Minimally Invasive, Maximally Intrusive – by Dr. Yousif A-Rahim

There are many medical specialties. Each has its rewards and challenges, and med students often find focus during third year rotations. I chose to specialize in therapeutic endoscopy and minimally invasive gastrointestinal procedures due to an event that occurred much earlier in my own progression: a family tragedy in childhood. My Uncle Yousif died of massive gastrointestinal hemorrhage: he bled out in a hospital bed at the shockingly young age of twenty-seven, leaving two young sons and a heartbroken family, among them my dear mother. It was a tragic event because with the appropriate medical intervention, a physician could have saved his life. Looking back, there was little doubt that I would land in this specialty, and I am grateful for the opportunity to save lives with that same intervention.

Recent advances in gastroenterology and surgery have allowed a marriage between surgery and endoscopy: two previously distinct fields of medicine, giving rise to a new complement of therapies called minimally invasive gastrointestinal therapeutics. Extensive training is required to achieve competence in these hybrid procedures, which resemble surgery more than they do routine gastroenterology. The majority of these procedures are performed by therapeutic gastroenterologists, the name given to a new breed of specialized GI doctors who perform them; the rest by surgeons who also acquire the requisite knowledge and training. Examples of minimally invasive GI procedures include placement of metallic stents in the esophagus, stomach, small intestine, or colon to re-expand the lumen, which is compressed and blocked from a cancer arising in or adjacent to the site of blockage. Or, in some cases, a stricture or narrowing of a benign or nonmalignant cause. Other therapies include dilation or stretching of the narrowing, laser ablation of a tumor, or surgical excision of the culprit tumor altogether, all done with a specialized tool called an endoscope: a tube with a light source, inserted into the mouth or anus and advanced to the site of pathology where an endoscopist performs the procedure without the need for incision in the skin. The same techniques can also be performed inside the liver and pancreas- a highly specialized and complex procedure called ERCP, short for endoscopic retrograde cholangiopancreatography. ERCP is also widely used, in fact the majority of these, to remove stones in the bile duct.

This new era of therapeutic endoscopy has catapulted the status of GI doctors to a level previously occupied solely by surgeons. Therapeutic endoscopy has gifted gastroenterologists with a renewed sense of purpose and credibility, challenge and prestige that has made their heads bigger and spurred some of them to strut around the hospital like real surgeons, as if they own the place. I’m sure it’s obvious to most that there’s a lot of ego in medicine. I am over generalizing somewhat, articulating openly a belief we have long expressed privately; but there is truth to it. Relations between most GIs and surgeons prior to this era were fraught with disdain and arrogance on the part of surgeons, many of whom viewed themselves as Gods incarnate on Earth. Cross collaboration between GIs and surgeons was virtually unheard of prior to the era of therapeutic endoscopy. Now, however, such collaboration has become a necessary requirement in the management of patients with these complex maladies. I should mention one notable exception to my coarse depiction of the surgical profession: the great surgeon Dr. Mark Grief, who I came to appreciate as a colleague and for whom I have great affection. Dr. Grief is a surgeon’s surgeon, a seasoned elder statesman who tirelessly navigates hospital politics and patient advocacy. As a clinician, he is thorough and thoughtful; his clinical judgment is sound, and his decision making incisive. Magnanimous and gracious, he is a kind elder and fatherly figure who epitomizes modesty and dependability.

My choice of specialty requires sophisticated, complex technical skills and unerring precision. These procedures are also associated with a very high risk of morbidity and mortality, facts that increased my focus, resolve, and desire to succeed. When successful, I would burst out of the OR glowing, triumphant, strutting confidently around the hospital, my patient’s jaundice from the cancer in her pancreas quickly subsiding. She would soon be in surgery once again to have the cancer resected; a highly complex surgery called a Whipple procedure, and radiation for cancer palliation. In other cases, when I performed an ERCP on a septic patient barely hanging on to life, an incision made on the roof of the ampulla of Vater where the bile duct and pancreatic duct drain into the duodenum would evacuate putrid pus, blood clots, and remove an obstructing stone. A plastic stent left in the bile duct assured continuous drainage of infected debris. The life-threatening sepsis usually subsided almost instantly. The body cleansed and healed itself.

But sometimes tragedy struck; a heart attack or a cardiac arrest occurred during the procedure, accelerating and guaranteeing the inevitability of death. No small matter, there is also the uncompromising need for a high level of technical skill; if the incision is a millimeter too deep, or should it dither too far upward, downward, left or right, your patient is gifted with another feared complication called a perforation. That is a hole in the intestine, liver, or pancreas. Unlike a machine, a surgeon cannot replicate the incision with perfect accuracy every time, nor operate repeatedly at the same skill level or efficiency. We are human, and not infallible. The best of us err infrequently, but when we do, an unintended error can kill a patient. The famous French surgeon Rene Leriche is quoted as saying, “All surgeons carry cemeteries within themselves of the patients whose lives they‘ve lost.” Because real life situations are so complex and a patient’s needs individual and contextual, I sometimes found myself torn between the choice to urge a patient to undergo surgery, or advise against it. Thinking it wise to avoid a malpractice lawsuit that could have cost my license to practice medicine, my nest egg, or both, I often found it prudent to deliberate on factors that deterred rather than incentivized one to perform these high risk and complication fraught surgeries. Reason should triumph over interests.

