9 - Surgical Accountability: Leading Through Complications with Dr. Steven Cohen

In every operating room, in every ward, in every clinic, and every team meeting, a silent battle brews. Conflict, negotiation, identity. Welcome to the Scalpel and Sword podcast, where I, Dr. Lee Sharma, physician and conflict analyst, Explore the hidden negotiations beyond modern medicine. Let's trade burnout for boundaries and learn the art of healing with precision and power.

Welcome colleagues, friends, peaceful warriors. I am your host, Dr. Lee Sharma, physician and conflict analyst. Welcome to the Scalpel and Sword podcast. I am so excited to have as my guest today Dr. Stephen Cohen. Dr. Cohen got his medical degree from the University of California, Los Angeles. He did his residency at Boston University. And his fellowship in colorectal surgery at Cleveland Clinic in Florida. He also has an MBA from Walden University. He currently resides in Richmond, Virginia, where he is associate faculty with the Virginia Commonwealth University and also a staff surgeon at the Veterans Administration Hospital. He publishes extensively. He has worked as an expert witness. He has mounds of experience, and I am thrilled to have him on the podcast today. Welcome, Dr. Cohen.

Thank you very much, Dr. Sharma. Very happy to be here and talking about some of these complex, intricate, important topics.

So one of the things I think, because you are an expert witness and you have done so much extensive work in the medical legal arena, obviously you have reviewed charts, you have testified in court, and of course, I'm sure professionally and personally, we've all been witness to bad outcomes that may or may not have led to legal outcomes as well. In doing this, I'm sure you I know that you have seen trends that occurred in reviewing charts and listening to testimony about the occurrences that happen after the bad outcome. There's always conflict, there's finger-pointing. That's something that I know that you've seen and witnessed a lot of.

Correct. I will tell you, one of the more common themes that I see is, you know, and I tell the residents this all the time, you're— as a surgeon, we're going to get complications. Right? But if you actually ask and poll many of the residents or even staff surgeons, and you ask them, is that complication, you know, is the outcome of your surgery, is that relevant in standard of care? And the answer obviously is no, right? You can do everything correctly. I can take out a piece of colon, I can hook it together. It's a well vascularized, tension-free anastomosis. I do the air leak. It looks good, yet on day 3, that can fall apart. So is outcome relevant in standard of care? Absolutely not. And that's the key. Just because you have a bad outcome doesn't mean you're a bad doctor. But the trend that I've seen going through reviewing many charts is physicians taking care of a complex patient, whether it's you have a leak, now you're in the intensive care unit, now you have an infectious disease doctor, nephrologist, cardiologist, is badmouthing the complication and pointing fingers at one of your colleague providers in the chart. So you can't do that, right?

Right.

So you have to be on the same team. You have to, you know, be collegial. And I know it's easy to say that, but in the heat of the moment, if I'm calling, if I need a gastroenterologist emergently, And they don't want to come as quick as I think they should, I shouldn't then write in the chart, I called the gastroenterologist, they're not coming now, right? Because that's going to turn around and bite you.

Right. So it's interesting. I think as surgeons, of course, we all want every case to be perfect. We all want the perfect outcome. That is who we are. We are perfectionists. We are driven. We want the best for our patients. We do. And as you say, and I think this is one of the things that, at least, and I think in training for myself, I felt like that was something that I didn't get a handle on. It's inevitable. I'm going to have a bad outcome at some point. It is. And once I have it, the question then becomes, how do I handle it? And if my way of handling it, because I don't like the feeling of, I'm at fault, I did something wrong, I'm starting to internalize this, I start to blame other people. Right. And I'm going to throw blame wherever I can to make myself feel better. So this finger pointing that comes from this outcome that I'm dealing with starts to beget all sorts of other bad conflicts that I am sort of creating in the chart because I want my good outcome. I want my patient to be well, but because I'm having a hard time handling this, as you start to see this finger pointing, one of the things that becomes a question is. Who owns this? Who owns this conflict? Who owns this outcome? And this is part of the finger-pointing; this is part of the blame. So, we're not really taught how to handle this. One of the things that I love that, as I was looking through your publications and as we were talking and I was looking at the information that you had given me, was this idea of pausing.

Yeah.

That we need to learn how to actually pause. And in that pause, that there is power to, instead of React, that we can respond. How do we learn how to do that?

