Friday, April 27, 2007
I've Seen Ghosts
As a med student, I did a few circumcisions, in the free-hand style. Later, as an intern, on one occasion I had just finished a very well supervised hernia repair, along with which the adult patient had requested a circ. My attending couldn't have cared less about doing, helping with, or observing that part of the deal. "You can handle it, can't you?" Spoken through his back, and then through the door as he exited the OR, it wasn't really a question. Adult circumcision isn't the same, I discovered, as doing it on an infant. To my horror, I left the man's shaft looking on one side like a pink banana after some monkey had partly stripped back the first section of the peel. The feeling remained in the frontmost of my mind for the remainder of my training. When I helped, I stuck around.
A reader asks what I think about "ghost surgery." Complicated answer: depending on terminology, I'm ok with it. Simple answer: it's complicated.
First, the semantics. For one thing, I think the reader and I are not talking about the same thing: to me, "ghost surgery" implies deception and dishonesty. It means borderline, if not actual, criminal behavior. "Ghost surgery," as I've understood it, is the happily rare practice of a (usually less-than-competent) surgeon lining up patients for operations, telling them he'd be doing it, then having it done by others while he was somewhere else, collecting the money. (In a related arena is "sham surgery," wherein a patient is faked into thinking something was done when it actually wasn't. There was a time when such things were done hemi-demi-semi honestly, as a way of testing for the placebo effect of an operation. On the other hand, when I was in med school, there was a later-infamous "surgeon" who did so-called brain surgery at a nearby osteopathic hospital. Until they'd show up at our institution where xrays showed no skull entry under their scalp scars, they believed he'd done something in their brains. They'd paid for it; monetarily, and otherwise.)
As I infer it, by "ghost surgery" my reader meant something different: being operated on at teaching hospitals by surgeons-in-training; and there's an implication of failure fully to inform people of the extent to which such surgery will be done by the trainee instead of their presumptive surgeon. Whatever the proper term for such a thing is (the operative part, not the informing part), it's that of which I'm in favor. And which is complicated. Without it, I'd be nowhere.
Part of the question we can dispense with easily. There's no excuse for not letting a patient know a trainee will be doing all or parts of the surgery. Which is not to say it's always been clearly laid out, nor that in every instance in every location under all circumstances it now is. And whereas a patient ought to have the right to opt out, to demand that their surgeon will do every bit of their operation, I think a surgeon ought be free to tell his or her patients that in coming to a teaching institution, they must expect and accept that such supervised operating will take place and that if they want the knowledge of that surgeon and the support of that institution, they must agree to it or go elsewhere. In the best of worlds, that would be worked out well in advance of the patient showing up for surgery.
Surgeons are made, not born. It's a long process. When I was applying for surgical training, one of the places I checked out -- which is now very highly regarded -- was on probation and in danger of losing accreditation from the American Board of Surgery, or College of Surgeons, or something, for failing properly to supervise residents doing surgery. (I figured if I couldn't get in anywhere else, surely I could there.) The place I chose (and which chose me) was quite the opposite -- and its approach is entirely the norm now: baby steps. Interns are allowed little bits of operating at first: close the skin, place a clamp here or there. When it's apparent they can handle a knife and fork without spilling food in their laps, they may get to do an "intern's case." A hernia repair, for example. The attendings are there, describing every step and, in fact, holding tissues in such a way that there's no possible misstep. Truth is, I "did" many hernias without a clue as to what was really going on, so carefully were the moves orchestrated. Which brings us to the complicated part. At some point, you have to have your umbilical cord cut.
My friend just soloed for the first time after a few months of flight training. Had he crashed, most likely he'd have only taken out himself. In surgical training, there does come a time when you operate without an attending in the room. He or she is close at hand; but there you are. It doesn't happen, however, until you've shown yourself to be ready, over a period of several years, and with many an attending signing off. Still, as opposed to flying for the first time, the danger is not to oneself.
I love to teach. In training, by the time I was Chief Resident I was the "supervisor" on many an operation done by a junior. I was, if I may say so, good at it. There were times when I called in an attending, but not often. And the cases, by definition, were not the biggest of the big; if they were, I'd be doing them myself, with an attending there much if not all of the time. (Most Chiefs relished doing as many big cases alone as they could. I figured it'd be soon enough that I was on my own and I wanted to pick the brains across the table for as long as possible.) In my private practice, the teaching I did was at the tail end, when I mentored newly-hired surgeons. In those cases it was their patients and I was providing pointers, sharing a few tricks. Letting them know how a four-hour total colectomy with J-pouch could be done in two. Had it been my patient, I'm not sure I could have let them actually do parts, given my need for speed. (Controlled speed, may I add!) More paradox.
Inevitably, there are classes of care. Time was, there were "charity patients" and "charity hospitals." One can argue the ethics, but it was understood that patients there were "teaching cases." Nowadays, there's still a difference between "private patients" -- meaning those with insurance and who've come specifically to see a particular surgeon and who are admitted to that person for surgery -- and "clinic" patients, meaning those that came to the hospital clinic and were seen there by residents, under the supervision of an attending. Mostly, those patients are uninsured or are on some form of assistance. At a teaching institution, whether private patients have residents doing parts of their operations depends on the attending. Some let residents assist only, never doing any part; others let trainees do parts, or even all of an operation. No private patient would have any surgery done without the attending there and breathing heavily down the neck of the resident. Clinic patients well might. It needs to be made clear; yet it needs to be.
Does care suffer in training institutions? No, mostly. Yes. Ironically, I'd say having a surgical resident participate in your surgery is the least likely arena in which problems occur. The supervision is eyeball to eyeball, hand on wrist. My most influential technical mentor (you can read all about him in "Cutting Remarks"), without exception let me, when I was Chief Resident, do every one of his operations, and he had some pretty hoidy-toidy patients. But he was literally at my side (as opposed to across from me like everyone else in the world), controlling and cajoling as if wired directly into my head.
In training, operations take longer, and time under anesthesia adds up to problems in a small percentage of patients. Still, it's in the hours outside the OR -- especially the wee ones -- that problems may occur. May I hasten to add, that applies equally -- more, in fact -- to the medical wards. Again, there's irony. In no community hospital are there as many doctors present around the clock as there are in teaching places. If I get run over by a truck, get me to a trauma center in a university setting. If there are a few people running around with minimal experience, so are there plenty with plenty. It's the humdrum stuff that's more likely to be delegated down, to people without the experience to recognize what's going on and who therefore fail to call for help.
Safeguards break down anywhere. In a community hospital, when there were problems with my patients, I was the one called, not an intern. That's better, as long as I got the call. It didn't always happen.
When I was in training, I believed evangelically that the best surgical care anyone could get was right there, not despite but because of all of us trainees and attendings in the mix. After a couple of years in practice in a community hospital, devoid of students at any level, I came to feel the exact opposite (meaning the best care was in that community), and I still do, except for certain highly special situations. It's a hell of a paradox. If my reader has made it through my ping-ponging thoughts to this point, I imagine she's more concerned than when she asked the original question. Scary, huh?