Surgical Training: Reform or Revolution

Standard

I recent read with growing dismay a series of essays in the Bulletin of the American College of Surgeons. (Bulletin ACS, V99, No. 11) These were the first and second place essays from the 2014 RAS-ACS Symposium on the topic “The five year general surgery residency: revolution or reform?”
My dismay stems from the ideas put forth for changing the future of surgical training in this era of work hour restrictions, cost containment and advancing technology. The claim was often repeated through several of the submissions that surgical residents of today are asked to learn a broader range of surgical procedures due to the advent of laparoscopy, robotics and endovascular repairs. They also claim that the body of knowledge learned in training will become obsolete at an ever-increasing pace. This makes it incumbent that we train surgeons who cannot only do, bit also think. This last statement is one of the few in the series of essays with which I can whole-heartedly agree. I don’t subscribe to the view that the body of knowledge is too broad to be mastered. It has changed in nature, but is no broader that it was when I trained. What has changed is the ability to search and review specialized knowledge as needed. We need smarter surgeons, not surgeons who have memorized a body of facts.
The first place essay makes the statement: “Future endocrine, breast, or vascular surgeons should no longer need to acquire competency in hernia repairs or cholecystectomies. . . . (residents) should not have to demonstrate proficiency in managing conditions for which they will not bear responsibility in their careers.”
The other essays continue in the same vein – training should be more focused; career selection should be made earlier; the concept of the ‘General Surgeon” is obsolete.
I must ask: when did we, as a profession, lose our soul? I do not advocate a long rigorous, training program with no work hour restrictions just because I did it. This is not a case of “They did it to me, so I will do it to you.” We do not spend hours learning specific procedures to be duplicated step-by-step the way that our mentors taught us. What we spend hours learning is a set of manual skills, developing an intimate knowledge of anatomy in all it’s variations, and an intuitive understanding of tissue, its strength and weakness, its tolerances for traction and manipulation. You do hernias and cholecystectomies and colectomies even if your goal is to be a plastic surgeon so that you have an inbred understanding of how to handle and manipulate tissue, not so that you can master a particular procedure. A good surgeon who has a well-developed skill set can do most open operations, EVEN IF HE/SHE HAS NEVER DONE THAT PARTICULAR PROCEDURE BEFORE. There are some differences when it comes to the use of specialized equipment (e.g. Robots or laparoscopic instruments), but a good basic skill set will allow most surgeons to do any procedure. One may not be as fast or smooth the first time through a new operation, but the skill set is the same.
I don’t buy the assertion that the body of knowledge is too large to be mastered, not when the access to detailed information has kept pace with the amount of knowledge available. One may not have all the details on the tip of one’s tongue, but the ability to find the information is as close as the smart phone in your pocket. What is needed is a discipline that recognizes what information is critical and what can be looked up when needed. What is needed is a discipline that recognizes the value of broad understanding of surgical principles. What is needed is a discipline that advocates total responsibility for patient care and does not abdicates the diabetes care to the internist and the cardiac care to the cardiologist and rely on the hospitalist to handle the day to day inpatient care of the post-op patient.
I don’t advocate detailed training in all of those areas. Only enough basic knowledge to understand how they affect the care of the surgical patient.
In my day, (yes, I know that marks me as an old man), the surgeon was expected to be a passable Internist with superioir technical skills. That ideal has not changed. You don’t have to have the level of expertise that a specialist has acquired. You do need to know enough to know what they are talking about and decide if their care is good or bad for your patient.

Advertisements

A Question About the Standard of Care

Standard

A Question About Standard of Care

To all of my medical friends and colleagues, especially to PA’s, NP’s, and Nurses, I need some guidance.
Is it acceptable for a specialty surgeon, for example and orthopedic surgeon, to leave routine postoperative care to a PA and Hospitalist and never see a patient postop until the office follow up one to three weeks after discharge? I ask because there are surgeons at one of my primary hospitals who maintain that they do not need to round on patients after routine elective surgery as long as the Hospitalist is dealing with the patient’s medical issues and the surgeon’s PA sees the patient and keeps the surgeon informed.
The question has arisen because regulation language has been proposed at one of my primary hospitals requiring the surgeon to follow the patient for at least 48hr after surgery. The fact that I am dismayed by the need for such a regulation tells you where I stand, but I am an old dinosaur. Perhaps the modern standard of care has changed and it is perfectly acceptable for a surgeon to delegate routine postop care to a PA as long as the patient is doing well and there are no complications.
What is the current practice? Say a healthy 70 year-old has an elective hip replacement. Is it acceptable for the postop care to be handled by the surgical PA with medical management by the Hospitalist? Does the operating surgeon have any duty to see that patient in the hospital if the PA is able to tell him/her that the patient is doing well with not surgical related problems?
I was trained in an older, harsher school that required hands-on care of any patient, no matter how routine the procedure. But in those days, we didn’t have surgical PA’s. The Physicians Assistant was a new concept. Most of the PA’s I knew were military and were involved in outpatient care on isolated duty stations, not seeing routine postop surgical patients.
Times and practice has changed. Mid-level providers are given much more responsibility now than when I was in training. I am married to a Nurse Practitioner and am cognizant and sensitive to the issues of their scope of practice. Still, I have difficulty in embracing this idea that a PA can be the only one responsible for postop care in any surgical patient, no matter how stable. Am I wrong? Am I simply behind the times?
Contrary to popular belief, I can change with the times. If this is the way of the modern world, I will accept it, albeit reluctantly.

Lifeguard

Standard

There was a time, during my training and early in my career when the trauma surgeon was the fighter pilot of the surgical world. We were the Top Knives, the Master Surgeons, of our respective hospitals. Certainly the surgeons who trained me in the craft embodied that, and it was something I aspired to.
The nature of trauma has changed over the thirty years since I finished my residency. Penetrating trauma has fallen off to less that 15% of our total evaluations at the same time that non-operative management of liver and splenic injuries has become the norm. Cars are safer than they were two decades ago and the injury patterns have changed as a result.
I recently reviewed my trauma experience for the past year in preparation for applying for the ABS recertification exam.
I attended 518 Level 1 trauma activations in the past year. Of those, 294 were admitted as Trauma Service patients. Out of that total I did 21 major surgical procedures (not counting sewing up lacerations or chest tube placements in the trauma bay).
Those numbers seem to be in line with reported national averages. Operative intervention is now only a small part of what the trauma surgeon does, although I would argue that the acuity of those operative cases is higher than it was twenty years ago.
I reviewed the charts of the trauma admissions with which I was involved. 86% presented with a blood alcohol level in excess of 0.8 g/dl, or legally intoxicated. 47% returned a positive urine drug screen for other drugs such as opioids, benzodiazepines, methamphetamine, or marijuana. 76% were uninsured or underinsured (meaning that without the stop-loss portion of my trauma contract, I would not have been paid for my work).
The trauma service these days consists mainly of baby-sitting recovering orthopedic and neurosurgical patients. That’s not to say that these patients don’t have ongoing problems that are best managed by a team of surgeons, but they are not patients that we as trauma surgeons have operated on. All too often, the operating service signs off on day three or four and we are left doing the bulk of the postoperative care, rehab care and discharge planning.
Not terribly exciting to a fighter pilot personality. I fear we have gone from being the Master Surgeons, to the lifeguards at the shallow end of the gene pool.