, you know, maybe they come into the office with some level of, you know, this seems like a good guy, you know, he, he’s got, you know, he’s got a lot of credentials, he works at a big medical center, and maybe my internist told me, he’s a good person. But how do I prove that to my patient? Well, I prove it by actually listening to them, and, and providing them information in a way that is meaningful to them and sort of meets with their level of desire for detail. And some patients want a whole lot more detail than others, and I feel like that’s what we owe them then. Some people are, you know, they want less detail and that’s okay. As long as they get the they need a certain minimum, but not everybody needs the same level of detail.

Chad Ball  30:08

You know, knowing your audience is really what you’re what you’re getting at. I think and I know it’s interesting in my practice as an HPV surgeon, for example, the way that I discuss options, risks and benefits, as you point out, you know, pancreatic cancer that needs a Whipple is a very, very fundamentally different conversation than someone who has necrotizing pancreatitis with really little other options. I mean, you know, you can’t unhook them, you can’t palate them effectively, here’s this operation that’ll make you better versus probably dying of that disease. And, you know, I, on top of that, of course, we have different educational backgrounds and patients different experiences, different regions of the world where they’ve grown up and interacted with the medical systems and the surgical systems that may or may not be trustworthy, from their point of view. I’m curious, with all that said, how do you what are some of the tricks that you use or techniques maybe as a better term, in terms of dealing with patients who stand off, it’s just the wrong word, but just using all your personal techniques when you can’t seem to get through to them. And I guess that could be on either side of the equation, meaning that they don’t seem to grasp the magnitude of say their necrotizing, pancreatitis and the underlying disease, or maybe they, they’re overly anxious or overly concerned or distracted. You know, we see this obviously, with engineers and accountants and other physicians, where they’re almost too detailed and having trouble with that knowledge base and all the permutations of it.

Peter Angelos  31:49

It depends, obviously, on the clinical situation. And there are some situations in which, you know, if it’s an emergency, and there aren’t a lot of alternatives, then sometimes trying to talk to family members, and engaging family members to try to help the patient feel better about a decision to have surgery, sometimes that can be valuable. in circumstances where timing is not quite so urgent, and it’s a little bit of a more elective situation, I have found that often telling patients, look, it’s, it is okay, to get a second opinion. And, you know, you certainly don’t need to do what I’m recommending, but at least you ought to have another conversation with another doctor about it. Whether that be your internist or that be another surgeon, you definitely should talk to someone because this is really important that you have this operation. And then the lat and you know, I think those strategies are often effective, although not always. And the last thing that I do think is always essential, especially when, you know, when the patient hasn’t agreed and is sort of leaving with the idea that, well, I am not accepting your recommendation, I always want to leave on a positive sense of, I am here to help you. And, you know, ultimately, you make the decision that you think is best for you. And I think that this decision for surgery is that but you have to feel comfortable. And so if that means coming back to see me again in a couple weeks, or coming back to see me again in a couple months. That’s okay. I’m I’m going to be willing to see you again, and happy to discuss it further. And it’s interesting, because I’ve occasionally had patients who I recommended surgery, and they chose not to have it. And then you know, a year later they came back and said, well, you know, I’ve thought about it and now I think I want to have surgery. And although it doesn’t always happen, I think that leaving the door open that you are on their side is critical. And the fact that I think if it becomes antagonistic, then it’s much less likely that patients ever going to come back. So you know if the conversation goes the route of well, this is what I recommend. And I really am you know, I’m an experienced guy and I’ve got a lot of training. So if you’re not taking my recommendation, then you know you’re crazy. That patient is unlikely to come back and see me. So I think leaving it not in a personal negative way but very much in a way of you know, I’m I’m trying to make right recommendations that are for you what I think is best, and you know, feel free to come back and revisit it if you if you so desire.

