Learning to err on the side of compassion

This was rage — I had no doubt about that. The fire exploding upward from my chest, consuming me from the inner reaches of my core was pure, unbridled fury, the sort that I hadn’t encountered in some time.

Silence choked the operating room as every eye fixed upon me. My own attention was locked on the naked torso prominently displayed in the center of the room. There, permanently etched in the skin of the young man lying motionless on the table, was an unassuming tattoo of a swastika. 

Immediately reminded of my setting, the paralysis imposed by my initial response quickly relented, and I instinctively resolved to quell the tension in the room. 

“Hmmm,” I snorted through a forced smile.  I turned to my scrub tech. “I wonder if he knows?”

The truth is, while still in my first year of private practice as a general surgeon, my elective schedule has been rapidly expanding for a variety of reasons, and I am not altogether certain where these patients all come from. In the era of Google, Healthgrades and myriad other public rating sites, it is a common occurrence that folks show up in my clinic with uncanny detail in their knowledge of my personal life.  In 2016, the majority of people research their health care providers long before passing through the door of the examination room.  Among the most readily discoverable details regarding my personal life is the fact that I am Jewish and active in a number of local Jewish organizations. 

The operating room staff let out a nervous, collective giggle at my response. Then the circulating nurse, who had removed the patient’s gown in preparation for the operation, gasped. She was standing on the opposite side of the patient. I stepped forward and turned my attention to the flank that had previously been hidden from me. I was confronted with the instantly recognizable portrait of Adolf Hitler. 

A few moments of silence passed. “What are you going to do?” the surgical assistant asked me.

“I’m going to fix his hernia,” I said. 

The gentleman had presented to my office a few weeks prior to this moment, fresh from a visit to the emergency room of a crosstown hospital, seeking relief from the unforgiving discomfort that had evolved with the expansion of a weakness in the wall of his groin. He had patiently suffered for a few weeks as we awaited authorization from his insurance company to pursue definitive correction of this affliction. He was in pain, nearly debilitated physically at this point, yet he had continued to work through the discomfort, primarily out of necessity. There was no doubt in my mind that I was morally obligated to help him.

“It’s not my fault he didn’t adequately research his surgeon,” I said.

As I started the ritual of cleansing my hands and arms in preparation for the surgery, I began to manufacture a detailed personal history for this young man. The tattoos were clearly faded, suggesting that they were acquired some time ago. I imagined a disillusioned soul in his late teens or early 20s, burdened with the new responsibilities and expectations of adulthood, seeking a target for the angst and animosity these pressures so commonly foment. I have often hoped that, as I approach my fifth decade of life, I will not be held to account for the unending parade of bad decisions I made as a young man. In my mind, I fashioned an individual who was truly contrite for his past prejudices, though branded with evidence of those ideals for perpetuity. 

I suddenly found myself in admiration of his courage. Here he lay, willingly assuming the most vulnerable position imaginable, utterly dependent upon others for the most basic of human needs, down to the breath, without which life ceases to exist. In just a few moments, I would be placing sharpened steel to his belly, encountering the vital structures of the human organism on my journey to the source of his malady. Had he known of my Jewish faith when we met in clinic? Surely he would have informed me of the existence of the tattoos prior to the surgery if he had. If he hadn’t known, would he want to be made aware after the operation? I briefly contemplated awakening him from the anesthesia to offer the information, in case he would prefer to seek a new surgeon if he knew this personal detail about me.

All of these thoughts proved to be fleeting. As I have done thousands of times before, I finished washing my arms and hands, gowned up, and applied the skill I had gained in over a decade of surgical experience to mend the defect in his abdominal wall. The procedure was uneventful, and when I met the young man in the post-anesthesia care unit after his recovery from the cocktail of medications he was given over the course of operation, I described my findings, gave him a few postsurgical instructions and smiled as I left, promising that we would see each other in clinic in a few days.

Over the ensuing weeks, I thought frequently of this event, wondering mostly if I had handled it skillfully. As I considered what my alternatives might have been, I recalled one of the first patients I encountered in my practice as a freshly minted, attending surgeon. I had performed no more than 50 operations since completing my training and felt as green as I must have seemed to most of my patients to that point. I had occasion to consult on a 92-year-old man in my clinic, who had come to me to ask about correction of longstanding — and very large — hernias in both groins. For a nonagenarian, he was remarkably healthy, and I was beyond surprised to learn from the medical history forms he had provided that his sole previous surgery had been on his lung, done more than 70 years prior at the age of 20. A rough calculation indicated that this would have occurred in the 1940s, predating our modern understanding of mechanical ventilation by at least a decade. This, naturally, led me to question why he underwent such a risky procedure by the standards of the time. Following a brief pause, he smiled and said, “I suffered a gunshot during the war.” 

I have no doubts that he had encountered this conversation many times over his lifetime. I also have no illusions about the challenges generated by such conversations. After all, the gentleman had an undeniably German name, and his impeccable English was highlighted by an accent unmistakably Deutsch. He immediately followed this first statement with, “Yes, I fought for the wrong side.” 

In that moment, I became painfully aware of just how inexperienced I was. He went on to explain that he had been a 16-year-old boy growing up unimaginably poor, but with the intelligence, ambition and drive to be an engineer. In his reality, the only path to fulfillment of his dream was through the army. When he entered the military, Hitler had not been in power long, and the unspeakable atrocities he would ultimately bear responsibility for most likely had not yet begun, although this had offered my patient little consolation over the course of what turned out to be an extraordinary lifetime. No doubt shaken visibly, I wanted no more details, however.

“Sir,” I said, “I have to tell you: I’m Jewish.”

He again smiled and said, “I know. I can see your necklace.” 

I glanced down at the Star of David nestled in the “V’”of my blue scrub top. 

“I was hoping that you would fix my hernias, anyway.”

I repaired his hernias a couple of weeks later, and he presented to clinic to receive my congratulations for a flawless outcome two weeks after that. He was exceptionally gracious in showing his appreciation, and I last heard from him upon receipt of a brief “thank you” note through the mail some time later.

The human condition bears no prejudice. I happen to possess the training required to address the physical ailments that invariably affect all people, but human needs take on many different forms beyond the purely physical: emotional, psychological and spiritual, to name just a few. Regardless of race, creed, gender, politics or pedigree, maintaining health in each facet of the whole human being requires a constant vigilance in the battle against forces — both external and internal — that ultimately work toward their degradation. These forces act without concern for any variable that we may construct or artificially use to define ourselves as individuals or communities. I have the conviction that it is my moral obligation to use my abilities — both innate and acquired — to alleviate the suffering caused by this degradation without discrimination. In short, I seek to allow myself to be governed by the fundamental principle of kindness. If I have it within my power to lessen suffering, I will.

What did I learn from the patient with the Hitler tattoo?  That in such moments, it is imperative that we have a clear, unwavering sense of our values and that we act in a manner consistent with those values. I resolved that day that, when in doubt, I would always err on the side of acting compassionately. Kindness, it turns out, is sometimes the bold path forward. 

James Wiseman is a graduate of the Keck School of Medicine at the University of Southern California, and the Residency in General Surgery at Houston Methodist Hospital. He currently lives in Tucson, Ariz., where he is an associate in a multidisciplinary surgical practice.