Yeah, I mean, it's a challenge, but what you need to do is get all the stakeholders involved. I mean, the nursing staff, the other physicians taking care of the patient, the family members. I mean, I tell the residents that if you're not getting complications as a surgeon, either you're lying or you're not doing enough surgery. So pick one, right? You're going to get the UTI post-op, you're going to get the DVT. I had a patient once That was a high-risk surgery who had a previous DVT. She was obese. She had rectal cancer. So I decided on my own preoperatively that I'm going to put a greenfield filter in her and do sub-q heparin and do sequential hose. Okay, I did all three. Guess what? Post-op day seven, massive bilateral saddle pulmonary embolus and died. Right. That's a terrible outcome, obviously, right? I presenting it. The vascular surgeon at the conference is shaking his head. I said, "Doctor So So, what would you have done different?" He goes, "Nothing." I said, "What's the chance of a fatal pulmonary embolus in a patient with a filter and sequentials on prior to induction when the clots form and sub-q heparin?" He said, "Three percent," right? So. Its outcome is irrelevant in standard of care. Hypothetically, if you ask me, would I have done anything different? No. Most people in that M&M room would not even have put a filter in her. That— it's above and beyond. So I went above the standard of care and still had a problem. But getting everybody involved, getting the family involved, setting expectations, apologizing. I mean, I called, you know, the family came in. I'm so sorry this happened. I'm sorry, this is a bad outcome, right? So, but you're right, we take it personally. When this patient walked into my office, I told her she needed surgery and I killed her essentially, right? Not on purpose, obviously, but it's getting everybody involved, being honest with the family members. And as long as you meet the standard of care, then you did everything right. But we're in the profession that you're going to have these kinds of things.

Right. But there's so many things that you did just after this happened. And you were transparent. You documented everything you did. It's like, I'm going to take all these steps. I'm going to do everything I can to do to prevent this outcome. And this I'm going to do to document it. You, after this outcome, you reached out to the family, you were transparent with them, you sat down with them, you talked with them, you knew, I am sure, that you felt horribly about what happened. But you were also equally sure you had done everything you could do to prevent it.

Right.

colleagues. He was like, I'm going to share this story with you. And part of me sharing the story is, number one, I'm going to show you that I did everything I thought I could do to prevent this outcome and still had it. And is there anything else that you would have done differently?

Right.

Takes a lot of courage. And that's something that also, again, sometimes as surgeons, we're not good at. We've all got, hopefully, these 1 or 2 people that we can always call. It's like, hey, can I run this by you? I did X. I'm getting Y. What did I do something? What did I do? Could I do something different? And, you know, if you've got really honest surgeons in your corner, they will tell you, I think you did everything right, or I think you should have done X, or I think now you can do Y and you can help the patient. So all of those things really contributed.

Right.

I do think one of the things that you talk about in terms of working with this is the value of documentation. You know, it's not even the fact that you talked about it. It's the fact that you wrote it down. I was looking at a case today on one of the online med mal sites of a patient that was going to have an ENT procedure. ENT sent them for cardiac clearance. The cardiologist wrote a note and said, probably should get some respiratory workup as well. That went to the anesthesiologist in surgery center. They looked at it. They didn't take any action on it. Patient has the ENT procedure, goes home. Husband checks on the patient, like at 8 o'clock, she's fine. At 3 o'clock in the morning, he finds her arrested. She dies. The family sues everybody involved.

Everybody.

And then all of a sudden the finger-pointing starts. You know, ENT blames cardiology because you didn't call us and say the patient had a respiratory problem. Cardiology then blames anesthesia. Well, I sent the note to anesthesia. Anesthesia didn't act on it. Anesthesia says, well, ENT should have looked at the clearance before they operated on the patient because they're the ones that did the surgery. So all of these things that you, and you have a wonderful word for this, this is all happening in silos. This is all happening. Everybody's separated. Nobody is actually having everything in one place that they can look at it.

Right.

So one of the things that you talk about in terms of this has happened, everybody's blaming, everybody's finger-pointing, that preemptively, if we have all of the data in one place, if it's all shared and we're all looking at the same thing, That is keeping us all accountable to each other. And if there's something that needs to be acted on, we can do it together.

Right.

So is this something that you teach to your residents as well, this idea of having a shared data list or data system?

Well, I do and I don't, because what I teach the residents is that you are the one making the incision. You are the surgeon. You need to be accountable. So, you know, I take it I feel bad that happened to that particular patient, but as a surgeon, if I'm making an incision and I send the patient to get not cleared, but medically optimized, I'm asking them to help me. So I really teach the residents, it's trust but verify. Don't trust anybody.

That's right.

If you do that, then it's fine. And I tell everybody, I don't even trust my mother when she told me something. No, I'm going to check it myself. Every patient that got sent to me with a lesion in their colon, and it was maybe marked by the gastroenterologist, I always scoped them ahead of time. Because in my career, I've been— not to anybody's fault, but I've been sent lesions they told me was the sigmoid colon, it was the hepatic flexure. I was told it's the hepatic flexure, it's in the rectum. If you've ever been in a place where you think a lesion is in a location, And you can't find it during surgery, you will learn to live by trust but verify. So I really think that as what I teach to the residents is you are responsible for this patient. They walked to you with a surgical problem. You told them they need surgery. If you send them for medical optimization, you need to make sure that all the boxes are checked before you operate.

