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Bruce Campbell MD

A Fullness of

Uncertain Significance:

Stories of Surgery, Clarity, and Grace

BRUCE H CAMPBELL, MD FACS

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By Bruce Campbell, MD

Published in Doximity on August 8, 2022


View the original essay here.


Featured in Op-Med, a collection of original articles contributed by Doximity members.




Your close friend, Caleb, knows you work in a hospital, so he tells you a story: His healthy 35-year-old sister Melissa has thyroid cancer. She had surgery this week to remove her thyroid and nearby lymph nodes. That evening, she developed a large blood clot and had to go back to the OR. In the morning, her fingertips tingled and they gave her calcium and vitamin D. At breakfast, she choked trying to swallow and they determined that one of her vocal folds is paralyzed. After lunch, her neck was swollen and there was chyle under the skin. She may need to go back to the OR again.


You say that his poor sister has had pretty much every complication of this surgery. Caleb says he asked the doctor, “Can you say why this happened to her? Was there some mistake? How much experience do you have doing thyroidectomies?” The doctor says complications happen, and it was just bad luck. For now, Melissa is a mess, but the doctor says she will get better as time goes on.


Caleb wants to know what you think. “Oh, and by the way,” he says, “I looked up the surgeon’s age.”


So, what do you tell Caleb? Does your answer change if the surgeon is 33 years old? What if the surgeon is 73 years old?


There are relevant data on both sides of the “young vs. old” debate. If the surgeon is young, they might be more current, both in the relevant literature and surgical techniques. If there is some newfangled way to solve a surgical puzzle, they likely have encountered it and played with the technology.


For some procedures — particularly those that are evolving over time — younger surgeons have the advantage. A 2005 study of laparoscopic inguinal hernia repair outcomes published in the Annals of Surgery showed that inexperienced, “older surgeons” (here, defined as older than 45) had significantly higher rates of recurrence against inexperienced “younger” surgeons. These findings parallel other quantitative studies that document gradual declines in quality-of-care delivery as physicians age.


However, procedures performed by younger surgeons can also be associated with higher complication rates. A 2020 CMAJ paper demonstrated that the incidence of death, surgical complications, and 30-day readmission rates dropped 5% for each subsequent decade of surgeon age. Similarly, a 2018 BMJ paper found that older surgeons had lower mortality rates after operations on a cohort of almost 900,000 Medicare patients. The BMJ study also found that the patients had the best outcomes when their surgery was performed by woman surgeons in their 50s.


Why might younger surgeons have more perioperative complications? Given their relative youth, they might not have encountered all the clinical “zebras” and might be less circumspect about their own limitations. Being fresh out of training, they could be more rigidly fixed in their fidelity to the ways their mentors insisted things be done. As a result, they might rush headlong into fraught clinical situations or miss things that will become obvious later in their careers.


Older surgeons, to their credit, have accumulated a breadth of clinical experiences over the years and are less likely to get trapped in no-win surgical situations. They might be more comfortable going “off script,” if needed. On the other hand, older surgeons might be too cautious, and avoid procedures that could carry low, but still real, opportunities for success. Depending on their own health and stamina, they might be less likely to take on complex procedures.


To help me understand what others think, I asked more than a hundred of my social media contacts to chime in on the younger versus older surgeon dilemma. In general, given equal credentials and characteristics between a hypothetical young and old surgeon, almost half refused to make any recommendation. Of the rest, two-thirds recommended Melissa see the older surgeon based almost entirely on the sense that they would have more experience and would be better equipped to deal with complications. Those who preferred the younger surgeon cited their recent training, up-to-date knowledge, and better reflexes. When complications occur, my friends agreed that “stuff happens,” and that the problems were unlikely related to the surgeon’s age. When asked to assign a range when surgeons are in the “prime of their careers,” the majority put the sweet spot between 45 and 60.


“Young vs. old” expertise is relevant both inside and outside of medicine. Think back to your own journey from being a complete novice to mastering a hobby, profession, or body of knowledge. My own sense of being an expert has fluctuated over the decades. I found my development of expertise as a surgeon to be iterative, complicated, and variable.


My view of whatever proficiency I possessed also evolved. I completed my head and neck surgical oncology fellowship when I was 32 and am now 67. Over the years, I accompanied patients through surgical complications and, although my suffering never compared to theirs, I ached for them. When I was younger, I blamed postoperative problems on the cancer, the condition of the tissues, the patient’s nutrition, and a host of other “not my fault” factors. Now that I am older, I wonder if many of the problems were the direct result of my own failures and shortcomings.


On the flipside, surgeons, like everyone, are prone to age-related decline and experience deteriorating sensory functions, a loss of habitual and controlled analytic memory, and decreased visual-spatial abilities. A surgeon’s declining function and absence of insight is a very dangerous combination, indeed.


