Something’s Got to Give

The AAS Ethics Committee held its first annual Artwork and Essay Contest in 2021 – the topic for the essay contest was “What is the most challenging ethical issue, personal or professional, you have encountered in the COVID era?” The winning essay and artwork were selected by the Ethics Committee and will be published in the October issue of the Journal of Surgical Research. But we also want to share many of the powerful entries we received for this contest, so look for more of these essays to post as blog articles between now and the 2022 ASC – thank you to everyone who participated in the contest!

Krista Haines, AAS Committee Chair & JJ Jackman, AAS Executive Director

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At the beginning of the COVID-19 pandemic, hospital administrators were working hard and fast to develop protocols, re-distribute the hospital, and re-allocate resources in preparation for an influx of critically ill patients. Elective surgical cases were promptly cancelled, with the operating rooms reserved for emergent cases. The general surgery program began soliciting resident volunteers to assist with staffing designated COVID teams.

At this point, very little was known about COVID-19 as a disease entity, and volunteers were few and far between. Though the altruism of stepping forward to fill the role was not lost on me, the idea of walking into the unknown was nothing short of daunting. Not only did I fear for my own health, but I was well aware of the medically oriented management involved in taking care of these patients, after having spent residency training learning to manage surgical issues.

Ultimately, I was one of two general surgery residents first assigned to the COVID ICU. I was scared – scared of being ill-equipped and of the unknown. I was confused – confused as to how my name had been, perhaps randomly, selected. Quite honestly, the system initially felt similarly to the “Hunger Games” and, for those familiar with the reference, I was chosen as “tribute” to fulfill a role I felt entirely unprepared and unsuited for.

With the first string of COVID ICU shifts under my belt, the initial fear gradually transformed into frustration. I felt like I had served my time, and I desperately wanted to go back to being a surgical resident. My ongoing assignment to the COVID unit felt like an educational compromise, and I did not feel empowered to bring this to the program’s attention. I feared being viewed as a non-team player and as no longer willing to work in solidarity for the greater good, at the expense of my surgical education. I worried that communicating my concerns would be viewed as weakness and therefore felt as though I should internalize them. Eventually, my turn was up.

In the following weeks, a hospital-based trial was advertised among employees to assess for antibodies to COVID-19. I volunteered, curious in light of my prior exposure. Shortly thereafter, it dawned on me that should I test positive for COVID as part of the trial’s testing, this would remove me from the resident work pool for a 2-week period. Realizing this, I immediately regretted signing up, instantly feeling like I had done wrong by my colleagues and by my residency program. What if I test positive? Of course, if I tested positive, I should not be at work exposing others to the virus. And yet, somehow it felt much worse to think that if I tested positive, I would be to blame for additional work burden and responsibility placed on my colleagues, having voluntarily risked being away from work to quarantine for 2 weeks. The guilt I felt had me wondering if it was better just not knowing at all. COVID positive or not, I continued to feel like participating in this trial when I was asymptomatic was a betrayal to my colleagues and was the wrong choice. Thankfully, for everyone’s sake, I tested negative. Still, the conflicted feeling of having signed up for the trial continued to linger with me.

In introducing these experiences, the COVID-19 pandemic amplified ethical dilemmas already deeply rooted in surgical culture, which continue to morally conflict individual trainees. Surgical culture introduces trainees to the belief that physical and emotional compromise are ordinary parts of the job, such that trainees are programmed, so to speak, to feel guilty when they behave against this standard and when they choose to take care of themselves above performing the job. Amidst the COVID-19 pandemic, the established standard of surgical culture was suddenly accompanied by streams of messages depicting clinicians as heroes and implying expectations of personal sacrifice at all costs. In surgery, we instinctively adopt a mentality that caring for oneself is a disservice to our colleagues and is a trait characterizing flawed trainees. Though this mindset has long been ingrained in surgical training, the COVID-19 pandemic added a complex layer of expectations deliberately placing clinicians in the position of facing the unknown and putting their own and their loved one’s health at risk, above and beyond the existing demands that already plague a burned-out workforce. But this was not the time to say No. After all, we signed up to serve and we learned to do so without asking questions and certainly without complaining. Stepping aside in this moment was not an option and doing so felt like turning one’s back on a profession so publicly placed on a pedestal.

Morality, however, means drawing the line at some point – something’s got to give. The two personal dilemmas illustrate pervasive ethical conflicts among trainees wherein fear of missed opportunities and of being seen as weak, incompetent, or unfit to be a surgeon are frequently at odds with the ability to advocate for one’s education, well-being, or need for support. In an already high-stress and demanding environment, it is particularly exhausting and isolating to silence personal needs to live up to a surgical ideal.

We must ask ourselves, though, what is ideal about this ideal? It has been shown that self-censorship, compromised clinician well-being, and lack of psychological safety are significant threats to the quality and safety of patient care. We as a surgical community must accept that we are human and that we can be impacted by trying times.

In order to take good care of patients, we must learn to take care of ourselves and each other. Medicine, and surgery in particular, is a team sport. Teams grounded in blame and inauthenticity cannot succeed. Let the experiences of the COVID-19 pandemic be a call to action to embrace humanity within the surgical community and to take steps towards much-needed change.

Twitter usernames:

Vanessa Welten: @VanessaWelten

Kirsten Dabekaussen: @KDabekaussen

Nelya Melnitchouk: @NelyaMel

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Vanessa Welten, MD, MPH

Vanessa M. Welten, MD, MPH, is a general surgery resident at Brigham and Women’s Hospital. She grew up in a small French-Canadian town in Eastern Ontario. She obtained her Bachelor of Science in Biology at Brown University, where she also competed as an NCAA Division I athlete on the women’s ice hockey team. She received her Doctor of Medicine and Master of Public Health degrees at Northwestern University’s Feinberg School of Medicine. She is currently a research fellow in the Center for Surgery and Public Health at Brigham and Women’s Hospital, primarily conducting colorectal cancer health services research.

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• Something’s Got to Give - December 21, 2021

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Kirsten Dabekaussen, MD, PhD

Dr. Dabekaussen, MD, PhD, obtained her medical degree and honors in leadership at the University of Groningen, the Netherlands. She combined her medical studies with a PhD, studying the role of health care professionals’ attitudes and behaviors in creating safe and continuous learning environments. In her current role as a postdoctoral fellow at the Brigham and Women's Hospital, she is driven by developing new systems that optimize clinical workflow, facilitate unified data collection and reduce administrative burden, so that clinicians have more time for meaningful patient interactions. She aspires to apply for a surgical residency program in the near future.

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• Something’s Got to Give - December 21, 2021

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Nelya Melnitchouk, MD, MSc

Nelya Melnitchouk, MD, MSc, is an Assistant Professor at Harvard Medical School and a Colorectal Surgeon-Scientist at Brigham and Women’s Hospital. She is the lead faculty for Cancer and Comparative Effectiveness Core at the Center for Surgery and Health at Brigham and Women’s Hospital. Her research interests are in appendiceal and colorectal cancers, and she has expertise in mixed-methods research, dissemination and implementation, decision analysis, and cost-effectiveness analysis. She serves as Program Director for the Colorectal Surgery Fellowship and Director of the Program in Peritoneal Surface Malignancy at Brigham and Women’s Hospital. She has served as the primary research mentor for many general surgery residents at Brigham and Women’s Hospital.

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• Something’s Got to Give - December 21, 2021