I love that. And I absolutely agree with you. I love it when older surgeons adopt younger surgeons in a mentor relationship. And when I first moved here in the early 2000s, there was a neurosurgeon here. His name was John Dulligan, self-described as a crusty old brain surgeon. He literally introduced, hey, I'm John Dulligan. I'm a crusty old brain surgeon. But one of the things he used to tell me is, now remember, Sharma, you're the captain of that ship. You walk in that operating room, I don't care what else is happening in that operating room. That's your ship. You're the captain. You're responsible.

Own it.

Right. And I was very fortunate to have somebody like that early in my career who basically set that expectation for me. And I And I have been able to work in that the rest of my career. And I've been able to teach that to other people. It's like, you know, what goes on in that operating room, that is your patient, that is your responsibility. It doesn't matter who else is in there. You're the one who brought the patient there. And I think that perspective, the idea of ownership, not only makes it easier to work through conflict because you know you're the final common pathway, you know that it's you.

Right.

You're collecting data, but it also avoids that finger-pointing, blaming thing that can happen because ultimately it is your responsibility. And I think that really helps.

Yeah, it's another— it reminds me of a story that happened recently. We were doing a minor anorectal case and the resident who was with me, intern, did not think it was their job to be in the room when the patient is intubated to position them prone jackknife. I was in the room because I came from the private sector and I am in there when they wrote. I think that's important. And I wasn't very nice to that resident when they came in after the patient was already positioned. If you're gonna do the case and this is your patient, when the patient turns, whose responsibility is that? Yes, I know anesthesia does it. But if there's a complication, if the patient falls, if the patient has an ulnar nerve injury or something, no, you have to take ownership and responsibility. You should be in the room on induction when you flip. You help the nurses flip them back. You don't leave the room until they're extubated and everything is fine. All your responsibility. So that goes with the territory. But I am an old crusty surgeon. Yes.

And see, I hear that phrase and that just— because I don't know that my dad would have described himself as an old crusty surgeon, but I think he would have described himself as an old surgeon. And I do think that one of the things I see is that there is that way of doing things. That we train, you know, we don't deviate. You know, it's such a temptation, I think, as you get further in your career to see other people taking shortcuts and sometimes you think it's okay and it's not ever. We always want to make sure that we are at this level and above. That's the goal for sure.

Well, anything that happens in the OR, since you're the surgeon, you're talking to the family, right? You. It's not the anesthesiologist. Generally, it's not the cardiologist, it's not the pulmonary doctor, that's the surgeon. Because you signed the consent and you told them they need a surgical procedure, and now there's a problem. You can't go out and say, well, anesthesia did something bad. No, you're not going to say that, right? So that's important. So it's really taking ownership, being responsible, and being accountable. I mean, being accountable for your patient.

Absolutely. And I think also part of that being sort of the captain of the ship, Kind of being aware of everything, is you're also aware of the power dynamics. You're also aware of the relationships, who works well with whom, um, this resident, this intern, this scrub nurse, this circulator. So, at what point in your career did you really start to see how important understanding those power dynamics are?

Well, so I started reviewing medical legal cases year 1, because I got asked by my partner, will you review a case? I didn't even know what that meant. But as the years have gone on, it's the common themes that I've seen in those cases. I mean, I don't make a lot of friends talking to plaintiff attorneys. I get that. However, I think it makes me a better doctor because it's the common things that you see. It's surgeons not taking responsibility, not being accountable, not following up with their post-surgery patients, you know, getting calls on day 7. After a simple routine rubber band ligation, the patient has fever, pain, and drainage, and is without a physical exam placed on antibiotics and pain medicine, you know, 48 hours later is in septic shock. I mean, that's not standard of care. So definitely makes me a better doctor, makes me keep up with trends. The way we do surgery now is very different from 30 years ago for sure, right?

Mm-hmm.

Laparoscopy is now standard of care. I was told in 1990 that it should never be done. So, you know, robotics has come on the scene. Endovascular for vascular surgery is a whole different thing that we didn't have in the '90s. So it's reviewing cases. It's also continuing to be involved in teaching, training, and educating. I mean, you know, the kids have a computer in their pocket. Okay. Dr. Cohen did not have a computer in his pocket in 1987. I had the Washington Manual in my pocket and I was reading it constantly, but we didn't have it. So they keep you honest. But Dr. Cohen, I read something and here's an article and here's the data. I have to keep up. If I don't keep up, I'm not that credible, right? So I think a combination of reviewing charts, being continually involved in teaching, training, educating— I need to be smarter than the residents and they're pretty smart. So I think that's been a big help in my career.

That's awesome. You're obviously really, you're very engaged with your residents. But there's also a hierarchy in that. I mean, obviously you're open and, you know, receptive to the information they're giving you, but they're also respectful of your clinical experience and the amount of time that you have been doing this.