So, what to tell Caleb and Melissa? Well, first of all, her surgeon is correct. Each of Melissa’s complications is a challenge, yet each might resolve. But, what about the choice of a surgeon? That’s more difficult for me. Young surgeons bring fresh vitality, along with evidence-based, cutting-edge perspectives to the conversation. At the same time, older surgeons bring a wealth of experience and insight. As Mark Twain noted, “Good judgement is the result of experience and experience the result of bad judgement.” There are some moments that must be experienced to be deeply understood.


So, here’s another way to look at the dilemma. Benjamin Franklin cautioned his contemporaries to “beware of both the young doctor and the old barber.” We surgeons trace our roots to the barber surgeons of Franklin’s time, so he was warning his readers that young doctors are unsafe since they have yet to hone their skills, while old barbers are dangerous since they don’t maintain the sharpness of either their razors or their techniques. His aphorism still rings true.


From my own personal experience, I know many surgeons who are wonderful, wise, and talented. Still, I might tell Caleb and Melissa that, although the surgeon’s age isn’t that critical, they should avoid those whose insight has yet to develop, those in whom it has started to evaporate, and especially those in whom it never appeared in the first place.





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Illustration by April Brust of Doximity

 

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What Readers are Saying About
A Fullness of Uncertain Significance

In this tender and candid collection of short essays, Dr.  Bruce Campbell illuminates how much medicine is truly  the sacred act of holding vigil with and for our patients.  Through his reflections, we get a glimpse of how surgeons  hone their instincts, grow through challenges, and cope with  disappointment as they navigate the uncertainty inherent in  medicine. Through his polished lens, the reader understands  how even in the pressurized world of surgery, heavy with the  responsibility of healing through a scalpel’s cuts, there are  moments of intimacy that are filled with grace. 

 

—Rana Awdish, MD, FCCP, FACP, author of In Shock: My  Journey from Death to Recovery and the Redemptive Power of Hope  

Dr. Bruce Campbell turns his scalpel on his own history  as a surgeon, probing the medical field past, present, and  future. His vibrant stories illuminate the fundamental human  underpinnings of medical science, bringing to light the glories,  tragedies, imperfections, and uncertainties we must all grapple  with. Eminently readable and richly satisfying.  

 

—Danielle Ofri, MD, PhD, Clinical Professor of Medicine  at New York University School of Medicine, Editor-in-Chief of  Bellevue Literary Review, and author of When We Do Harm: A  Doctor Confronts Medical Error 

Dr. Campbell’s reflections will resonate with those who treat  cancer patients as well as those who have had cancer themselves.  Medical students and residents will also be inspired by his life’s  journey as a surgeon and teacher, aspiring to their own joyful  and meaningful lives in medicine. 

—Julie Ann Freischlag, MD, FACS, FRCSEd(Hon), DFSVS,  CEO Wake Forest Baptist Health, CAO Atrium Health, Dean of  the Wake Forest School of Medicine, and 2021-2022 President of  the American College of Surgeons.  

In this rich collection of stories and essays, Dr. Campbell  reflects on his years of caring for patients and training young  doctors to follow in his footsteps. With compassion, humility,  and shimmering prose, he shares the joys, pains, and somber  responsibility of being a surgeon. 

—Gayle Woodson, MD, surgeon, educator, and award winning author of After Kilimanjaro and Leaving La Jolla  

Bruce Campbell is no average surgeon and no ordinary  writer. He takes the excellence of his medical trade and weaves  the challenges, exhilarations, and tough decisions of surgery  into beautiful prose. Here is one who clearly doesn’t reduce  patients to a diagnosis, but who sees them as whole persons  worth getting to know. The chapters in this book are like  windows into the humility and generosity of a man I’d like to  have as my personal physician. 

—Peter W. Marty, editor/publisher of The Christian Century 

With his willingness to delve beneath the surface, Bruce  Campbell has created a deftly interwoven series of lessons gleaned  from poignant moments of a fulfilling surgical career. In a warm,  compassionate, and honest voice, Dr. Campbell delivers to the  reader not just insights on medicine, but truths about humanity.  

—K. Jane Lee, MD, author of Catastrophic Rupture: A  Memoir of Healing 

Humorous and humble, serious and sublime, these lean essays  offer a glimpse behind the surgical drape to show what it’s like to  be a cancer surgeon over the course of a long, rewarding career.  From Campbell’s first invitation into the “inner sanctorum” of the  O.R. as a nurse’s aide while in college, through tender interactions  with patients, to his projections about the profession when he is  long gone, this smart, sensitive surgeon illustrates how doctors can  listen to, care for, and learn from their patients. He courageously  goes to the “hard places” as well as sharing those special moments  that make it all worthwhile. Early in the collection, Campbell  writes, “Besides being a surgeon, I am also a human being.” This  beautiful book is about both. 

