Sunday, November 26, 2006
Don't get me wrong: I admire family practice docs. I recognize what a tough and undervalued job they have; and the ones I know do it well. It's just that it was not always the case, either in terms of my admiration or their job performance. There was a time, of course, when all doctors were generalists. We can long for those days, or not; they drove their Model Ts to the farmhouse, passed out potions, delivered a baby or two, cut off a dead toe, comforted the dying. I might like to have a Model T to drive on special occasions. But for regular use, I'm glad I have a nice radio, air conditioning, and traction control. Thanks, but no thanks. The concept applies generally.
Years ago, family docs expected to assist in surgery for the patients they referred. Internists, who early on made up the bulk of my referring docs, hadn't the slightest desire to do so; was it because they didn't care as much about their patients? Did their patients, for some reason, not need the comfort obtained from knowing ol' Doc'd be there? Self-selection by patients, or self-delusion by doctors? I have an opinion. Whatever the answer, I can say without equivocation that having the family doc assist in surgery was an enormous pain in the ass. It began with scheduling, and got inexorably worse. The doc could only be there at such a date and such a time, usually first thing in the morning. Since I had certain reserved times in the operating rooms, and since I usually had people scheduled well in advance, signing up the FP patients meant making lots of calls to rearrange my other patients, along with a bunch of calls to the doc's office to make sure he/she knew the final arrangements. Ordinarily, such calls weren't necessary, because I had my own assistant; highly skilled, totally familiar with how I liked to do things, there from start to finish. People who really understand surgery (or people who've read my book) know how excellent it is to have an experienced team working together in surgery. People who spent a few weeks rotating through surgery during training do not understand surgery. If they did, and if they really cared about their "whole patient," they'd INSIST that the surgeon to whom they sent their beloved patient use his best and most experienced team when cutting on them. They'd know without being told that the best team decidedly did NOT include them. But we're talking about knowing limits, and about knowing what you DON'T know...
So after rearranging my list several times, and making calls and followup calls to the doc's office, invariably that doc would show up late. Regular readers of this blog know how I feel about lateness. (For a short operation, their lateness sometimes allowed me the pleasure of finishing before they showed up.) If they made it into the OR in time for the incision, they'd arm themselves with the cautery pencil and start buzzing the tiny skin bleeders as soon as my knife moved on. Drove me crazy: those things stop bleeding; cooking them probably adds to scarring, and I'd have to stand there while they got off on their workmanship. They also loved to tie knots. Slowly. Deliberately. Feeling surgical.
None of this is particularly critical: I'd get the operation done just fine, if a little less quickly, and with a little less of the pleasure one gets from an operation done rhythmically and artfully. If being annoying assistants in the OR was the only problem, I might not be writing this.
It's puzzling. How much familiarity with a thing is necessary to know how unfamiliar one is? Where's the dividing line between understanding and kidding oneself? What's the responsibility of a training program to make the delineation clear? What I do know is that seven years elapsed between getting my MD and finishing my surgical training; and that during that time I'd gone from knowing nothing to knowing a hell of a lot. And a lot of what I knew was that I didn't know everything. For example, when I first went into practice my partner asked me if I wanted to do vascular surgery. I told him I didn't think I'd had enough experience in it. (I trained right at the time of transition: earlier, all vascular surgery was done by general surgeons. In my time, vascular fellowships were appearing, and at my institution, which included one of the premier vascular departments in the country, general surgery residents were doing fewer vascular cases, as fellow were doing more.) My partner offered to observe and mentor me until I was more confident. To me, that seemed like a deception to a patient: I've always believed if I were to operate on people, I should be able truthfully to tell them I thought I could do it as well as anyone. I knew how to do those operations; yet I would not have and did not feel right passing myself off as a vascular surgeon. I knew enough to know that ability to sew a graft was only a small part of vascular surgery. And were a complication to occur, I don't know how I'd live with myself. So how is it that family practice docs were coming to town, right out of training, and asking to do (click warning: gross, NC 17) hernia repairs, C-sections, and tubal ligations? Tracheostomies! What did it say about them, and about their training? Since, as I eventually learned, these are good people, I think it says their training sucked. They learned from teachers with an inflated sense of the primacy of primary care, and a deflated sense of what's involved in surgery. They were told that the more they did themselves for their patients the better it is, and to the extent that they referred to specialists, they were letting their patients down -- subjecting them to narrowly focused monomaniacs who didn't care. Whereas my training was characterized by the constant reminder of how little I knew, by the public out-hanging of every error big or small, theirs must have been the opposite: the paltry time you spent on a surgical rotation, doing OB, is enough to have given you everything you need to know. (Again: this was a while back, when the holy grail, the salvation of American healthcare, was the gatekeeper.) A few examples may serve to explain why I felt that way: (most of these refer to incidents in my community but not in my clinic, I hasten to add.)
