Age and the Trauma Surgeon, Part 3
I’m on day five of an eight-day run of Port–and-Starboard trauma call (Navy talk for every other night), and am feeling my age. There was a time when I could do this for weeks at a time and still have the energy to play or go out with my wife. Now I drag home at the end of my off day and collapse into a snoring heap. It hasn’t helped that I’ve had an elective schedule with a couple of complex surgeries on the days when I wasn’t at the Trauma Center.
I’m not complaining (much). I did this to myself so that I could attend a couple of conferences this month and pursue a personal hobby as a side trip to one of them. I also got to get reacquainted with an old friend and her husband, which I enjoyed tremendously. So there is a price to pay for fun and travel.
Aside from the physical toll this week has taken, there has been a mental struggle as well. I accept that I am a dinosaur and that the way that I approach the craft of surgery hearkens back to a bygone era when primary care doctors still saw their patients in the hospital and surgeons accepted full responsibility for the postoperative care of the patients on whom they operated. I feel old when I find myself out of step with the current style of patient care.
I missed a critical meeting this morning at one hospital because I was up to my elbows in surgery at another. The meeting involved a discussion with a group of surgeons who believe that it is OK for their Physician’s Assistant to see their patients after surgery and only involve the surgeon when there is a problem. Even the usually laissez faire Medical Staff president had a hard time with that and wanted a regulation requiring surgeons to see patients for at least 48hrs postop. The fact that we need such a regulation is appalling to me. I had intended to speak out strongly but patient care got in the way. I am awaiting word as to how the meeting turned out. But the mere fact that this is an issue leaves me feeling out of step and, well, old fashioned.
Then there was the surgery that I was doing rather than attending the meeting. My patient had a gallstone stuck in her common bile duct, the tube connecting the liver to the intestine. An attempt to remove it endoscopically had failed yesterday and so she needed surgical treatment. This is a procedure I have done hundreds of times. I’ve done it both with the laparoscope and with the old fashioned open technique. On this particular morning I was working with a surgical resident at the Trauma Center. It came out in our discussion prior to surgery that the resident had never done any type of common duct exploration, either laparoscopic or open. I was mildly surprised. While the procedure is done much less frequently than when I was in training, I hadn’t thought it rare. By the time I was at this resident’s level I had done 20 to 30 common bile duct explorations and was by that time teaching the procedure to my juniors. But no, it seems the operation has become so uncommon that a fourth year surgical resident hasn’t even seen one. Again I felt my age. Times have indeed changed.
In the end, I was unable to get the stone out with the laparoscope and had to do a traditional open duct exploration. It went well and the patient is recovering. The resident was tremendously excited, especially since I let her do much of the procedure herself. Watching her bounce out of the operating room as we wheeled the patient to recovery, I remembered many of my own first times and smiled. I may be an old curmudgeon, but I still enjoy teaching what I’ve learned.
Opening Day is April 6th this year. Spring Training is in full swing and hope is once again in the air. In other areas of the country, Spring is marked by the first green shoots of new plants or by the return of migrating flocks of birds, by the melting of snow and ice or by the onset of the rainy season. Here in Arizona, we don’t get much in the way of winter weather. It gets cooler and there is more rain during January and February, but by and large, shirtsleeves are the norm year round. For the past twenty-some years, I have marked the season by the return of Baseball.
I have always been a fan of the game. Not a fanatic, mind. For a long while my interest was confined to the occasional attendance of a Big League game and some passing attention to the World Series. I have always loved going to the ballpark and watching a game, any game. But I didn’t follow the stats or watch baseball on television (still don’t, but more because television misses much of what’s truly happening on the field).
Then in 1998 a friend convinced me to get season tickets to the newly enfranchised Arizona Diamondbacks. I rediscovered my love of watching live baseball. That same friend had played professional ball as a younger man (Triple-A minor league for the Oakland A’s), and became my baseball tutor. He taught me how to watch the game. He taught me that much of the most important action wasn’t between the pitcher and the batter but was out on the field, before the ball was even pitched. Observing the disposition of the players, their shifting of positions for each batter and in each situation, was as important as whether the pitch was a ball or a strike. My appreciation of the game and its science deepened and I now see far more than I did before his instruction.
Baseball and surgery have much in common. They are team sports played by individuals. You may be a great hitter or stellar fielder, but one individual can’t win a ballgame alone. Surgeons, no matter how proficient, rely on a team to help care for their patients. Big league baseball demands a high degree of expertise and craftsmanship. Subtle clues tell a batter what the pitcher will throw; fielders rely on intimate knowledge of the hitter’s proclivities and weaknesses to position themselves for each pitch; catchers do more than simply catch what the pitcher delivers. Big league surgery demands a similar degree of intuitive perception combined with technical skill.
Baseball is still a major release for me. The rhythm of the game lends itself to quiet reflection and observation, as well as a chance to cheer your own team and jeer the opponents. For the two or so hours I spent in the stands, I am released from obligations and cares. I have no decisions to make, other than whether to get a hot dog or a brat, and I can watch other professionals pursuing their craft with the same spirit I bring to my own.
So come April 6th, I’ll be in the stands with a dog and a beer, full of renewed hope and quiet enthusiasm. Play Ball!
The hospital where I do much of my elective surgery recently terminated the contract it had with a large Hospitalist group and announced plans to hire Hospitalists directly as hospital employees. A less publicized part of that move is an attempt through the credentials and bylaws committees of the medical staff to terminate the credentials of physicians who are associated with that group under an ‘exclusive contract’ provision in the hospital bylaws. In essence that provision states that certain areas are recognized as being best served by an exclusive contract and that physicians credentials to admit and treat patients under those arrangements are contingent on the continued contract.
