Advocate Illinois Masonic Medical Center
Chicago
The doctor–surgeon relationship can be tense. As gastroenterologists, we often want to exhaust every medical option before we call in a surgical consultation. Surgeons, on the other hand, tend to want to perform surgery sooner rather than later, before the patient’s condition deteriorates and risks surgical complications.
Sometimes this battle of egos causes us to forget the real reason we do what we do—to care for the patient. And it’s not so much the battle of our egos collectively but a struggle with our own.
I’ve had conversations about this with a surgeon colleague, Joaquin Estrada, MD, in which he said “gastroenterologists need to call the surgeon in sooner.” He suggested that “perhaps, you see the referral of inflammatory bowel disease patients as a sign of failure. We need to change that.”
There is a patient case that I often reflect on with Dr. Estrada, a board-certified colorectal surgeon and the surgical director of digestive health at Advocate Illinois Masonic Medical Center, in Chicago. The patient presented with severe ulcerative colitis off therapy for an extended period of time. She failed outpatient therapy and required admission. As a result of her protracted course, she developed significant comorbidities, delaying her surgery further and complicating it. Ultimately, we had three options: remove her colon, remove her limb or continue with medical management.
The details of the case aren’t the true issue here. The issue is when to sound the alarm and call surgery when failure arises in the medical management of inflammatory bowel disease. Although there is no clear solution, perhaps the best next step is to have that conversation out loud. Here are some ways Dr. Estrada said he believes we could do so.
Cultivate a Culture Of Collaboration
I asked Dr. Estrada to describe what he wishes would happen to prevent delays in surgery. He said, “When there are multiple treatment options, it is essential to get consensus and buy-in from all team members. Many patients with complicated scenarios benefit the most from interdisciplinary meetings with the care team. The goal is to cultivate a culture of collaboration.”
He noted that as a surgeon, he “may not be aware of the nuance of cutting-edge techniques on the medical side, and vice versa,” but when clinicians and surgeons collaborate, it “re-centers the patient as the most crucial person in the process. To do that in a complex and evolving field involves everyone having a seat at the table.”
Dr. Estrada added that he is concerned that “when we go too far off in one direction without team buy-in, we ultimately put ego before the patient.” He noted that when this happens, and surgery is needed, it can make the surgery more difficult if comorbidities arise during the delay.
When I asked Dr. Estrada to expand on his views on communication breakdown that can occur, he said he considered “lack of communication ... the No. 1 cause of bad medical outcomes.” Noting that communication breakdown can occur between the doctor and the patient, between doctors, or between nursing staff and doctors, he said, “When we do a root cause analysis of this, the result is the need for a more structured and consistent system for communication.”
These problems have become more complicated in the COVID-19 era. “We are all swamped,” Dr. Estrada acknowledged. “That being said, we need to take the time to have necessary conversations regarding complex patients.”
Although these conversations are not required for every patient, Dr. Estrada and I agreed that GIs and surgeons need to make more time to discuss treatment for complex patients.
Have a Plan for ‘Gray Zone’ Patients
We dove deeper by breaking down what the process should look like for “gray zone” patients, whose condition presents a legitimate argument for both medical and surgical treatment.
“If a patient could truly go either way between medical and surgical, the answer on what to do will come from the patient’s input,” Dr. Estrada said. “Any plan has to start with a mutual agreement that the patient is a member of their own care team and has a significant say. The GI and surgeon should have a conversation together with the patient so they can voice what they think is best for their particular lifestyle. Once this happens, both parties need to meet low-threshold requirements to facilitate more communication.”
Dr. Estrada also stressed that all physicians, including surgeons, “must be willing and accepting of therapies outside of their expertise. Egos must be put aside so both sides can articulate their positions.” He said he sees a tendency for medical doctors to “think that they should avoid surgical consults because surgeons will always recommend surgery. On the flip side, surgeons need to accept that the best patient outcome often means they won’t need surgery. Plenty of my colleagues are aggressive in surgical recommendations, while I think we need to be much more nuanced.”
Complement, Don’t Compete
As a gastroenterologist, I want to work harder to embrace this idea that we need to look at our counter-specialties as a complement rather than competition.
Dr. Estrada also suggested that gastroenterologists can try a different approach to relationships with surgeons. “If your perception of failure is keeping you from cultivating an environment of collaboration, appeal to surgeons on a fundamental level. We all took an oath as doctors to put the patient first, and we all speak that universal language. It can get you further than you think.”
I feel fortunate to have a strong relationship with our colorectal surgeons at Illinois Masonic. I recall sharing a story like this with a GI colleague at a neighboring hospital. He was put off by the concept that GIs sometimes wait too long to call surgeons. I respect that. However, we don’t operate in silos, and I truly believe that the only way to offer great care is to have great people by your side—even if we spend a tiny bit of our ego as collateral in doing so.
Dr. Albert is a member of the Gastroenterology & Endoscopy News editorial board.
This article is from the May 2022 print issue.