Right. Yeah. So the textbook or AI or the internet search is not always correct because there is something about education, experience, and training. And yes, I know the book says this. However, this is why I wouldn't do that in this particular patient. So yes, I take all the information and, you know, patients too, obviously in the last 10, 15 years, doctor, I looked this up and the internet says something different. Somebody said that to me the other day. Oh yeah, I was talking to, it was a post-op patient that was calling that had white patches in the back of their throat and they thought they had strep throat. I said, well, you know, my daughter had white patches in the back of her throat. She had COVID. So again, it doesn't— I know the internet says that, but there may be something else going on. So, you know, it's important to take all that information. I'm fine when patients look up stuff on the internet. I think the more involved they are in the care and in their disease process, it's helpful to me. It's not hurtful. So I like that. And the residents do the same thing. And it's putting everything together. And patients are different, right? Patients don't read the textbooks. Not all patients follow the guidelines. They're a little bit different. Their comorbid conditions may be a little bit different, right? So you have to take all that into account.

Absolutely.

Also, I love how you're validating what the patients are doing, but you're also, it's like, you know, I respect the research, I respect the question, but this probably is more in line with my clinical experience. This is something that I've seen more of because it's gotta be all of it. It can't just be data off the internet. It's gotta be your experience as well. Right.

Well, there's nothing authoritative, right? So that comes up in my deposition. all the time. Doctors or anything authoritative? No. It's even, you know, textbooks are always 5 years outdated, number one. The literature, it depends on the author, depends on the location, depends on the patient population, right? So it's hard to compare sometimes that exact patient that's on your operating room table or in your clinic when you're making a decision of what to do to put them in a box. That's the thing. It's not so easy. It's not clear-cut all the time.

But I bet you can also sense, like, you've done this such a long time. You've worked with residents, you've worked with patients, you can sense, I am sure, if there's some conflict brewing in those relationships. You can tell if you're having a conversation with somebody, and it's like, okay, this conversation may, or the interaction may not be going the way I think it should be or where I want it to be. What do you do when you feel like it's headed that way?

So I can usually tell in about 90 seconds. And, you know, most interactions, When you meet somebody new, they've already judged you in about 90 seconds. It's your nonverbal cues. It's how you're looking at them, right? I mean, I needed a primary care doctor because I needed them to order a cardiac calcium scan. I tried to do it on my own. They wouldn't let me do it. Fine.

Yep.

So, I met this doctor. She was nice as can be. She never looked at me in the eye. She was looking at the computer the whole time. And I didn't tell her I was a doctor. I don't want— I'm a 58-year-old man, and this is what I want, right? And I'll tell you my history. Don't treat me any different. That's fine.

Right.

But she never looked at me. And then she goes to listen to my chest sounds, and I had a— it was the wintertime. I had 3 shirts and a jacket, and she starts to listen through my clothes. And I'm thinking to myself, I never learned that in medical school. Where did I— and I said, I could take off my shirt or jacket if you want. No, no, it's fine. It's okay. So Back to the question. In 90 seconds, I can tell how the interaction is going to go. Usually, I'm not right all the time. Right. But so I usually will give my opinion based on after my physical exam, and I will always offer a second opinion. Always. I am not the only doctor out there. I'm not the only colorectal surgeon. I'm not the only general. Would you like another opinion to see if there's anything different that they may offer that I'm not offering? And I explained my reasoning, obviously, but always offer a second opinion. I will tell you that 95% of the time when I say I'm happy to get a second opinion, I can get somebody in my group, I can find somebody local, whatever you want. 95% of the time they do not take me up on that.

Yep.

Because they're not expecting that.

No.

Because most doctors, especially surgeons, right? Oh, I'm the doctor. I know better. You know, no. It's like that's fine if you want a second opinion. I think that helps.

I totally agree with you, and I'm the same way. I always say I would be more than happy to get you a second opinion. And I think what that does, number one, is it gives the patient okay. Well, this doctor is not afraid for me to get a second opinion because I do think they can sense if you're afraid to that to happen. I think that's the first thing. And the second thing, and I'll say this if people really press me on it, like you know why do you have me get a second opinion? It's like well one of two things will happen. You'll agree with me and you'll feel more confident about what we're doing, or they won't agree with me and I will learn something. So either way, this is a win-win.

Right.

And for the patient, once you express that, they're like, oh, okay, well, I'm good. I don't want one. And I agree with you.

Right. That's normally what they say. That's normally what they say, which is fine. I'm okay with it too. Sometimes if the interact— you know, I deal with a lot of inflammatory bowel disease, Crohn's disease, ulcerative colitis. You know, the Crohn's patients have a— They can be mean sometimes. They're dealing with a lot of disease. I don't blame the patient for that. We always wonder, is it the personality that brings on the disease or the, you know, they're chronically in pain, a chronic bowel obstruction. They're miserable patients. Crohn's is terrible. And a lot of times I'll want them to get a second opinion and sometimes a third opinion, right? Because I said, let's go get the other opinion. This is an excellent doctor. See what they say. I won't tell them anything upfront. You can decide who you want to be the surgery. I think you need surgery. You've maxed out medical therapy. You're in the hospital every month with a bowel obstruction. You have three CAT scans that show there's a problem, but I want you to be comfortable with your surgeon. And I tell them, I told this to somebody this week: I never want to do surgery on a patient, and then you wake up and say, "I wish I didn't have surgery." Oh my gosh!

