Friday, February 8, 2013

Saving Urological Face – this has nothing to do with Zachary’s Disease

Urology is a great specialty that provides many opportunities to make a contribution to our field. At times we encounter moments for which we are never prepared; these are not always strictly of a surgical nature but do call upon our skills as surgical leaders.    A recent blog that I read about live surgery, sparked my memory about a personal experience I had with a live surgery demonstration, which in turn reminded me of issues associated with potential loss of face.

A number of years ago I was invited by a national urology association to participate in a live case workshop and to both lecture on and perform photo-selective vaporization of the prostate.  The usual regulatory requirements were appropriated sorted out to enable me to perform surgery in their country.  I first delivered a presentation to an audience of almost two hundred urologists and was then efficiently escorted up to the operating theatres where the readiness of the first case had been timed to perfection.  The urologist at the host hospital had made a late decision regarding who would perform the surgery and he had decided that he would perform the live case while I would provide him guidance as well as commentary to the eagerly attentive audience in the auditorium below.  He commenced with a cystoscopy which was uneventful but once he started the PVP surgery, it was immediately clear to me that his experience was very much in the learning curve and he was clearly not up for performing live surgery.  Soon endoscopic visibility was lost and with irregular vaporization, the anatomy also became difficult to appreciate.  The calls then began to come from the audience for me to take over and fortunately the urologist had good sense to do so in spite of great loss of face amongst his colleagues.  Taking over was certainly challenging but with laser control of the bleeding, visibility suddenly returned and I was then able to create a nice cavity.  I developed a couple of mounds of tissue on the floor of the prostate and then announced that I was handing the surgery back over to the host surgeon.  These mounds of tissue as you could imagine, were in such a configuration where any surgeon with basic PVP skills would have no trouble dealing with.  He did indeed do an excellent job of flattening down these mounds and was done with my verbal encouragement and compliments.  The patient did very well clinically and irrespective of what his colleagues or you as readers might think, the issue second to the welfare of the patient was the fact that he felt a resurrection/preservation of face.  This story might be used as an example as to why live surgery should be banned but I plan to cover my view on ‘not throwing the baby out with the bathwater’ in later blog piece.

In another time and another place, I was invited to operate where very little English was spoken and where we really had to scratch around to find an interpreter. It was however, wonderful how our operative actions enable a transfer of knowledge in spite of the language barriers.  There were no issues with the surgery that was performed but the problems were at the dinner held that evening.  I was taken to a wonderful restaurant where local delicacies were served and as is often the case, substantially more food than any of us could reasonably consume.  Also on the menu was an unlimited supply of spirits.  For my travelling colleague and myself, we were fully cognizant that we were in a very foreign and developing land where little English was spoken, that this was not a place to lose your sensibilities.  We had one interpreter who was actually a medical physician who worked at the hospital that they managed to rustle up at relatively late notice (a useful role for physicians/internists?).  Towards the end of the evening, one of our hosts, who had clearly consumed more than his fill, rose and made an announcement that he would personally drive us to the airport the next morning (our flight was departing early).  It was clear that his blood alcohol levels in 7 hours were still going to be sky high and we politely indicated to him that it would be no trouble for us to proceed with the hotel car booking that had already been made.  He was most insistent and even the interpreter was encouraging us to accept his offer as it was stated to be customary for us as visitors to accept this offer.  Knowing the track record of road deaths in this country, there was no way that I was going to get into a car with him (incidentally he had driven me from the airport to the hotel when I arrived and remembered thinking that he was having trouble seeing the lane markings on the road).  After most of the dinner party had left, he again reiterated his intention to take us to the airport and I am sure that all who were there at the dinner had thought that the matter was all resolved and that this was what was going to be happening. We didn’t push the issue of “no bloody way” as we had not yet come to a stage of “push coming to shove” on the matter.  I had already determined that I was going save making an absolute stand on the matter until when we actually had to leave the hotel for the airport -  essentially, we still had time to resolve the matter.  We were dropped off at the hotel using a sober driver and in the lobby of the hotel, it was now just our host, my travelling companion, myself and a hotel employee as an interpreter.  With him being removed from his colleagues and the dinner party, we gently reinforced our preference to not inconvenience him and to allow us to take the hotel car to the airport.  With this discussion removed from others who were at dinner, he was able to withdraw and say our goodbyes as the best of friends.  As far as the others who were present at dinner were concerned, he was taking us to the airport and that was the end of the matter.  The fact that this did not occur is something only the three of us know.  With this out of the way, I was able to collapse into a great sleep before the journey the following morning.

I have learned from these episodes that saving face can mean a great deal to some people, and especially in some cultures.  Never assume that issues that you might take in your stride are not those that cause enormous angst for those in other cultures. 

(Definition of Zachary's Disease)

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