The traditional view of surgery is clean and simple—there is a problem, and the surgeon fixes it. A blockage, tumor, ruptured appendix, or failing organ, something in the body has gone wrong, and the work is to repair with skill and confidence.
For Ana Berlin, MD, general surgeon and palliative care physician at Columbia, that view of surgery only leads to deeper questions, like what does ‘fixing’ actually mean to the person on the table? What does an operation give them back? What might it take away? And how much of that conversation happens before anyone reaches the operating room?
The Larger Territory of Palliative Care
“Palliative care is specialized interdisciplinary care for people with serious illness and their families,” says Dr. Berlin. “It’s focused on improving quality of life, reducing symptoms, and focusing decision-making on patient-centered values.”
Too often is palliative care mistaken for hospice or end-of-life care. “I always say, it’s like a Venn diagram, and end-of-life care is a small island within palliative care,” she says. “Hospice is an even smaller island within an island of end-of-life care.”
The larger territory is more like an archipelago, a chain of islands dotted with symptom management and caregiver support, navigating serious illness long term, decision making, the many facets of recovery, survivorship, and the complexities of bereavement. Unlike most medical specialties, palliative care treats both the patient and the people surrounding them.
“People go through the equivalent of climbing Mount Everest as far as what it takes in terms of physical toll, as well as emotional toll on the person and the family or the care partners,” Dr. Berlin says. “And a lot of times, they come out the other end, and there are lasting implications of that. There may be pain, debility, panic attacks, anxiety, PTSD.”
That’s why palliative care is more about preparation. “Sometimes we name things that nobody wants to name and nobody wants to acknowledge as possibilities,” she says. “But as soon as they’re named and as soon as they’re out there, a layer of anxiety can be shed.”
A Better Conversation Before Surgery
Dr. Berlin describes a shift in how surgeons think about the goals of surgery itself, one influenced by the work of Margaret Schwarze, MD, MPP, a vascular surgeon and ethicist at the University of Wisconsin. Dr. Schwarze’s research has focused on how surgeons communicate with patients, particularly around high-stakes operations, informed consent, and the lived consequences of surgical decisions.
Serving as a site principal investigator for one of Dr. Schwarze’s multisite randomized controlled trials, Dr. Berlin tested whether a question prompt list (essentially a small brochure developed with input from patients, families, and care teams) could change preoperative conversations. The study was mixed. Surgeons and patients liked the tool, even if objective measures were limited. Beyond objectives, though, the study generated a collection of more than 450 recordings of real conversations between patients and surgeons. A trove of communications data.
“It was a lot of, ‘You have a problem,’” Dr. Berlin says. “‘And I’m going to fix it with this operation. Or this operation will fix it.’” Compassion or intention were not lacking; it was actually the structure of the conversation that did not always serve patients as well as it could. “People retain less than half of what they are told in an informed consent conversation,” she explains.
A new approach called Better Conversations in Surgery, developed through the Patient Preferences Project, reframes informed consent to focus on what surgery can actually do for a person. “There are only four possible goals of any surgery, from a patient’s perspective: I feel better. I live longer. I prevent a disability. Or I get a diagnosis,” Dr. Berlin says. “Those are the four things. The goal, the fundamental goal, is never to fix a problem.”
Excising a tumor, even when tumor removal is technically what the operation does, is not the end goal. It’s returning to oneself. Prefacing treatment and approaching conversations with this framework in mind opens the door to discussing the downsides, too. Not just the reportable risks that patients often glaze over–the fuller set of downsides: recovery, function, pain, dependence, time away from work, rehabilitation, the possibility of an ICU stay, and the burden on caregivers.
“When we talk about downsides, we suddenly can deliberate between the goals and the downsides and ask, is it worth it?” says Dr. Berlin. “Then you get a much more robust informed consent that leaves people feeling much better prepared, less blindsided.”
In the Better Conversations model, surgeons show their cards early. “Sometimes the card is: we usually do surgery for this, or I think surgery can help you. Sometimes, I am on the fence; surgery and another option are both reasonable,” she says. “And sometimes it is, I am really worried about surgery for you. I do not think an operation is a good idea.”