Can I tell you how many times I have used that line? I have oh verbatim. I have used that line with patients. Saying, the reason I'm going to these lengths is my worst nightmare is for you to wake up in recovery and go, wish I wouldn't have.

Right. I don't want to hear that. Don't want to hear that. You know, right? No. And sometimes I've heard that, but it's in like, you had rectal cancer and you need a permanent colostomy. So you needed the surgery. So when you say, I wish I didn't have surgery, well, the option is death. I mean, I don't want to kill you, right? So it's not said in a mean way. It's almost like, I wish I didn't have the rectal cancer, which I get that obviously.

Right.

So, right. But elective surgery, you don't want to hear that.

Correct. And I think that to me is such a— you're almost in a sense when we're making these kind of statements as surgeons, we are not anticipating conflict, but we are trying to preempt it. We're trying to make sure that we have sort of looked at all of this before we go into it. And that's just going to make for a better outcome for the patient because at that point you have given the patient every single option. You feel confident about doing the surgery. The patient feels comfortable going into the procedure. That is how you want that engagement to be. So I think that's really cool that you say that. Like when he says like, oh my gosh, that's me too. I totally do that.

Well, especially in things like hemorrhoid surgery. Patients come, they want surgery. I said, well, what medical therapy have you done? So, I haven't done anything. Well, wait a second. We don't go right to— most people with hemorrhoids don't need surgery. You have to fail medical therapy. You fail medical therapy, then we do rubber band ligation, office procedure, not painful. 90% of patients with hemorrhoids don't need surgery. And they go, really? My friend said I needed surgery. Oh, okay, right. But again, that's what I say. You want to have surgery, you may regret it. It's not fun. It's very painful. You're going to want to kill me, and I'm leaving town. So no, let's try medical therapy first. And they usually appreciate that. And they do.

Yes. And I say the same thing because I see female patients with hemorrhoids all the time. So that happens all the time. And it's not even just sort of In terms of patient care, but we do this in terms of charts with our colleagues as well. You talked about with the hemorrhoids, it's kind of an if-then thing. If we do all of these things, if the patients with irritable bowel syndrome, if we do all of those things, we treat you medically and nothing's getting better, then we can consider X. It's sort of this if-then. Do you find that's also a helpful tool in terms of documentation? If you're documenting in a chart where you've got multiple specialists involved and you're trying to avoid inter— Departmental or specialty conflict. Is that also a useful tool?

Yes, because a lot of, you know, primary care doctors, family practice doctors, emergency room, they have a butt problem, a hemorrhoid problem, they send them, they're assuming they're getting surgery. And early in my career, what happened was I didn't offer surgery right away. There's some primary care doctors that actually called me and said, look, Steve, we're sending you the patient for surgery. Why are you not operating? And I'm thinking to myself, wait a second. I'm the one that has to decide they have surgery. They have a complication. Someone's going to look at my chart and say surgery wasn't indicated. And I have reviewed cases exactly like that. You know, because I'm a specialist and I do a lot of anorectal surgery, I review a lot of anorectal cases. Post-hemorrhoidectomy, if you excise or cut out too much of the anoderm, one of the disastrous complications is an anal stenosis, a stricture. It is one of the most difficult things for me to fix. I've had patients where I've had to take out their rectum with a permanent colostomy from an iatrogenic injury from a too aggressive hemorrhoidectomy. And I've also opined on cases like that, and they never had medical therapy. They had a little bit of rectal bleeding, grade 2 hemorrhoids, they went right to surgery. So it's again, I don't expect the internal medicine doctor to know that. I don't expect the Primary care, family practice. I trained for, I know that I'm supposed to know that. They don't need to know it, right? I don't expect it.

Mm-hmm.

So it's very important to go through that for everybody to see. Patient came for hemorrhoid surgery. This is what I found on exam. We are gonna start medical therapy. If this fails, we'll do the next step, which may be rubber band ligation. So yeah, I think that's important for everybody to know how you're caring for the patient. Because they're assuming that you come to a surgeon, you're getting surgery.