—Kim Suhr, MFA, Director of  Red Oak Writing and author of Nothing to Lose   

In lucid and succinct vignettes, Dr. Campbell illuminates  the myriad of emotions and sensations that accompany a life in  surgery. These stories of persistence, camaraderie, shame, grief,  guilt, and regret 

vantage point of experience. These ideas serve as the springboard  to discuss unique, personal insights whose wisdom is of import to  anyone in the healing profession. With elegant and engaging prose,  Campbell beautifully expresses the honor it is to be a physician. 

—William Lydiatt, MD, Chief Medical Officer Nebraska  Methodist and Women’s Hospitals and Professor of Surgery,  Creighton University in Omaha, Nebraska 

“Over the years, I have made an uneasy truce with failure,”  says Campbell in the opening pages of his debut anthology, and  yet his stories are anything but. Captivating, heart-wrenching,  inspiring—he chooses his words as meticulously as he conducts  his surgeries. 

And it’s just like a surgeon to keep you up in the middle  of the night. “One more story,” you’ll tell yourself, but with  Campbell’s reflections, it’s hard to stop. There’s a familiar ease  with which he flourishes his pen; everything falls away, and it’s  almost as if you’re sitting across the table from him as he recalls.  You laugh when he laughs, you cry when he cries, and you wait as  he waits. His memoir of stories is sure to become a rite of passage  for future doctors and patients alike, enjoyable little tunes that all  hum together in a harmony of sound. 

Turning the last page of Campbell’s novel, I succumb to my own  “fullness of uncertain significance”—I have been charged to seek  meaning, to reflect, to sit in the silence of his reverberating truths.  

—Olivia Davies, MD, poet, writer, and dermatology resident at  Massachusetts General Hospital

 

 

The words “clarity” and “grace” take on heightened  significance in this honest yet lyrical set of essays by Bruce  Campbell. The immediacy and intensity of these stories  immediately swept me into the consulting room and OR. I felt  as if I were a privileged witness to an almost sacred encounter  between surgeon and patient. Subtle language lays bare a primal  relationship. It is impossible to read this book and not be  changed by the experience. 

—Carol Scott-Conner, MD, PhD, Professor Emeritus of  Surgery at University of Iowa Carver College of Medicine and  author of A Few Small Moments: Short Stories  

Dr. Bruce Campbell sets a new milestone for doctor-writers. As  an otolaryngologist and head and neck surgeon, he treats patients  with the most advanced and aggressive cancers imaginable. Internists  like me wonder how head and neck surgeons like him do it; this  book gives me the answer. Dr. Campbell brings luminous sight  to his work. His writerly gifts let him capture the delicate and the  solemn, the tragic and the everyday dimensions of illness. Not a  set of doctorly instructions (though instruct it does), A Fullness of  Uncertain Significance: Stories of Surgery, Clarity, & Grace lays open  the profound mysteries and truths and awe about this life of ours.  These stories will change lives. 

—Rita Charon, MD, PhD; Bernard Schoenberg Professor  of Social Medicine and Professor of Medicine; Chair of the  Department of Medical Humanities and Ethics; Executive Director  of Columbia Narrative Medicine, Columbia University, New York  City; Co-author, Principles and Practice of Narrative Medicine 

 

 

In this compelling, insightful, and beautifully written  compendium of stories, Bruce Campbell shares the lessons he  has learned, and continues to learn, throughout his medical  education and his years as a highly successful surgeon, faculty  member, and teacher. A Fullness of Uncertain Significance is  refreshingly honest and introspective, exploring not only many  of the desirable outcomes when he had been faced with a broad  array of professional challenges, some potentially life-and-death,  but also those outcomes that were less than he had hoped for.  Readers will appreciate the author’s willingness to reveal that,  “As a surgeon, I have made mistakes that have hurt people. This  should not surprise anyone since, besides being a surgeon, I also  am a human being.” Providers, teachers, and students of health  care in every field and at every level of service will benefit greatly  from what the author has accurately labeled “Stories of Surgery,  Clarity, & Grace.” This isn’t merely a book about one man’s life  as a surgeon. It is a book about the need for understanding and  compassion when dealing with others, especially those in distress. 

—Myles Hopper, PhD, JD, author of My Father’s Shadow 

In this collection of essays, Dr. Campbell pulls the reader into  his Milwaukee otolaryngology clinic, the operating room, and his  medical work in Kenya. He tells story after story with wonder,  humour, and affection. He looks back on his medical training and  fantasizes about medicine in the mid-twenty-first century. He lets us  in on his unique vantage point on humanity, and does so with such  humility and grace that his own humanity is never in question.  

—Martina Scholtens, MD, author of Your Heart is the Size of  Your Fist