Why a Patient Refused Surgery

After a grueling year as an intern, an even harsher reality awaited: the residency years. Internships serve as a time to explore different specialties before choosing a residency. And as is often the case in life, once you collide with reality, the plans you once had tend to shift. Some interns, for instance, began their rotations declaring, “Of course, real medicine means internal medicine!” only to change their minds after experiencing its punishing workload. Others, who had little interest in pediatrics, discovered a hidden affection for children and ended up pursuing pediatrics as their specialty.

I can’t point to a single reason I chose surgery. But if I had to name two, the first was that I wanted to test my own limits. Surgery is notorious for sleepless nights, endless operations, and relentless on-call duties. If I could endure surgical residency and emerge as a board-certified surgeon, I would prove to myself—and to others—that my health and stamina were more than enough.

The second reason was that surgery deals directly with life itself. It was a specialty where I could experience both the precision of drug therapy and the drama of the operating room. My decision tied back to my original motivation for training: before one day returning to my dream of telemedicine, I wanted to absorb the very essence of clinical medicine. Surgery, with its direct impact on life and death, offered that chance. By learning everything from drug administration to the responsibility of holding a scalpel, I believed I could gain the foundation I would need later.

Still, I worried. My impression of surgeons before starting internship was that they smoked and drank heavily, and that their hierarchy was suffocating. I doubted whether I could survive four years in such a world. But when I joined the surgical department as a resident, I quickly discovered that my fears were unfounded. The surgical office was, after all, just another workplace filled with ordinary people.

Surgical residents divided their work by seniority. Juniors learned from seniors, and when they became seniors, they taught the juniors in turn. As a first-year, my main task was prescribing for ward patients—those preparing for surgery and those recovering afterward. To an outsider, they might all look the same, but each patient had different needs, and every prescription carried weight. For someone who had only drawn blood or transported patients as an intern, writing an actual medical order felt like stepping onto thin ice.

In the second year, residents began entering the operating room in earnest, starting with minor procedures under local anesthesia. Unlike general anesthesia, where the patient is asleep, local anesthesia leaves patients awake while only numbing the surgical site. In surgery, that usually meant hemorrhoid procedures or the removal of benign tumors like lipomas.

By mid-second year, we moved on to the pinnacle of surgical training: operations under general anesthesia. These ranged from appendectomies and cholecystectomies to resections for gastric, colon, rectal, gallbladder, breast, and thyroid cancers. Occasionally, we even assisted in organ transplants. Surgery was a string of unpredictable moments. A vessel could suddenly rupture, sending blood gushing. If you found the bleeding point quickly, you could clamp it, but often you couldn’t see it. Then you had no choice but to cauterize blindly or press until the bleeding stopped. Operations could last an hour—or stretch beyond ten. Looking back, that period was the hardest of all my training, physically and mentally. But it was also when I felt the most fulfillment as a surgeon.

By the third year, I had moved from assisting to operating. I began with minor local anesthesia cases, then progressed to laparoscopic appendectomies—shorter procedures under general anesthesia, usually lasting about an hour. A staff surgeon would stand right behind me, pulling the strings like a puppeteer, but the scalpel was in my hand.

Here I should pause with an aside: going to a big hospital doesn’t always guarantee the best outcome. Teaching hospitals must train interns and residents, which means they often participate directly in patient care, including surgery. Sometimes, a resident—not a board-certified surgeon—leads all or part of the operation. Patients rarely welcome this. By contrast, in a private surgical clinic, smaller though it may be, operations are almost always performed by experienced specialists themselves. Of course, private clinics lack the backup of other departments, so if unexpected complications arise, they cannot match a general hospital’s response. Each has trade-offs.

In time, the life of a surgical resident grew familiar. Someone once said the moment a surgeon feels confident is the moment to be most cautious. I had just reached that precarious stage.

