Editor's Column: Surgical Wisdom

Martin McKneally

Russell Gruen, Professor of Surgery and Public Health at The Alfred and Monash University and Director of the National Trauma Research Institute, Melbourne, Australia, and our Peter Crossgrove lecturer, gave a stimulating review of practical problems in the control of bleeding. Russ had spent a year in the Harvard Bioethics Program, while studying Health Policy in Boston. His essay on Surgical Wisdom (1) prompted me to look back at my formulation of the normal process of linear thinking that leads from observation to decision-making.

We ordinarily simplify our observations of the universe to a manageable set of observed data and look for relationships. Validating these relationships leads to information. We can make more sense of our observation - in patients or experiments or life, if we next place them in a conceptual framework, such as the framework of neuroscience or biology or other scholarly disciplines. When we succeed in organizing our information within these frameworks, we come up with knowledge. The final step in the linear pattern of thinking is trying to make judgments to predict or evaluate the importance and consequences of our knowledge - of a particular case or a particular biologic phenomenon. Those who make reliable and sound predictive or retrospective judgments develop a reputation for wisdom.

Russ describes wisdom as “a complex human trait that embodies rational decision – making, general knowledge of life, empathy, compassion, altruism, comprehension of diverse values, emotional stability, insight, self-reflection, and the ability to proceed …. in the face of uncertainty.” This definition is based on his study of Aristotle’s description. Aristotle “had a particular practical view of wisdom. He proposed that being wise required the ability to see on which occasion which course of action was best supported by reason.” “The wise surgeon consistently (chooses) the best course of action, based on superior judgment, rich understanding, few unjustified beliefs, and a strong moral compass.” “In our own moments of indecision we are likely to wonder ‘What a wise surgeon would do in this situation?’. The wise surgeon also has a rich understanding of the extreme nature of patients’ experience when undergoing surgery. Miles Little (his thoughtful Melbourne surgical colleague) characterized this as an ordeal, a need for rescue, a sense of proximity and privileged knowledge inherent in the surgical encounter and its physical and emotional aftermath.

“Completion of training signifies competence, sufficient to enter clinical practice… Wisdom, however, is not just the accretion of layers of experience upon a core of taught competencies... Superior judgment requires the deliberative emotional and social skills that are refined by solving problems many times over.”

This thoughtful essay is incompletely represented here, but will reward careful reading. How we balance our judgments, what frames of reference we use to make surgical decisions is generally based on frameworks we learn from our mentors and role models. Reflective thinking about our experience and careful evaluation of our previous judgments leads to a level of wisdom – of reliability of judgment that characterizes the wise surgeon. On the basis of these assessments, surgeons are better able to handle the complex issues that confront us, like the hotly debated current issue of organ donation after cardiac death. How long should the hands-off time be before we initiate restoration of circulation to salvage transplantable organs? How should we think about terminal sedation of suffering patients? When is it reasonable to try a new and unproven treatment on someone’s parent or child? What is the fair distribution of our ability to work hour after hour, or of society’s expensive healthcare resources? Information is accumulating at a staggering rate. There is a pressing need for managing it using thoughtful assessment and surgical wisdom. Jeffery Matthews, our recent Peter Crossgrove Lecturer (2) told us that “current surgical practice is an accumulated wisdom, mixing fact, opinion, and magical thinking in unknown proportions.” More on this in our next issue.

M.M.

(1) Gruen RL, Watters DAK, Hollands, M J. Surgical Wisdom, British Journal of Surgery, 2012; 99: 3–5

(2) Matthews, J. Truth and truthiness. Peter Crossgrove Lecture, UHN Surgical Grand Rounds, June 14, 2013 (to be featured in the next issue of the Spotlight)