That is such a powerful tool and a great way to explain it, because I think especially for referral surgeons, specialists, I think that happens to us all the time. As you were verbalizing that, I feel like that happens to me a lot where I get referrals from primary care, you know, patient having bleeding, having X, having Y, referring for surgical procedure. I'm like, hold the phone. We haven't worked the patient up yet. We haven't tried medical therapy. What if this patient wants future fertility? We haven't addressed all of this yet. We got a lot of work to do. And I love how you put that or kind of talk about that in the documentation. If we do X, Y, and Z, and none of this works, then let's consider a surgical procedure. So we're not saying no, because I think sometimes in terms of conflict, if you're trying to really work within disciplines or even just individually, person to person, clinician to clinician, no Can come across as you don't respect my opinion. You don't want my referrals. It's like no, no, no, no. That's not it at all. You verbalized it. This is my area of expertise. This is my sandbox, and this is where I like to play. But as a result, I have a lot of perspective. You may may have seen one or two patients with this problem. I see twenty a day. So as a result, I kind of know before we jump right into doing a major surgery, we need to do these other things first. And so if then is giving you a way to communicate your plan. So everybody knows what you're thinking as the subspecialist, but you're also not slamming the door on the referring doctor. They don't think you're saying, he's never gonna operate on my patient. No, that's not what I'm saying.

Right. No, and I think when you position it like that and explain it like that, and in private practice, a patient I saw would get a letter back to the referring doctor. Thank you for the referral. Here's a copy of the history and physical. Here's the plan. That's what they want to see. What are you doing for my patient? Right. And I think that's important, but I had to learn that the hard way. So I didn't know that out of the box. And that example I gave that primary care doctor, because I was new in practice, thought I knew everything. Of course I don't. It didn't put the this then. I didn't do that. I just said, we're going to do medical therapy. And that was it. He was not happy with that. And I see why now in retrospect, because I'm the surgeon, patient wanted surgery. He sent it to a surgeon. Surgeon said no. Well, wait a second. You obviously don't, like you said, respect my opinion. You don't know what I'm talking about. And he had been in practice for 30 years. So correct. So I had to learn that the hard way.

Yeah, I think that's one of in terms of being a good referral base. You know, you want patients, you want people to refer to you and feel comfortable referring to you. But it is a learning curve. It's something I feel like we all had to learn. I definitely had to learn that. My husband is pulmonary critical care, so he gets a lot of referrals, and I think he. He was one of the first people that sort of taught me about being a good referring person. One of my dad's big tenets, and when he was in practice, was when someone refers a patient to you for surgery, the first thing you do after you get outta the operating room and you go talk to the family, the second phone call is to the referring doctor.

Oh, absolutely.

You know, almost every day.

That's a great practice. I did that all the time, especially the gastroenterologist that sent it for the colon cancer. Absolutely. Yeah. That's— love, love that.

Yeah.

'Cause it's still there, you know, they started with the patient, they are the one that sent it. Right.

And I think there's something that's so very positive about that, that you have made that come full circle. Like you said, the referring physicians feel empowered because you have included them in the process. They get to know the outcome of their patient because they care. They're the ones who sent the patient to you to begin with. And I think that's something that doesn't always happen. You know, that's not something we're always taught to do still. That's one of those things that I think for the crusty old surgeons that pass that on to, you know, keep it going. We want the people coming after us to do this as well, because it is a very important part of our professional practice.

Well, it doesn't happen much in the academic setting, right? So remember when you were residents, it was, you know, you got the consult, you didn't want to go see the consult. Now all of a sudden you're the attending. It's like, thank you so much for this interesting pruritus ani. I mean, I'm just so happy you sent me anything, right? So it's a different mindset. And I certainly spend a lot of time with the chief residents that are going into private practice to try to explain to them that it's very different than being a resident because now you're in charge, you have to make the decisions, you know. So there's a lot of dynamics that go on in private practice that you don't see in an academic setting, right? I mean, when I started in private practice, because I did lots of colonoscopy, See, what I tell the residents is the day before you start your practice, the referral patterns are already set. The day after you start, they have not changed. What are you going to do? You have to tell people you're there. I'm the new surgeon. You got to meet the OB-GYN. You got to meet the family practice. You got to meet the internal medicine. I used to have 3 lunches. I would go to 3 different hospitals just to introduce myself. I think I gained 15 pounds. Right? Just nobody knows I'm there. Why would they send me a patient? I moved into a new town, joined 2 other surgeons. They don't know me. Why would they send a patient to me? Right?

Right.

So the residents, when I tell them that, they go, oh, they don't realize that, right? Because you're on the service, you're busy as can be, right? It's in a facility that the patients are being sent to the general surgery service or the colorectal service or the You don't know that dynamic, right?

Right.

And I tell them that, they look at me like I have 3 heads. They go, I never thought of that. And of course you didn't. Why would you think about that? But all of a sudden you're in practice, you introduce yourself, be friendly, be nice to everybody. I mean, I used to walk around, I tell the residents, everybody in the hospital is pre-op, right? Everybody's pre-op. Every— in my field, everybody has an anus, everybody has hemorrhoids. I got a lot of referrals from the nurses. Right? So everybody's pre-op that you see.