This has been traditionally applied to services such as radiology, laboratory services and pathology. More recently (20 years) it was applied to Emergency Medicine. At my hospital is has not been applied to anesthesia, cardiology or hospitalist services. The administration would like to change that.
Standing in the way is specific language in the current bylaws that addresses this eventuality for those areas where exclusive contracts have not previously existed. The proposed change in the bylaws language was put forth by several employed physicians and almost got through committee until a sharp-eyed private practice physician on the committee noticed it and had it removed. (No, it wasn’t I who did that, but I applaud his vigilance)
Why should I care? After all, this is about Hospitalists. I rarely, if ever, use them for my own patients and the group involved does not consult me with any regularity. It would seem that I don’t have a dog in this hunt. But I do. And so does every private practice physician or surgeon who sees patients at this hospital.
This is just the latest in the low level war between private practice and the big healthcare companies (and their silent partners in the government). Under the guise of CMS/Medicare requirements, ‘best practice guidelines’, hospital service contracts, and the control of information through the Electronic Medical Record, BigHealth has made the hospital a hostile environment for the solo private practitioner. They have almost completely driven out the Internists. They are limiting the freedoms of the General Surgeon, and have made specialists into mere technicians.
To be sure, we have allowed this to happen to ourselves through complacency, inability to cooperate with each other and a willingness to cede authority to those with the desire to take it. Unfortunately, those willing to take that authority are employees of or shills for the company. The voice of the private practice doctor has nearly been stilled in favor of ‘clinical consensus groups’ and case managers who dictate everything from antibiotic choice to lengths of stay.
There was an old custom during the Edo period in Japan. A Samurai would display his daicho, the two-sword combination of wakizashi and katana, on a wall or stand in the household common room. If the swords were stored with the hilts to the left, the House was at peace since one would have to turn the sheath around for a right hand draw. If the swords were displayed with the hilts pointing to the right, the House was at war.
I turned my swords to the left when I resigned from the Chairmanship of the Surgery Department after eight years in the job. Within six months, every change I had fought against during my tenure had come to pass and the restrictions on surgeon choice and freedom have continued to increase. Perhaps it is time to turn the hilts to the right again, although I fear it will end as a grand futile gesture.
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.
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.
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.
I got an e-mail recently from a Dr. Tim Race, MD, FACS. I didn’t remember knowing a Dr. Race and almost deleted it. I’m all over the Social Media these days and have gotten some increased notice because of some columns I’ve written for Physician’s Weekly. I’m happy to respond to friend requests on Facebook, and often respond to comments on my PW posts. But e-mails from people who aren’t on my friend list are uncommon and I don’t usually open them. As I said, I almost deleted the message until I noticed the subject line. “NMCB-5” it said.
That brought it back to me. I’d known a Petty Officer Race when I was the battalion surgeon for Naval Mobile Construction Battalion Five during my operational tour, the year after my internship. I had been a naïve, young (very young) doctor who went from playing at being a Naval Officer to thinking I might one day actually become one. For the first time in my life, people expected me to lead, to take sole responsibility for potentially life or death decisions and to be the expert that others turned to with questions about my area of responsibility. It was transformative.
Tim Race had been the Public Health technician for the battalion, a Third Class Petty officer, just out of C-school and a bit of a troublemaker. He took his duties seriously enough, but was smart and cocky. He had little patience with the regulations and protocols of enlisted life in the Navy. My first act as a division officer when I reported to the battalion was to convince the Master-at-Arms to let Race out of the brig so that he could do the monthly galley reefer inspection on time.
Race used to volunteer for the unpopular ‘midwatch’, the midnight to four AM watch, at the dispensary, mostly because there was no one else there to tell him what to do. I had a bad case of recurring insomnia during that deployment and used to hang out in my office rather than disturb my hut mates. Race and I often talked. I don’t recall those conversations being particularly deep or overly friendly. To me he was a bright 20 year-old kid with a bit of a chip on his shoulder. I did know that he was working on a degree in biology but not much about any future plans. Neither of us was looking much beyond the end of that deployment. Race left the battalion when we returned to Home Port and I didn’t hear from him for almost 35 years.
He finished his degree and went to Medical School on the GI Bill. He trained at Virginia and did a Colon Fellowship in Pittsburgh.
In his e-mail he told me he’d seen my column on the Etiquette of Help in Physician’s Weekly and got my e-mail from my Facebook page. He then surprised me by thanking me for setting him on the path to Medical School. He recalled our late night conversations in the dispensary on Diego Garcia and told me he’d been impressed by my commitment to going back to Bethesda to finish my training. Apparently at some point in what I though was a casual conversation, I told him that he was smart enough to be in my position one day. No one had ever told him he was a smart person. I’d earned his respect by getting him out of the brig and then letting him do his job without a lot of intrusive oversight. When I told him he could make it to Medical School, he believed me.
I struck me as I read his note that we never know how much influence our everyday actions may have on others. I recall mentors and teachers who had a profound affect on me. That isn’t unusual. But I also know that some of the people who inspired or motivated me may have had no idea that they had done so. I recently reconnected with an old high school friend whose father inspired much of my own ideal of how to be a good husband and father. I think she was surprised to hear he’d had such an affect on me, since he and I weren’t particularly close. I’m not sure he even liked me. But he became for me a sort of ideal to aspire to. I know he had no idea that he’d affected me so, but a large part of who I am as a family man is down to his example.
Dr. Race and I will try to get together sometime in the future, maybe at the ACS Clinical Congress this fall. I’m a bit humbled to have learned that I had a role in shaping his career, and wonder what effect, good or bad, I may have unwittingly had on others.