tag:blogger.com,1999:blog-30499448.post5943686574526435492..comments2024-02-18T13:53:30.168-08:00Comments on Surgeonsblog: Family MattersSid Schwabhttp://www.blogger.com/profile/14182853083503404098noreply@blogger.comBlogger21125tag:blogger.com,1999:blog-30499448.post-18622852526184477392014-06-01T16:48:00.950-07:002014-06-01T16:48:00.950-07:00Yes, there are no easy answers to ensuring medical...Yes, there are no easy answers to ensuring medical competence.<br /><br />We have a lot of specialists in the United States. We have three specialists per primary care doctor. In the EU, I'm told, they have three primary care doctors for every specialist.<br /><br />I love specialists, let it be known. As an ER doctor, not a shift goes by where I don't lean on the experience and skills of specialists. But I don't want specialists to get so specialized that I can't find one when I need one. <br /><br />And I don't want generalists in office practice getting so meek and neutered that they send me every minor emergency, every procedure, every work-up for admission, although that seems to be the way the world is going sometimes.TheTrackerhttps://www.blogger.com/profile/10011829472333355911noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-57324793222388570192014-05-31T21:23:18.216-07:002014-05-31T21:23:18.216-07:00Don't disagree with anything you said. "M...Don't disagree with anything you said. "Mindless" specialization would be particularly egregious, especially if it were a universally accurate characterization.<br /><br />Would that there were such a thing as good standardization, and reproducible measures of quality control, too. Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-66082767214496520702014-05-31T19:51:52.303-07:002014-05-31T19:51:52.303-07:00I agree with lots and lots of this, and could supp...I agree with lots and lots of this, and could support it with plenty of stories from my own practice. But that's no fun, so I'm going to take some issue with parts of it.<br /><br />Specialization is great: but we need some way to rationally decide what the stopping point is. I trained at a level one trauma center. One night, in the ED <i>one of our own employees</i> came in with a crushed hand, an on the job injury.<br /><br />We of course called the hand surgeon (Plastics or Ortho would have deferred to hand). The hand surgeon on call said, "No way." Why? Because he had done his fellowship on elbows. Only ever worked on elbows. Refused to even look at the injured hand.<br /><br />You can ask why this guy was on call, but the episode reflect something important about the medico-legal zeitgeist: specialists get narrower and narrower, generalists get more and more fearful, and at some point the over-specialization turns into a man-made shortage of specialist.<br /><br />Another story, from residency. Cardiology was having a problem with bleeding when femoral artery caths were pulled. Rather than, say, give everyone a quick refresher on the concept of holding direct pressure, the rule came down from on high: only cardiology fellows are allowed to pull the lines and hold pressure (as overworked residents this give us some guilty delight.) But, evidently they were still having problems, so they decided that only <b>second year</b> cardiology fellows and above could pull the lines. So in summary, you had to have:<br /><br />13 years of K-12 education<br />4 years of med school<br />3 years of internal medicine, and<br />>1 year of a cardiology fellowship<br /><br />>21 years of formal education in total, in order to be entrusted with putting direct pressure on a site of bleeding -- which was if memory serves covered in week two of my EMT Basic course.<br /><br />Mindless specialization is not the answer to incompetence. Good, standardized training and quality control are the answer to incompetence.TheTrackerhttps://www.blogger.com/profile/10011829472333355911noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-29458485313925977602006-12-08T20:55:00.000-08:002006-12-08T20:55:00.000-08:00I'm a rotating intern ("family practice" as one gr...I'm a rotating intern ("family practice" as one graduate described to me), wrapping up 2 brutal months of being a "low-level schlepper" (So anointed by a GI who we frequently consult--my rejoinder: "floor monkey") for a very busy surgical team with 3 active attendings (~8 cases per operative day), 2 senior residents, and 1 junior resident (me), lately joined by another junior resident acting mostly as a 2nd year w.r.t. me. <br /> I have not scrubbed into a single case. I'm going into ER; I can safely say I probably will never open an abdomen, so I'm happy learning perioperative management. I've learned, by osmosis, and sometimes by forceful verbal assault, how surgeons approach patients on the floor. Because I stay on the floor, I've found a niche as a locus of communication, and as kind of a referee. <br /><br />Our patients appreciate the extra time I spend discussing/explaining their management with them, and both patients and nurses appreciate the luxurious accessibility I provide, instantaneously triaging and managing s/sx or notifying supervisors for an assesment and plan. Everything gets done on our service, and all the patients are satisfied. Tests are done, consultants are called and recommendations carried out. I don't do anything I think I couldn't manage the complications of (I've had bad luck with drains because of poor communication), and I arrange consultation for problems over my head.