It was not unusual for me to call a patient with the good news that her liver and pancreas CAT scans were normal, feel a wave of relief and gratitude from them, hang up and make the next call in which I had to inform another patient of his metastatic rectal cancer. Some systemically unstable patients with advanced diseases kept me alert all night. I would hunker down in some obscure basement office to receive the vast number of calls relating to their illnesses. After hour calls are supposed to be strictly urgent in nature; however, some do not respect this. Without fail, many of these non-emergency calls were requests for narcotic prescriptions. Thankfully, narcotics cannot be called into the pharmacy regardless of whether the complaint is legitimate or not, so my hands were tied. I was able to avoid the controversy over opiates that currently consumes our nation.

Then there were the truly urgent cases that called for lifesaving intervention. Few things provoke more anxiety in a doctor than a patient with cirrhotic liver disease who presents with hemorrhage, secondary to sudden rupture of large engorged esophageal veins. For some odd but very consistent reason, these most often occurred after midnight and almost never during the day when doctors, nurses and assistants were already awake, alert and physically able to assist.

It is a well-demonstrated fact that sleep deprivation and REM sleep disturbance have serious physical and mental effects on a person. Medical students and Fellows simply learn to cope with this, and manage a grueling schedule which is hostile to any kind of normal life or sleep cycle. The disruption of desperately needed rest becomes routine, especially in the unpredictable world of emergency cases.

The typical course for such a patient started when the emergency room notified me which exam room my patient was in. After a thorough physical exam and after obtaining crucial lab results, I would declare high acuity and need for treatment. It would be another two to three hours before I actually performed the procedure. These were not idle hours, as this was the time needed to start an IV, begin fluid resuscitation and blood transfusions. Concurrently, hospital staff would transfer the patient to the intensive care unit. I would start the procedure around 3:30 in the morning, and wrap up by 5:00. After assessing the patient’s status post procedure, I would drive home to drink black coffee, shower and get dressed for my regular twelve hour plus day, having had virtually no sleep.

As an attending in private practice, the situation was even more stressful. I was on call, meaning available and accessible, around-the-clock, 24-7. At home during the evenings, although technically “off duty”, I was online constantly, receiving and reviewing patient results. Occasionally, the lab notified me of urgent lab results for a particular patient that I or one of my colleagues had ordered. I would need to notify the patient of these results, often invoking fear and dismay in the poor person, do my best to reassure them, but ask that they surrender themselves to the emergency room.

The cadre of referring physicians who had my cell phone number could call at any time, whether I was in Tokyo, Seoul, Kuwait or back on the mainland with my family. Malady never goes on vacation, nor does it recognize Thanksgiving, Christmas, New Year’s or my children’s birthdays. I will never forget the tense drive to the emergency room, having just finished a wonderful Thanksgiving feast with my family, where I swiftly removed a sizable chunk of turkey (similar to the one I had just consumed) lodged in a patient’s esophagus. He was uncomfortable, anxious and remorseful at having inconvenienced himself and others, and clearly glad to see me. Doctors in my profession get paid in gratitude for interventions like this. Interestingly, less urgent procedures could be disruptive as well, for example when a patient showed up, unannounced and unscheduled, after consuming the colonoscopy preparation, even though the actual appointment was weeks later. Accommodating this patient’s mistake would cause the rest of my schedule to run behind by nearly an entire hour. The ripple had an unstoppable force… an hour late for hospital procedures, an hour behind in my office schedule and paperwork, an hour late for my daughter’s basketball game or my son’s baseball game. Finally, the ripple-turned-tidal wave of schedule disruption would spill out on the shores of my dentist’s office, who could not see me an hour late for an office appointment; I would need to reschedule.

Unfortunately, most doctors in my specialty live this frenetic existence. In this profession, we sacrifice our family and personal life endlessly for the unending needs and requirements of our patients. We are always in demand, and expected to keep a stiff upper lip. While some of us are rewarded handsomely, both financially and egotistically- the effect on our psyche is often detrimental. Doctors have disproportionately high rates of depression, suicide, divorce, and alcohol and drug abuse. Our profession tends to attract highly intelligent individuals with a remarkable ability for perseverance. The majority of us are highly driven, well-intentioned, benevolent and caring humanists. Still, these are the very traits that can land us in trouble psychologically, and leave our personal lives vulnerable to damage and neglect.

Despite the frustrations of a constant clinical life, I love medicine and I am still excited to go to work every day. It is immensely satisfying to intervene in a life-threatening emergency and, with pressure on, transform chaos into order and save a human life. If I had the chance, and the choice, I would do it all over again. Even with the devastating (and often illogical) bureaucratic demands, unrealistic patient expectations, and the ever-looming specter of malpractice, I continue to thrive and receive tremendous gratification as an integral part of a system that has the honor to heal and to save lives. This alone makes the repayment immeasurable. It really is a fascinating field and I’m eternally indebted to medicine and to my patients for the privilege to serve them.

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