A) Fresh out of training, a young FP asks for tubal ligation privileges, and is denied by the OB department. She goes to the hospital board, threatening suit. Over the resignation of the OB chairman, she's given privileges. At the independent surgery center, which grants privileges based on the hospital's, she does her first procedure, assisted by her slightly more experienced partner. Pathology report from the right tube: "normal appendix." A general surgeon handles the subsequent admission for sepsis, from which the patient recovers without sequellae.
B) I'm referred a patient with a hernia, repaired by his young family doc. The doc assists as I repair it, finding the original operation was one I thought universally abandoned because of its well-known high recurrence rate. I didn't hide my surprise. "Well, that's what Joe taught me," he said. Joe was his senior partner, an older guy grandfathered into pretty broad surgical privileges, having learned most of what he knew from HIS senior partner, long since retired. Joe usually managed to get general surgeons, to whom he referred those cases he didn't do, whorishly to help on his own operations. I wasn't on his list.
C) Another young study of Joe hacks into the femoral artery during a hernia repair. (Trust me, that's pretty damn hard to do.) He does have the sense to hold a finger on it while awaiting the arrival of a surgeon.
D) Called to see a man hospitalized with a bowel obstruction, I find a FP had admitted and cared for him without consult for several days. The dead bowel I removed wasn't enough to leave him nutritionally affected, and he did fine after several more days. Consultation on admission would, I'm certain, have led to a quick operation with no dead bowel, and many days fewer in the hospital.
E) I run into one of my old mentors at a meeting; he's a trauma guru, and a strong advocate for surgeons managing ICU patients. In training, I did manage those patients, with their ventilators, cardiotonic drugs, their multi-organ failures. In practice, I thankfully dealt with such critically ill people far less frequently. Intensivists, I tell Don, are much better at it than I'd become. "Don't give up your role," he says, strenuously. "You don't understand what it's like in the real world," I tell him. "I'm not as good at it anymore." He glowers.
F) While I'm serving on the board of my ever-expanding clinic, in the midst of the gate-keeper frenzy, a family doc presents a form he's planning to send along with his patients to every specialist, requiring specific enumeration of reasons for every test, every procedure proposed. He'll not authorize anything without its return and personal review. After some possibly ill-chosen words, I resign from the board.
G) Having saved a woman who'd showed up in the ER with a perforated stomach due to cancer, requiring emergency gastrectomy (and washing her belly with distilled water to kill any cancer cells that were spread by the perforation), I ordered tests after she recovered which showed a solitary metastasis in the left lobe of her liver. Liver resectionally, the left lobe is more or less a piece of cake; but I hadn't been doing elective liver surgery because it just didn't come up much. Despite her strong desire to stick with me, and despite knowing how to do the operation, I referred the patient to a more experienced liver-surgeon (who fucked it up royally, I must say.)
It wasn't fair: taking young docs right out of too-brief training and immediately telling them they must be in charge of everything. Even if they knew at some level they weren't ready, they really weren't in a position to say no. And I think, because of their training, many didn't think they weren't ready. Until they found out, the hard way. At the time, I could fathom neither the training that sent them into the world so misinformed, nor the system that demanded it of them; nor especially the fact that many seemed not to have the warning mechanisms built in to have kept them above water.
Other realities settled in: for one thing, as reimbursement for surgery steadily declined, and as the assisting fees did likewise, it became clear to most family docs that it simply wasn't cost-effective for them to be out of their offices. I guess their patients' need for knowing ol' doc was there disappeared at just the right time. Meanwhile, pre-paid healthcare, with its extraordinary pressure on primary docs and its placing them in direct conflict with their patients, came to be seen as a false profit. (Good one!) So family docs began, perhaps first of necessity, but eventually as a matter of reality-testing, to realize they could with impunity leave specialty care to specialists. Most are even giving up OB, if sadly.
I can't say if I was right about what they were told then in training, or if it's different now. I can say that most family practice doctors now have practices mainly in their offices, and that I think it's a good thing. I don't think their surgical patients are any worse off for their doctors' absence from the OR. And whereas I think it's true that the referring docs with whom I worked -- if for no other reason than being in a contained group with frequent interaction -- eventually came to trust me with their patients without having to throw up roadblocks, it's also the case that I came to understand what an important and difficult job family docs have. They're the central clearing house, the entryway, the providers of continuity; and they still have pressure to do as much as possible themselves. They need all the love they can get.
Postscript: It's not as if I think surgeons don't make errors. I have. They do. But I can honestly say I've never made one because I over-reached; never because I failed to recognize when I was in over my head. Such errors ought, in my mind, never occur. Inculcating the sense of limits, giving doctors and nurses the intuition and knowledge to know what they don't know, and when they don't know it, is the single most important mission of training, as I see it. Nor am I absolutely certain it can be taught. I think it can, and I know for sure doctors (and nurses) who don't have those mechanisms ought not be in the business. Maybe there's a way to pre-test for it... And based on experience, I can say it's surgical training that comes at all close to the mark, with the medical specialties not far behind. For a while there, family practice was decidedly (bringing) up the rear. I'm guessing not all readers will agree.