Some years ago I sat in on a parent information session on spina bifida given by a senior orthopaedic colleague. Surgeons, he said that day, fundamentally love to operate — and holding that impulse back is part of the craft. If you follow the thought all the way to the operations that go wrong, or that fail to deliver what was hoped for, there are moments when surgery is a choice worth keeping in reserve. Listening to him, I thought about my patients with vesicoureteral reflux. The condition is different and so are my reasons for waiting, but I recognised the effort of swallowing the words "let's operate" in front of a parent.
I am not blind to how frustrating the clinic is for a parent who brings in a child with reflux. They have been waiting for the appointment while wondering whether the fever will come back, whether the infection will recur, whether the kidney is quietly getting worse in the meantime. And if they hear the test results and still leave with nothing but another appointment date, "let's watch a little longer" may not feel like an answer at all. How much weighing and hesitating went into that one sentence is hard to see from outside the consulting room.
I also want to fix it quickly, with an operation. I want to end this uncertain state with my own hands. I want to use a technique I have spent years learning, and I want to show a result I did well. If I am honest, surgery is also tied to the income of the hospital and of the surgeon. Add the wish to relieve a parent's anxiety, and the reasons to lean towards operating are more than plentiful.
Which is why I have to hold back. Those reasons are a mixture of what the child needs and what I want. Put the child in the middle and count again, and one question remains: does this child need this operation now?
Declining to recommend surgery for reflux is not always about fear of failure. Ureteral reimplantation in particular has a high success rate, and there are options to fall back on when the result is not what was expected — so my situation differs from the one in that lecture. Even so, for a child who may improve with growth, I have to ask whether the benefit of operating now is sufficient, and whether the burden of anaesthesia and recovery is worth carrying. Being able to do an operation well and judging that the operation is needed are two different things. Not operating on a child who does not need an operation is also, I think, the responsibility of a surgeon.
So I steady myself and recommend observation — but the choice is not always a comfortable one. Some children will improve if we wait. Some will have another infection. Some will need surgery in the end. If I could know all of that in advance, both the decision and the explanation would be far easier, but no such doctor exists. From the imaging and the course so far I can judge probabilities, and a probability is not a certain future. Infection can follow a recommendation to observe, and a child I sent to surgery might have improved with a little more time. Sometimes I want to settle it quickly with an operation. When that happens I ask myself whether I am separating my own wish to end the situation from what this child actually needs.
There was a night when that uncertainty felt particularly heavy. After much deliberation I had said "let's wait just a little longer," prescribed antibiotic prophylaxis and arranged follow-up. That child came to the emergency department at one in the morning. The laboratory results raised the suspicion of sepsis. I was on call that night, with no residents, and my body was already worn out. Facing the child and the parent, fatigue was joined by a sense of having let them down. Thinking of the parent who had gone home trusting my words, I could not avoid the question of whether the night would have gone differently had I recommended surgery.
The fact that an infection occurred does not by itself make the earlier judgement wrong. Knowing that did not make it any lighter. I was worried about the child, I felt sorry towards the parent, and alongside all of it came the thought that I was very tired. The possibility I had described when recommending observation had, that night, become the child in front of me.
After something like that, I think again about the weight of recommending observation. While I make a decision in the clinic and go home at the end of the day, the parent spends that time at home with a hand on the child's forehead. The ones who live through the days after a decision to wait are the child and the parent.
So when I say "let's wait," I try to explain not only why we are waiting but what we will be watching for, in what circumstances they should come to hospital, and what we will revisit if the course changes. The anxiety can remain even after a full explanation, and I cannot promise that nothing will happen. What I must not do is keep holding to the same judgement simply because it was the one I made first. Steadying the wish to operate matters, and so does re-examining the decision to wait. Deliberating before saying it, and deliberating again when I next see the child — that, I think, is what is owed by the doctor who recommended waiting.