What a great way to teach them to think about it. This is a completely different dynamic than what you have encountered in the past. I also really like it that you are actively teaching them about power dynamics; that power dynamics, hidden conflict, all of those things directly influence the success of their professional lives. Understanding that this exists. Because we have an awareness, right, when we walk around in the world that there's conflict all around us. But the idea of formally kind of making an effort to understand it, understand how it affects us professionally, understanding how the nurses and those relationships, the scrub techs, the circulators, the anesthesiologists, the nurse anesthetists, all of those things have an impact on how we do our jobs and do them well. And being aware of those interactions and those conflicts really does make you a better doctor, but it also makes you more successful because you know all that's going on.

Right. I mean, there was a new surgeon that started with us at our hospital last week, and he did his first case. Everything went fine. The nurses the next day pulled me aside because he's the supervisor, I'm section chief, okay, and said, I have a complaint about the new surgeon. I said, why?

He—

what?

Why?

He's nice as can be. He said he came in the room, He did not introduce himself. We did not know who he was.

Mm-hmm.

I said, okay, the surgery went fine, but it's the dynamic. He was new to the hospital. Introduce yourself. Everyone's watching you, right? You make it 90 seconds, they made a judgment that because he didn't introduce himself, he's not a good doctor. He is a good doctor, but it's little things like that. Introducing yourself, know the team, know the nurses, know the circulator. Right. It's little things.

Yep. I remember, I think it was back— no, it was when I started at this hospital in '97. You know, when I came from Parkland. So we came from a big hospital. And of course, everybody had name tags, right? So I get to my new hospital. And there were maybe, I think, 150 doctors on staff when we started. So for context, we moved here in '74. My mother was the first female doctor at that hospital.

Wow.

She was the pathologist and was gonna be on a podcast at some point. And that woman's got stories.

It's amazing.

So the first month I get there and I go to, you know, medical staff services and I'm like, um, I didn't get a name badge. Where do I go to get my name badge? And no one gave me one. It's like, oh, we doctors don't wear them. I was like, really? Well, how do they know who we are if we're walking around the wards? And it was like, oh, well, the older doctors on staff just assume that everybody should know who they are. So they refuse to wear them. So as a result, we don't make you guys wear them. I'm like, okay. So I mean, I look pretty young anyway. So I'm running around in my white coat and scrubs and nobody knows who I am. So I'm having to introduce myself to the planet. It's like, hi, I'm Dr. Sharma. I'm in the OB-GYN because I know no one's going to know who I am if I just go walking up on the ward.

Right.

Yeah. Yeah. They're not, especially if I walk up in street clothes, they're going to think I'm some random family member trying to look at a chart. Right. And then it was interesting, about a year after that, we get the memo, everybody's going to wear name tags. It's like, that's cool. But it was definitely like hearing that, it's like, OK, so the power dynamic is surgeons really do expect, or doctors in general, I guess, at this hospital expected that everybody should know who they are.

Right.

And that, to me, was a profound expression of what that power dynamic looked like. And I think as time goes on, We understand that that's not only not practical, it's not really healthy in a healthcare system for doctors to walk around expecting all of us— people should know who I am. It's like, yeah, that's not okay. You know, we're the team-based mentality. We are here working together. I, and I'm, and I was really glad that it took about a year for that to go away. I thought that was really cool. But I think it's interesting too that, you know, when your new surgeon walked in and he did a great job and I'm in his mind and that was his first case. I'm sure he was really nervous. I'm sure he was like, I want this case to go well. I want them to think I'm a surgeon, right? He may not have introduced himself because he had nerves, because he was in his headspace, because he was focused and wanted the case to go well. But that's not a perspective the other team members are going to have. They don't know what he's thinking until he verbalizes, hey guys, I'm Dr. So-and-so. I'm really happy to be here. But I gotta admit, I really want this case to go well today. Yeah. Transparency. All of a sudden, if he had done that, I think every single person in that OR would've bent over backwards to do anything he wanted.

Right. Whatever. Exactly. Exactly. So it's little things like that. It's emotional intelligence. It's knowing what's going on around you, you know, and it's hard to teach that. I mean, I do try to teach it to the residents to be cognizant of when you're at the scrub table. You know, we see so many residents and some of them have some difficulty. They don't speak loud enough, the nurses can't hear them, and then the nurses think that they don't know what they're doing, right? So it's little things like that that I try to help them be aware of their surroundings around them, especially in surgery. I think that's important.

You have a great acronym for this. It's called the 3 Ps, which I love.

The 3 Ps? I have the 7 Ps.

Okay, well do the 7 because I knew about the 3, but do the 7.

Proper piss-poor performance. That's the 7 Ps before any procedure. Proper prior planning prevent piss-poor performance. So, you know, know what you're doing, verbalize what you're doing, let everybody in the room know, you know, try to stay 3 steps ahead of what you're doing, especially in surgery. It makes the case go better. Certainly it creates a much better atmosphere. Because things can go bad quickly. Right. Right.