Chad Ball  35:11

That’s, that’s so well said. You know, I think sometimes those of us who work in quaternary, or tertiary care, academic facilities with large teams, and I guess HPB would be the, the sort of current example of that, you know, we have superb fellows who obviously are board certified surgeons, and we have, we’re working in faculty teams. And so when they’re an inpatient, you know, you’re right there, there is a lot of opportunity for discussion across many experienced and savvy caregivers. But maybe in the in the clinic, you know, that that’s also a great point that we don’t necessarily have all of that all that group there, I think asking for a second opinion from a colleague or from someone across town, or whatever it might be, is a great idea. The other thing that I wanted to get your thoughts on along this line is the use of language, specific language and the terminology that that we use, and I know, right or wrong for me, you know, I will change the cadence of even my speech and the language I use based on who I’m talking to. Whether it’s a far that farmer from southern Alberta, who, who really sort of demands a simpler, more direct approach, or someone who has moved from New York City and wants all those details. And we did a couple of really interesting podcasts with folks who you know, Dave Urbach and and Tim Pawlik. And they talked about just as one example, independently, actually the use of the word “leak”, when we say to a patient, your risk of a leak from this, you know, gastrointestinal hookup is 2%. They commented on how misleading that word was because a patient’s own natural thought might go to the leak of their garden hose on the side of their house, but that’s not really what we’re talking about. So I’m curious how you think about language in the informed consent process, specifically? And does it change for you depending on who you’re talking to?

Peter Angelos  37:09

Yes, absolutely. And I think, you know, the, the folks that you mentioned, are incredibly thoughtful people. And I and I, and I absolutely echo the idea that we, we do I mean, I think I do, and I think that we all should alter our discussion based on the response of the patient. And, and so, you know, I, I sort of think about it, one way to think about that is sort of how much information to provide. So if a patient if a patient is asking a lot of questions, well, then I feel like, then, you know, that’s telling me that they really want more detail. And so you know, I can respond to that I can give them more detail. If a patient says to me, look Doc, I’m going to do whatever you say, I don’t even really care to hear about those risks. Well, that’s a patient that number one, I’m, I’m flattered that they have that much trust in me. But I’m also a little bit concerned that I run the risk of being of not engaging them appropriately in the decision making. And so I think that would be a situation when a patient says, look doc, I completely understand I’m good, I don’t need to hear about all these risks. My response is always well, you know, I, I’m flattered by your trust. But I really think it’s critical that you hear about these things because as much as I’m going to try to avoid you having these risks, I know that it’s a possibility. And it wouldn’t be right for you to make a decision without knowing what those risks are. And very few patients don’t want to hear those risks when it’s couched in that in those terms. And, and although I think that we never want to be we should never be talking down to people and we should never be you know, approach our interaction with patients in a condescending way because we know more and we’re more educated or we’ve got more experience. I do think that it is important that we try to use language that is meaningful to people. And so I think that’s actually one of the one of the real arts of the part of the art of being a good doctor. And I think this goes beyond surgery. I think the part of the art of being a good doctor is being able to communicate in a way that is meaningful to patients. And what words we use does make a huge difference there. And, you know, I often would think about as I was explaining things to patients, what if I was explaining it to my grandfather or my grandmother, who, you know, had come to the US as immigrants, and didn’t speak the language that well. Would I, would I feel comfortable with how I’m explaining it, would they understand what I’m saying? And, and I think that that attention to the individual patient’s responses to what we’re saying, that’s the sensitivity to the other person that I think patients really do appreciate. And I think that that’s something that we owe them.

Ameer Farooq  41:02

You know, it’s interesting in medical school, when we would have all these lectures about ethics, they would, they would talk about the demise of paternalism. And that, you know, really, it’s now about the autonomy of the patient. And, you know, you present them the options, and they choose from the options. But really, what both of you have talked about, both you and Dr. Ball have talked about is that we do have a role, whether we believe it or not, or whether we acknowledge it or not, we do have a role in guiding people towards a certain option that we think might be the better one for them. You know, I loved another piece that you had written in on that MD Edge column, where you talk about the role of paternalism and informed consent, and you have this really great sort of scenario where you’re doing an operation for parathyroid adenoma. And then you unexpectedly find this nodule in the thyroid, and it comes back and then you have this whole series of decisions you have to make the first being well, should I biopsy this? Or should I call the patient’s family members who are in the in the waiting room? So can you maybe expand a little, a little bit on that specific scenario that you had talked about? And also, is there a role there, then in surgery in particular, maybe more generally, in medicine for paternalism?