That transparency gives patients and their families a way into the conversation, and keeps everyone from trying to read between the lines while they are already afraid. “It’s not making a recommendation up front,” Dr. Berlin says. “It’s basically setting the stage for where this conversation is going.”
The plan may still involve surgery, even when the surgeon may have originally advised against it. Decisions may land without surgery, even when surgery is what is usually done. The point is not to steer patients in one way or another, but to deliberate honestly and put it all on the table.
For Dr. Berlin, this is surgery. “It’s indivisible,” she says.
Communication as a Surgical Skill
That belief also shapes how she teaches. Columbia’s general surgery residents have long participated in communication skills training with palliative care faculty through simulation-based sessions. This year, Dr. Berlin and colleagues piloted elements of the Better Conversations curriculum from Fundamentals of Communication in Surgery, a national effort to build communication training into surgical residency with the same seriousness given to technical skills.
Surgeons train for laparoscopy, robotics, and open surgery. They train for complications, and work to master every technical bit in between, skills get drilled until motion becomes memory. Communication, Dr. Berlin argues, deserves the same deliberate practice.
The training reaches into our collective use of language and even into how hope is embodied through language. We all know and probably have used phrases like "he’s a fighter” or “we’re still hoping for a miracle.” If a physician responds to the sentiment in a rushed or purely informational way, it can hamper the connection before anyone realizes. “We say ‘want’ is a four-letter word,” Dr. Berlin says. “We try never to talk about what people want because we all want things that aren’t necessarily possible.”
Instead, palliative care asks what the fight is for—More time? A milestone? Comfort? The chance to say I’m sorry or ask forgiveness? When someone says they are hoping for a miracle, Dr. Berlin urges physicians not to fall into the “cognitive trap.”
Rather than explain how unlikely that is, the better response might be, “Tell me what a miracle looks like,” she says. Then, leave space. “One thing that we find is that, in these conversations, if we shut our big mouths for a minute and let them talk, even if there’s a very uncomfortable silence that lasts longer than anyone would like, it often helps move the conversation forward in unexpected ways.”
The first thing they say may open an unexpected door. If the physician is listening, really listening, it can lead to another door, then another. Maybe revealing more about who that person is in the world could inspire an entirely different way of thinking about their treatment.
Remembering Why We Do Surgery
This is the crux of what Dr. Berlin is passionately trying to fortify within surgery. Not only specialist palliative care, but primary palliative care—the communication, clarification of values, symptom awareness, and support that should be rooted in surgical practice itself.
Palliative care is both ancient and newly urgent within the field. The first major operations in general surgery were often palliative. Surgical aphorisms still carry that history: to cure sometimes, to comfort always. “They reflect that palliation is central to the surgical identity and mission,” she says.
Advances in technology, care mechanisms, and biological understanding have transformed surgery and continue to create new pathways forward every day. “We’ve kind of lost our footing because of some of this technology,” says Dr. Berlin, “and the promise of all of these shiny new objects.”
Better Conversations may not look as dazzling as a new robot or groundbreaking surgical approach, but it’s the foundation for everything that follows, both in the hospital and outside. “It has been part of our profession from the beginning and continues to grow and evolve with it,” she says, “but palliative care hasn’t really had a home professionally.”
Dr. Berlin created the Surgical Palliative Care Exchange (SPaCE) out of this evolution, a much-needed professional space to connect online. Surgical palliative care has grown widely over the past two decades, but its community has had little opportunity to exchange experiences and make an impact. Some surgeons practice it formally, and some already teach it. Others recognize the need but lack a network, curriculum, or place to share what works. Now, through this new online community, they do.
These days, Dr. Berlin’s role is frequently connective. She mentors, introduces, points people toward one another, and gives freely of her time in ways that can be difficult to measure. That, too, is palliative.
At Columbia, she says, leadership has made that possible. “Having people like Craig Smith, Emile Bacha, and Katherine Fischkoff at the helm,” she says, “leadership who really gets it and can stand up for a more principled way has meant a lot to me, and it’s the reason I’m here.”
Here to help someone feel better. Or to help them live longer. Or to prevent disability. Or to make a diagnosis. To do these four things, and, with honesty, ask what they will cost.
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