One afternoon, after a long string of surgeries that had stretched from dawn into late day, I finally escaped the operating room. Hungry and drained, I tore the lid off a cup of instant noodles and poured in boiling water. Just as I was about to slurp the first mouthful, my phone rang. It was a fellow resident from internal medicine, two years younger than me but already a colleague.

“Hey, Shin. We’ve got an appe consult for you. Sixty-something patient, hypertension and diabetes but nothing else. WBC’s up, CT looks pretty clear.”

“Appe” was shorthand for acute appendicitis, and WBC meant elevated white blood cells, a marker of infection. I held my chopsticks over the cup and answered, “Okay, send me the consult. I’ll check right away.”

I wolfed down the noodles, then pulled up the electronic chart. The request had already arrived:
“Patient, followed in our department for HTN and DM, presented this morning with right lower quadrant pain. Physical exam and CT findings suggest acute appendicitis. We request surgical evaluation. Respectfully submitted.”

The phrasing—“Respectfully submitted” and the Japanese-derived “this patient”—was the kind of habitual jargon we all used without thinking.

Appendicitis is second nature to surgical residents, almost as familiar as cup noodles. The appendix is a finger-like pouch extending from the beginning of the large intestine. When it inflames, we call it appendicitis. Left untreated, it can burst, spilling gut bacteria and waste into the abdomen, leading to peritonitis—a life-threatening condition. But caught early, a quick one-hour surgery usually fixes it cleanly.

I scrolled through the CT images, moving slice by slice down the patient’s abdomen until, there it was: a thick, white, finger-sized structure in the right lower quadrant. Textbook appendicitis. I grabbed a consent form and headed to the ward.

The patient was a slender man in his sixties, hair thinning, his face marked with sunspots and deep wrinkles from years of outdoor labor. He looked older than his age. When I pressed his lower right abdomen, he winced in pain—confirmation enough.

I explained he had acute appendicitis and needed surgery, with a two-to-three-day hospital stay. He listened, then shook his head. “I can’t. I have to leave.”

It wasn’t unusual. Most patients, told they need surgery, hesitate at first. Some want time to think, others ask about alternatives. I told him to take a moment and stepped away.

Soon my attending called. “Is the appendectomy patient ready? Let’s do it.” I explained the patient hadn’t agreed yet. The attending, eager to make a dinner appointment, urged me to hurry. I promised I would try.

Back in the ward, I pressed again. I warned him: without surgery, his appendix could burst, and he could die. He seemed to understand, yet still wavered. Finally, he sighed and told me why.

He was an apartment security guard. He had taken the job to avoid burdening his grown children financially. It wasn’t easy—helping push double-parked cars, sorting through careless piles of recycling, enduring the occasional finger-pointing from residents half his age. But he endured, telling himself that sometimes losing was winning.

Recently, the minimum wage had risen, and he’d briefly felt joy at the thought of buying an extra toy for his grandchildren. But soon the management office announced they would cut staff to offset the higher pay. Two colleagues had already been dismissed. If he missed days of work for surgery, he was sure he’d be next. His voice trailed into another heavy sigh.

How could I insist on surgery, knowing his livelihood was at stake? It wasn’t just pity—I couldn’t bring myself to be that ruthless. What could a surgeon say to a man forced to choose between survival and survival, between his body and his bread?

In medicine, conflicts between patient autonomy and physician duty are common. Usually, autonomy wins. A person’s right to decide their fate outweighs everything else. That’s why hospitals have “discharge against medical advice” forms for patients who refuse treatment.

But should autonomy be accepted at face value if it’s based on incomplete understanding? Doesn’t a doctor have a duty to explain the consequences fully, to persuade the patient until he truly grasps the stakes?

That was the question before me: had I persuaded him enough? The answer was no.

So I hardened myself and tried again. “If you don’t have surgery now, you could die. You need to be alive to keep working.”

The words landed as much on me as on him. Tears suddenly spilled down my cheek. For a moment, silence hung between us. Then he asked me to wait. He picked up the phone, calmly told someone he wouldn’t be coming to work for the next few days, and hung up. Hours later, he was on the operating table.