Peter Angelos  42:24

Sure. So I do think that, that, that the very circumstance of the unexpected findings in the operating room, that’s one where I think we as surgeons are in a position to have to make decisions, often without any input from patients or surrogates much more frequently than other medical, other physicians do. And I do think that that circumstance of, you know, you see something and I do remember that case that I had written about. So you know, I see something in the thyroid, it doesn’t look right, you know, number one, should I take it out? And then, you know, I feel like, well, if it doesn’t look right, then I should take it out. And then number two, well, if I, if I take it out, I get a frozen section. Because if I get a frozen section, then I’m going to know the answer while the patient’s still asleep. And the patient’s not going to be able to participate in the decision making. And so, I think that, you know, all of these things are important when we find the unexpected. And part of the problem is that if it is truly unexpected, then it’s hard to have had a conversation about it ahead of time with patients. I do think that paternalism, although we so frequently, these days talk about the value of shared decision-making and respecting patient autonomy. I think that there’s absolutely a role for paternalism. And I think part of that role is in making recommendations for patients, not just giving them a list of options. But then also, I think, especially when patients are asleep in the operating room. It is that is where I do think paternalism is appropriate. And I think part of the importance of us having an individual conversation with a patient is to get some sense of that person and a little bit of an understanding of you know, their values and their level of worry and concern. And, you know, that way at least we’ve got some basis by which to decide how to proceed now. There may be circumstances where it is absolutely appropriate to talk to the family about a decision but sometimes the person in the waiting room is not the person that the patient would want to make the decision. And so sometimes the person in the waiting room is the person who had the car or who had the day off. And so I do think that we sometimes kid ourselves in thinking that by talking to the family in the waiting room that we’ve that we’ve somehow respected the patient’s autonomous choices. Because if we haven’t actually asked the patient, who would you like to make decisions, then we’re never really sure if it’s that person in the waiting room or not.

Ameer Farooq  45:39

One other aspect of, of informed consent that we haven’t really touched on, but that I think is so important, and something that perhaps we all kind of think about in the back of our heads, but don’t really, you know, explicitly say out loud is, how much should we really disclose to patients? And this sort of touches on some of the work that you’ve done in the ethics of surgical innovation as well. You know, you talk about again, I just absolutely loved that series that you had on MD Edge. So you have this other article there that’s called ” How was your night, Doc? ” And you talk about thinking about well, should I tell the patient that I was up all night on call, and I didn’t get much sleep? How much should we really be disclosing to patients? You know, and I also think about the fact, for example, if you’re introducing a new technique, or using a new tool for doing an operation in your early on your learning curve, is that something that you have to disclose? How do you sort of approach that dimension of informed consent?

Peter Angelos  46:42

It’s, I think it’s hard. I think that, you know, part of it, I think, has to do with what, what is the patient going to do with that information? And is it actionable information or not? And so, you know, if I walk into the pre-op area at 7 am to see my patient who’s supposed to, you know, be in the operating room at 7.30. And, and they say, you know, so I hope, hope you had a good night, I hope you got a good night’s sleep, you know, it seems to me that in that scenario, for me to say, I feel, you know, I really did not sleep well, I don’t know, you know, maybe I had some, you know, I didn’t, I had indigestion all night. But I, you know, I’m tired, but I’m fine. I, you know, there’s no question I can do your operation. It seems to me that I’ve just shared information that’s not really actionable. And that’s also unlikely to help that patient at that particular time. And so I really do think that we need to exercise a fair degree of discretion in saying, in assessing oneself, so if, for example, I felt like gosh, you know, I I’m going through a personal crisis, and I truly cannot concentrate on what I’m doing, then I need to tell the patient and I need to cancel the operation. And, you know, I’m reminded it’s an extreme example, but I’m reminded of a friend of mine, who had a patient scheduled for a parathyroidectomy the next day. And he had the death of a parent unexpected on the day before he was scheduled to do that operation. And he asked his office to call the patient and tell them look, you know, that your doctor had this death in the family, and he’s not in a position where he can do the operation. And and I remember the shock with which the response from the patient was, well, you know, we have a surgery date, and I’ve changed my work schedule, and I think he should just be there. And that sort of shows a level of lack of understanding of the extent to which one needs to be present in the moment in the operating room, and needs to be able to really focus on what we’re doing. And I think that that’s where we have to exercise discretion. I think that, you know, if if I if I had so little sleep that I really think that I’m going to put someone at risk, well, then I should tell them, I should tell the patient I should find another surgeon or find another day for the operation. But I but I do think that we probably shouldn’t overshare if it’s just gonna cause concern with no particular benefit. Now, when it comes to an innovative procedure, I think that the the question is, do we simply answer the question truthfully, when asked, or do we offer the information? And that’s I do think, again, it’s a, it’s a personal decision based on I think, where one believes one is on the learning curve. So you know, if you’ve never done an operation, this is the first one or the first handful, I think it’s important to tell the patient that. I think that it would be critical. And on the other hand, if you’ve done something, you know, 40-50 times and you feel like, you know, you’re really good at it, and there’s no longer an issue of ascending the learning curve, well, then I don’t know whether it, I don’t believe it makes much of a difference to tell the patient, you know, I’ve done 76 of them. And now I’ve done 86 of them. And, you know, I hit 100. I think that that’s a level of detail that they don’t need. But I feel that we ought to have be very strict about answering the question when asked truthfully. And, and I do think that if we truly believe that we’re at the early phase of our learning curve, then we should tell patients that. And I’ve been amazed at the extent to which patients say, well, if you think it’s a good idea doc, then I’m willing to have you do it, because I want to get it done. And I trust you. And that again, it is it’s not a it does it does depend on surgeons to exercise a level of professionalism in their interactions with patients that really puts the patient’s benefit ahead of their own.