And so much of that, I think, is dependent on the surgeon's composure, energy. If you are calm, everybody else is calm. My— one of my favorite stories about that goes back to when we first moved here. We'd been here like a month, and my husband and I were both on call. I was in labor and delivery, and PACU, or no, step-down progressive, was like a block down the hall. And I heard them call code blue and I wasn't doing anything else. So I just like walked over there to see what I can help. And it's one of my husband's patients who's crashing. And so he walks in, there's 17 people in the room, they're running around like chickens with their heads cut off. And he walks in and like looks at this chaos and goes, stop! And everybody stopped. The patient's arrested now. Turns and looks at him. He takes off his white coat. Now, he doesn't do this fast. He takes off his white coat. He hangs it on the door. He stops to straighten the sleeves. Now everybody's staring at him while he's doing that. And then he turns around and says, how may I help? And instantly the room calmed down. Everybody was very set and they got the patient back. And after, like, and I went back to L&D. I'm like, he got this. They don't need me. So I turned around and went back. And about an hour later, he's cruising through, says, comes to say hi. I'm like, That was impressive. He's like, what was impressive? It's like, the way you calmed that room down. And he's like, what'd I do? And he was completely unaware of the effect that his behavior had.

Wow!

But as the outsider looking in, I could see how that room changed. And I have no doubt that the reason why they got that patient back was because he came in, and he did not fall into the energy of the room. He actually took control of the energy of the room and calmed the room down. Everybody was able to do their jobs. And I feel like as the surgeon, that's so much— if things are going sideways, you screaming and throwing things and losing yourself, you're never going to help everybody else get the patient back. You have to be the person in the room that actually is the soul of calm, and you become the barometer, the thermometer for everything that's in that room.

Well, they look to you if things are going sour, right? So you have to Be in control. And it's hard for people if they're not used to doing it.

Right. I think that's such a great thing that you teach them. That's something that we all need to work on, practice. But I think once you see it illustrated, like for me, seeing that early in my career, I think was a really good lesson to me to learn to not do that. And plus, I joke about it, but it's really true. My dad, all, and his colleagues and all of his scrub circulars used to tell me this, your dad is the most calm person in the operating room. And dad used to tell me, I don't care if I'm dead. If I ever find out that you yelled through something, acted a butt in the operating room, I will come back. I will find you and I will haunt you. I think the era that he grew up, he did his training at the University of North Carolina and then his fellowship at Allegheny in Pennsylvania, that surgeons were gentlemen and gentlewomen. We internists who operated, we had a way of carrying ourselves and an intellect that really does set us apart of being people who are in the operating room. And I feel like that was something he definitely gave to me. I, I think it is so cool what you are giving to not only your patients as a clinician, but what you're giving to your residents as an educator. And I agree with you. I think reviewing cases does make you a better doctor. I think it makes you more aware, not only of hidden conflicts, because I mean, anytime you go through a chart, you're going to see chart wars. You're going to see hidden conflict. You can see the power dynamics. You can see the silos.

Right.

I think the awareness of that, the patient The process, the politics, being aware of those things. It's no question it makes us a better doctor. We start to uncover those things as well. If you have, obviously, residents who benefit from your experience, is there one thing that you always want, you know, they're, they're getting their training, they're going off into the world. Is there one thing you always make sure that they have, a piece of advice that you give them before they fly off into their careers?

Well, definitely it's the trust but verify. I mean, that's key. And I always tell them to, you know, the people around you are very important. So it's very important that the job that you take, whether it's academic, whether it's private practice, that you have people that have your back, right? Because it's very lonely at 2 o'clock in the morning when you have a patient crashing and you are by yourself. When you're by yourself in practice, I said we teach you the basics. But if it's two in the morning and you have a scrub tech that says, "Oh, Dr. Cohen, I've never done this case before. I'm so excited to operate with you," and you have dead bowel and the patient has a blood pressure of fifty, and it's just you and a scrub tech. Put on the big boy and big girl pants because you wanted to be a surgeon, right? So trust but verify. Have good people around you. You know, and that's really important.

I think that is fabulous advice. Dr. Cohen, thank you so much for being on the podcast today. This has been a fantastic discussion. I really appreciate your time and you being here. If people wanna find you, how can they find you on social media?

Well, probably the best way is LinkedIn. So LinkedIn is best. You know, so the residents have questions about anything, I'm happy to help them like I help many of the residents. Because I am an old crusty surgeon and I like to talk, so it's no problem.

Well, you have been a fantastic, like, fund of wisdom, and I just thank you so much for being here. Thank you so much for taking the time. So for all of you who've joined us today on Scalpel and Sword, I will have Dr. Cohen's LinkedIn profile in our show notes. Thank you so much for being here, colleagues and friends, and until next time, be at peace.

Every episode is an invitation To speak, to negotiate, to choose. I'm Dr. Lee Sharma. Join the dialogue by subscribing to Scalpel and Sword. Until next time, peaceful warriors, may your choices be sharp and your voice be even sharper. This podcast is a reflection of lived experience and research in conflict resolution. The Scalpel and Sword is not intended as medical or legal guidance. For personal matters, please consult a qualified professional.