(I'm hurriedly trying to change the subject from my sorry post below, so I'm rushing to print before fully fleshing out something I'd been working on. In retrospect, I wish I'd not posted my little fiction piece; but I've decided to leave it and move on. Quickly.)
This may sound self-indulgent and egotistical (what? from a surgeon??) but bear with me: I have a point.
I think I can honestly say my patients did well to have me as their surgeon, even as my wife may have gotten the short end, husbandly, and my son likewise, fatherly. By which I mean I spent my career, for whatever reasons, highly devoted to my patients and my practice, at the expense of my family and personal life. I simply had no choice in the matter: it's how I was trained, and what I believed. I was never entirely comfortable ceding surgical care to anyone else, even my closest partners. And for the first few years in practice, until I realized the folly, I even abhorred medical help: I felt obliged to manage even the intensive care of my patients. For a while, I was probably as good at it as the intensivists (of whom there weren't a lot, early on). As time went on, and I (happily) had only the occasional critically ill patient, I came to realize I wasn't the best one for the job. But surgically -- well, I never felt my partners would take as good care as I did. It might also be true that they felt likewise, in reverse. One would hope that all doctors felt that way. Or so I think. Thought. Wonder....
More than just imagining it, I lived it: I made hospital rounds no less than twice a day, and more commonly three. Except on the critically ill or unstable or as-yet undiagnosed: then it was four or more times. Six a.m. Between cases. Before heading to the office. At the end of the day. Go back in in the evening. I always took calls on my patients, whether I was the "on call" doc, or not. If a patient needed a re-operation, I'd usually do it -- on call or off. Although I think I may have overdone it, I'd say most surgeons of my era have similar commitment, if for no other reason than hearing the admonitions (to put it mildly) of our mentors in our heads. But it's more than that. To choose surgical training twenty or thirty (fifteen, ten) years ago was eye-openedly to enter into a contract; to agree that caring for patients was going to be the prime directive, and that it would be a never-ending commitment. That it was pounded in over and over for six or seven years of nearly twenty-four/seven training simply reinforced what was already implicit.
Considering my behavior mostly in hindsight, I have questions. How necessary was it? Did it really make a difference? Was it essential? Or delusional? An excuse for other shortcomings? In semi-retirement, it's clear my sense of irreplaceability was an illusion. But what of the rest? My younger partners never rounded as much as I. Unlike me, they took their full days off, and their allotted vacation days; weekends off were off. Their patients did well enough. Complications, for the most part, have their roots in the operating room. Data, when they were made public, confirmed my complications were fewer; but I think it had little to do with my post-op care. I do think those habits were part of why my over-all costs were less: in rounding frequently, I was able to expedite necessary testing and to get orders written sooner, discharge more efficiently. (Bureaucracy alert: the powers that be once decided to review afternoon discharges, intending to encourage doctors to make rounds in the morning to get patients out earlier. Afternoon discharges were to be some sort of black mark. Making rounds multiple times, I often discharged patients in the afternoon because some mornings they weren't ready but were later. I pointed this out to the medical director, asking if he'd rather I not make those afternoon rounds and wait till the next day, in order to avoid being dinged. The plan ended.) If my patients didn't have to get to know another surgeon during their hospital stay, if their hospital bills were lower, to whom did it really matter? No one mentioned it to me, much.
So what's my point? This: if any of this stuff actually did matter, I think it's moot. It's my sense that, as a generalization, things are changing fast. I'm not the first to blog about the recently restricted hours of trainees. In fact, nothing I'm saying is particularly original. I do, however, have several friends who are surgical professors in some high-level training programs, and I'd say it's unanimous among them that they are concerned about the surgeons of the future. "Shift-worker mentality" is a common theme in our conversations. The current crop of trainees, they say, aren't as committed as we were. They're happy to diddle around until the next shift arrives to solve a lingering problem. More importantly (but maybe a bit off the subject of this post), there's concern that the restricted hours lead to less experience, which works its way up the hierarchy: fewer hours means fewer operations. Senior residents are less likely to let the juniors do cases, which means those juniors, when senior, are less experienced. The need for formal mentoring after training is a concept being discussed seriously.
It's not entirely clear-cut: are patients better served by doctors less single-minded? The restrictions on hours resulted from a lawsuit over a death presumably due to mistakes by a fatigued resident. Avoiding fatigue, clearly, is desirable. But limiting experience? Selecting people less willing to make a full commitment? I imagine patients prefer a well-rested doctor. But one that plays the piano? Skis like a maniac? Coaches Little League? Not sure. Really. Not sure.
I burned out. After twenty-five years, chronically tired, dreading the phone-calls, missing family gatherings, I managed to wangle a temporary (I thought) leave of absence. It felt so good, I couldn't convince myself to go back to full practice. Had I been less crazily compulsive, maybe I'd have lasted longer; maybe I'd have, over a longer career, cared for more people (part of my problem was never saying "no." I did twice as much surgery as my partners, more or less.) So maybe it's better, from a cost-benefit sort of calculation, to have docs who want and have a life. And this: whatever else is true, the new crop aren't idiots. Surely they hear the cries; they know about decreasing reimbursement, malpractice, interference from all points of the compass. If there's much about the job that's become abhorrent, why give up your life for it? That's my point: is the current trend a bad thing, or a good one? Honestly, I don't know. Until a few years have passed, no one else will, either. And if it's true that the people choosing medicine now are different from those of a couple of decades ago, or have different expectations, I don't blame them. The essential rewards of being a physician, the privilege of caring for people, remain at the core: but the pleasures have become elusive, diluted by the myriad of impediments disguised as controls. It's illogical to expect docs to walk in the same way on ground that has fundamentally shifted under them.