Ameer Farooq  51:56

Contrary to what your medical student said, clearly, surgeons do have a relationship with their patients. And so much of our discussion revolves around how do we build trust with patients. And how do we communicate effectively with patients. One of the chapters you wrote with Darren Bryan, in the textbook surgical ethics was about how to solve everyday practical ethical problems that one might face on a day-to-day basis in surgery. Can you briefly touch on some of the potential tools that surgeons can use to sort out ethical problems? And maybe just briefly, when do you think it’s appropriate or necessary to get your hospital ethicist involved when you have an ethical dilemma?

Peter Angelos  52:39

Sure. Yeah. So you know, the my co-author, Darren Bryan is a wonderful guy who’s completing his thoracic surgery training now in Boston. And, you know, I think that it is some of the things that we can do to minimize our ethical, the ethical challenges is to be upfront with patients and their families and try to communicate in a clear manner. I think that ensuring that we repeat things that are important and give people lots of opportunities to get information. I think that that’s very valuable. I think that when there is a challenging ethical situation, I think it’s never a sign of weakness to ask for help from an ethics consultant or an ethics committee, if that’s what you have at your hospital. I think that sometimes just getting another perspective, has value not only for us as physicians, but also for our patients or their families. And so I would say, you know, it’s the way we think about voting in Chicago. Early and often, I would say, get an ethics consultant early and often, if you think it will be a value. And it may be a value for you, it may be a value for the team, or it may be a value for the patient or the family. But I think that having another group or another person to engage in that conversation is never, never assigned, that we’ve not discharged our responsibilities as long as we continue to remain engaged. So I think that, you know, asking for an ethics consult consultation, doesn’t mean that I now no longer have to talk to my patient or their family. It just means that I’m going to widen the conversation and involve more people in the conversation. And that I think is a really important thing. When we ask for help it should be, you know, the way we asked for a cardiology consult. We’re not going to ask the cardiology consult to then you know, take over all the care of the patient. Rarely are we going to do that. More likely, we’re going to ask them to give us an assessment of preoperative risk or something like that. But we’re going to continue to be engaged with the patients. And so I do think that getting those getting help is valuable. And we shouldn’t, we shouldn’t feel that we’re that that by asking for help we’re, we’re acknowledging that we’ve done anything wrong.

Ameer Farooq  55:31

Now that you’ve, you’ve spent your career working on surgical ethics, you’ve done so much work on this, you’ve, you’ve given so many great talks. You know, the first time I ever saw you speak was at the meeting for the Annual Society of for Colorectal surgeons, and you held a group of colorectal surgeons captive, which is impressive for  a thyroid surgeon. So just speaks to what you’ve done. But now that you’ve spent your whole career doing this, do you think that the conversation and the approach towards surgical ethics has changed as as sort of an overall culture from a 30,000 foot level? And the second thing is, what do you think are the big issues in surgical ethics going forward for the next few decades?

