Over the past few years, I have reflected each New Year on the state of my profession and on life in general. Forgive me my hubris. I’m just old enough to think that I have something of value to say. This year I have struggled to not have this post sound like some sort of Jeremiah-like rant against the state of surgery and the profession’s abandonment of its own core principles. While I proudly claim the title of “Dinosaur”, facing one’s own extinction is hard, although obsolescence may be a better term than extinction.
First, the good. There has never been so much information available to the average surgeon. Through the Internet, multimedia presentations, online conferences and various university programs we have access to the latest research, evidence based protocols, and expert opinions in a quantity and quality unmatched in history. Critical examination and pooling of experience has improved our understanding of some very basic surgical diseases, replacing some of our most treasured (but erroneous) ideas about how to treat them.
Technology has continued to advance making new tools, treatments and techniques available at a breakneck pace.
The core of surgery, the commitment to technical excellence in the operating room, remains strong. I am gratified to see this strong commitment in my younger colleagues despite the changes in surgical residencies that have limited their experience and exposure to many clinical situations.
Personally, I am in better physical condition than I’ve been in years. I continue to be healthy enough to take Trauma Call, and although it takes me a bit longer to recover from nights without sleep, I can still hang in there with the younger surgeons. Age and cunning can give you an advantage over youth and enthusiasm.
I continue to write, both fiction and memoir. I have been honored to have met some very good authors and have the opportunity to talk to them as an equal about the craft and profession of writing.
My wife and I continue to have a strong and intimate partnership. She has nearly finished her Doctorate and together we can make a powerful force for change. She is a smart, passionate, and compassionate woman, and I am daily amazed that she picked me.
Our family has endured some stresses this year as all families do. But we have found the strength that resides in love and will persevere. We have two sons who have become good and kind young men and a grandson who is the new light of our lives.
Then there is the not so good. Change may be inevitable, but that doesn’t make it good. At this stage in my career I had anticipated coasting to the finish. Instead, changes in the way medicine is practiced and paid for have left me scrambling to maintain my practice and my prerogatives as an independent surgeon.
The big hospital systems continue their drive to consolidation, buying up facilities, building competing trauma systems that duplicate rather than complement each other and generally creating an environment that is hostile to the solo practitioner.
The same drive to monopolize the marketplace is leading to restrictions on our choices of specialists and facilities. Exclusivity in contracting can create synergy and simplify referrals, but only if the contractor is at least as good as the rest of the available specialists. Unfortunately, exclusivity tends to lead to mediocrity and we who depend on certain specialists for consultation are left with no alternatives.
Meanwhile, protocols and procedures continue to take precedence over thoughtful evaluations. Process has trumped outcome as a measure of our competence. We continue to spend thousands of man-hours and huge sums of money documenting compliance with protocols that have been demonstrated to be at best clinically irrelevant. All to ensure a continued flow of money from CMS. Many of my issues with the ACA and Medicare have little to do with reimbursements or insurance, and much to do with medicine by bureaucratic fiat. The agencies tasked with ensuring the quality of medical care no longer listen to those of us in the trenches who actually provide that care.
Some of my colleagues have surrendered to the creeping mediocrity of healthcare in the 21st century. Management by committee, healthcare by protocol, fragmentation of routine care to multiple specialists in the name of a care ‘team’, have replaced for them, the core concept of the surgeon as the captain of the ship. They limit themselves to the operating room and leave the rest of the patient’s care to the dubious skills of the Hospitalist. The have succumbed to the pressure to be little more than technicians and in doing so abandon the singular skill of the general surgeon – the ability to meld good medical care with surgical skill and take total responsibility for the care of the surgical patient.
I am not given to conspiracy theories, but the direction of healthcare in this new century seems to be on a steady course to eliminate the private, independent practitioner and replace him or her with a vague ‘team’ of healthcare managers. Decisions are to be made by consensus under the umbrella of standardized protocols and care delivered according to best practice guidelines. The thoughtful, sometimes inspired diagnosis will be a thing of the past, replaced by high tech imaging and computer diagnostic programs.
As I said, pretty much of a Jeremiad this year. Still, I will continue to do the best I can to preserve a way of life and practice that I was trained for. If you are a surgeon, it isn’t something you choose. You don’t look at a list of medical specialties and say, “I think I’ll give surgery a try”. You just know that this is the life for you; that there are few thrills or pleasures greater than the time you spend in the operating room perfecting your craft. The long hours, the missed holidays and events become burdensome at times, but in the end, the craft itself is the greatest reward. As Miyamoto Musashi says in The Book of Five Rings, “The Way is in training. Do nothing that is of no use.”