Atlas is not alone: sharing the burden of clinical challenge

In the field of oncology where the disease does not respect any boundaries, it is essential for the treating physicians to reciprocate through the multidisciplinary charge. The expertise of a particular group is derived from their familiarity with cutting edge and salvage approaches to challenging situations within their field. In the setting of unusual situations, surgeons are guided by their personal experience, advice from colleagues and mentors, as well as other specialty-specific sources of eclectic knowledge such as case reports and presentations at society meetings. However, there are complex problems which enter into a gray zone beyond the routine approaches of one particular specialty. To fully and safely meet these challenges, the combined expertise of multiple surgical disciplines is required. Gone are the “days of the giants” where a single surgeon would go it alone and attempt to shoulder the full burden of a difficult problem which might be just beyond their capabilities. In the modern era, healthcare in general and surgery in particular have steadily evolved into a team-approach in which strength truly comes in numbers (1).

In this month’s Journal, Muñoz-Largacha and their team from Boston University present a case report of an impressive multidisciplinary effort exemplifying the capabilities of a highly coordinated approach to resection of a large metastasis involving the sternoclavicular joint and base of the neck (2). Four surgical teams including Thoracic, Head and Neck, Vascular and Plastic surgery came together to combine each group’s respective expertise to optimize the outcome for the patient. The authors provide a concise and instructive narrative of the preoperative planning and operative execution of resection and reconstruction in this challenging setting. The overall success of the team is readily apparent, nevertheless, there are two players whose contributions should not go unrecognized: the Vascular surgeons and the patient himself.

For a surgeon to “be available” often involves blocking off time in a busy elective operative schedule to assist in the possible event that their specialized services may be required. In a world where relative value units (RVUs) and surgical productivity are becoming an unfortunate focus in clinical practice, sacrificing operating room or clinic time is not trivial (3). Most surgeons have felt the pressure to balance patient care and operating room utilization time with the goal to avoid unnecessary delays, cancelled cases or unfilled block time (4,5) This juggling act becomes even more challenging when a surgeon is involved in a multi-team procedure taking place in another surgeon’s room. The best laid plans are quickly scrapped when the usual unexpected events occur such as emergency cases and “routine” procedures spiraling into higher complexity. “Being available” is not inconsequential. In this particular case, the vascular surgery team was prepared to participate in reconstruction of the patient’s carotid artery if needed. Thankfully for the patient, this was not required but for the vascular surgery team—their mental and time commitment became an uncompensated donation to the patient’s care team. By and large, the vast majority of physicians would not think twice about this sacrifice for the patient because it is the ethically and professional right thing to do. But the opportunity cost paid by teams such as the vascular surgeons in this case should be appreciated to emphasize that healthcare is much more than dollars and cents.

We should not forget that the patient is the central member of any and all health care teams. It can be easy for surgeons to become task focused when developing and executing a plan. But a tour de force surgery is for naught if the results or complications are not tolerated by the patient. The informed consent process is a cornerstone in communication between doctors and patients but most surgeons will admit that it falls woefully short in many ways (6). For example, it should not be expected for a layperson to grasp the intricacies of a complex disease or its treatment. Similarly, a patient may be told what challenges or complications might arise during the hospital course or beyond (7). Yet, in the comfort of a clinic chair, the gravity of what may befall a patient cannot fully be absorbed or understood. The post-operative picture in Muñoz-Largacha’s article (Figure 4) is a relatively common sight for surgeons but from a patient’s perspective, to see that image reflected in the mirror might be more than what was initially bargained for. The physical toll of surgery is only one aspect of a patient’s struggle which includes mental, social and financial stresses. Ultimately, the burden of both disease and therapy is the patients to bear.

While consternation of negative outcomes is a heavy weight, it is hope that balances and tips the scales. A study of patients with end-stage cystic fibrosis considering lung transplantation showed that a majority had a “do or die” mentality that made the high-risk decision “easy” (8). The desire to overcome a disease and the drive to take back life are powerful forces that manifest as resilience. There have been efforts to study how patient resilience impacts outcomes such as recovery and wound healing, including identification of biological markers to predict resilience (9). As indices of physical frailty are actively being created to predict surgical outcomes, it is an intriguing notion that a “resilience stress test” could further help identify or exclude patients as surgical candidates. A truly successful operation is arguably defined by a patient fully recovering from the procedure to achieve a good quality of life. This requires significant effort and spirit on the part of the patient which serves to highlight the patient’s key role in their healthcare team.

Dire situations that seem insurmountable can feel like the weight of the world resting on your shoulders. When faced with a formidable challenge that may test the limits of a person, be it a physician or patient, strength to overcome can always be found in teamwork. As elegantly demonstrated by Muñoz-Largacha et al., great success can be achieved through the collective efforts of patients and cooperative multi-disciplinary teams.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

References

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