Peter Angelos  56:17

Yeah, I think there has been a huge change. And I do think that I think surgeons take the ethical issues, I think much more seriously. I think that it is, you know, I think that organized surgery, the American College of Surgeons, for example, has lots more programs related to ethical issues in surgical care than it used to, I think that there’s a clear acknowledgement of the importance of the topic. And so so I think that that’s, you know, I think it’s a huge move in the right direction of really saying this is an important set of issues that we need to be cognizant of as practicing surgeons. I think if you, you know, if you think about what’s the biggest risk for us in the future, or the biggest challenge for surgical ethics, it strikes me that there’s lots of potential issues. And you know, informed consent will always be an issue and how we deal with innovative procedures and how we disclose our experience to patients, those are going to continue to be big issues. I think the biggest thing, though, and I, you know, I worry a little bit about it, and that is that, in the emphasis on volumes, and the emphasis on, you know, how many patients are you seeing, how many operations are you doing? You know, I don’t know whether you guys may not use it so much in Canada, but in the US, you know, all of our activity is counted as RV use, you know, relative value units. And so, you know, we know how many RV use we generated last month, in the month before and what our target is. And so there’s this huge emphasis on clinical productivity. And surgeons are most productive when they’re in the operating room. And so I think that there’s a tendency on the part of administrators to push surgeons to be in the OR more and spend less time with their patients. And, and I think we’ve seen a little bit of this movement, perhaps less in general surgery, and its subspecialties, but perhaps a little bit more in things like neurosurgery and orthopedic surgery, where there are departments that hire internist to sort of do the preoperative and postoperative care of their patients. And that’s not necessarily a bad thing, unless it pushes surgeons to be more just technicians. Because I think if we’re just technicians, then we’re really missing out on what we should be doing for our patients. And I think ultimately, if we’re just technicians, then, you know, we’re somehow losing a central aspect of what makes it great to be a surgeon and what allows us to engender the trust of our patients, which is that we do care about them as people and not just as someone who’s going to get an operation. And so I would say I think that’s a big risk. I think that you know, in an effort to maximize RV use, if we spend less time talking to patients and less time in our preoperative clinics, I think that’ll be a problem for us. And I think that most places realize that I think that if you ask surgical residents, I think most of them acknowledge the importance of learning how to talk to patients. And so I’m not too worried that this is going to happen anytime soon. But I think we should just at least be cognizant of the risk.

Chad Ball  1:00:15

I’m curious if if sort of the systemic changes in how we deliver health care and surgical care in the COVID era. You know, if you think both now, as well as in the future, much more electronic based platform, I mean, the amount of discussion we have with patients over the phone, or over over video calls now is unbelievable. And I can’t see it going back to the pre-COVID days entirely. Is there more risk in terms of consent and surgical ethics in that new environment? Or do the same principles apply and we should carry on with those as tightly as we can and have in the past?

Peter Angelos  1:01:01

Yes, it’s a it’s really an open question. And I share with you some concern that in this virtual environment in which, you know, sometimes we only meet patients in-person for the first time on the day of surgery, I worry that somehow we’re we’re not, we’re not able to have that same relationship or not able to engender trust the way we might have liked to in the past. And so, so I think the jury’s out on how much that’s going to impact that relationship. What I have my anecdotally, I would say, I think that patients have rapidly adjusted to the new normal as so many of us have to just, you know, in order to get through daily life, these the in the current environment. So I think it’s been a fairly ready shift, where people mostly are saying, you know, I feel comfortable. I’ve had a few patients who have said, well, I’d really like to meet you in-person before I plan to let you operate on me. And I feel like we’ve got to, you know, take those requests seriously and figure out the ways that we can continue to see people in person. I think that certainly with remote visits, it does give more patients the opportunity to engage with their surgeons, without necessarily having to travel long distances. And so I do think that there’s potential positives as well as the potential negatives. But I think that we, we still need to think about what we should do to continue to develop the trust of our patients. And it’ll be interesting to see if patients whose interactions with us up until the day of surgery were only virtual, if those patients are going to still feel that sense of comfort with their surgeons.

Chad Ball  1:03:05

The last question that we try and ask everybody, at least its some interesting, fun answers is, if we could take you back in time and talk to a younger you, what, what sort of advice would you have liked to have had at that time? What would it what kind of advice would you give yourself?

Peter Angelos  1:03:21

I think that early on, in my practice, I think that I perhaps was so interested in having patients trust me, and you know, want to have me operate on them that I think I may have been a little bit  I may have taken it too personally, when patients said, I appreciate everything you said, but I’m gonna go see someone else who’s more experienced. I think that I think that I probably was affected negatively by those interactions more than I should have been. And now as I’m now you know, most people would have been in the tail end of my career, it I feel as though I have such an advantage over people who are younger than me, and it’s not really fair. And so I would tell you know, I would tell the younger me to not take it so personally, when patients say I’m gonna have someone else do this.

Ameer Farooq  1:04:50

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.