<br /><br />This all being said, I fill a niche on my team especially as a conduit of information, and as essentially a mid-level, acting as agent for my attendings and my team, freeing them up to learn surgery. In return, I become familiar with the surgeon's "comfort zone," i.e. what is a serious surgical issue versus a B.S. complaint versus what is grounds for consultation/upgrade or downgrade/discharge. I also become familiar with the diagnostic tools and informational requirements of a surgeon. I know what a preop note consists of (CBC, Chem22, liver labs, pt/ptt, T&S, CXR, EKG, medical clearance), for example. <br /><br />In short, I tailored my rotation to what I thought I needed to learn for EM. I wish I could have done more consults, but c'est la vie. I'm glad my surgical experience is over; you can keep it.Dexhttps://www.blogger.com/profile/06318145066843764025noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-16486766235892578812006-12-01T11:11:00.000-08:002006-12-01T11:11:00.000-08:00midwest fp: I appreciate your comment; even your a...midwest fp: I appreciate your comment; even your analogy at the end. Can't really call foul. Some of my best friends are FPs. Wouldn't want my daughter to marry one. <br /><br />PS: I don't have a daughter. Or friends.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-8009508311618980652006-11-30T19:12:00.000-08:002006-11-30T19:12:00.000-08:00When I did my surgical rotation as an FP (about 10...When I did my surgical rotation as an FP (about 10 years ago), I was treated pretty much the same as the surgery interns. I learned a fair amount about perioperative care of the surgical patient, and took call with the trauma team. I never got the idea that I should or could do surgery. By any chance did the FPs you describe all come from the same program?<br /><br />Re: your patient in G) ; Boy can I sympathize. I had almost the identical situation occur with one of my patients, now deceased. Doesn't that make you ask yourself what role relationship and convenience to the patient should play in the decision of whether to refer when a case is within your ability but not your comfort zone? I don't think it's always as clear cut as you make it out to be. Say the patient with the solitary liver metastasis knows you well. He says, "Doc, the nearest liver surgeon is 3 hours drive away. I got no car, no friends, no relatives who are any good. Can't you do it here? I know you, I don't know this other guy." Now how clearly are your "limits" defined?<br /><br />You are of course right that I (an FP) am a little pissed off by how you come across in this post. You sound like my grandma talking about colored people: "Oh, he's so smart and clean cut, not like most of those people." A little love, then a slap in the face and collectively damned by anecdote. Love you, too, Sid.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-7406439500464749192006-11-29T19:29:00.000-08:002006-11-29T19:29:00.000-08:00Good post. I've always found the "cognitive" vs "...Good post. I've always found the "cognitive" vs "procedural" thing annoying and insulting. Once, as a urology resident, we were performing a radical prostate for prostate cancer when our med student told us that she wanted to be an internist because she liked "to think." We decided to make sport of her and then began to ask things like; what PSA is and what does it do? Oh you don't know. Why don't you "think" about it. Or, what is the t1/2 of PSA. Oh, you don't know. Why don't you "think" about it. <br />The surgical specialties are cognitive and to suggest otherwise is wrong and ridiculous. In addition, a surgeon who does an appy at 3AM should make more than an FP who titrates a patients HTN meds during an office visit, as important as this may be.Richard A Schoor MD FACShttps://www.blogger.com/profile/11520184749583009935noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-12741921805276959982006-11-28T22:05:00.000-08:002006-11-28T22:05:00.000-08:00Hey Sid!
Glad to see ya again.
I get so tired of...Hey Sid!<br /><br />Glad to see ya again.<br /><br />I get so tired of psychiatrists playing into the crap that other specialties try to bait us with--that "shrinks aren't real doctors." I think some shrinks end up trying to do more and more that they shouldn't do out of trying to prove they are real doctors.<br /><br />Anyway, I share your frustration with the family docs. I wish I had a nickel for every patient I had to "put back together" after a family doc tried to "shrink" him/her with psych meds. I've seen family docs try to manage their patient's bipolar disorder, even schizophrenia!!! I saw one patient come in toxic on lithium and the family doc came in asking why his patient was hospitalized!!<br /><br />Fortunately, for all the family docs that lack boundaries, there are more who do respect their training and mine.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-67130984029505730442006-11-28T16:21:00.000-08:002006-11-28T16:21:00.000-08:00Well, I figured there'd be a certain divergence of...Well, I figured there'd be a certain divergence of opinion along certain lines, and colored by not-surprising interpretations. Ain't blogging great?! Kumbayah.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-51581268389179047312006-11-28T13:47:00.000-08:002006-11-28T13:47:00.000-08:00As promised, here is my response.As promised, <a href="http://dinosaurmusings.blogspot.com/2006/11/family-practice-matters-more-than-you.html">here</a> is my response.#1 Dinosaurhttps://www.blogger.com/profile/01357845504444464397noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-11576186488137183472006-11-28T02:27:00.000-08:002006-11-28T02:27:00.000-08:00I wish I understood this post and the comments, bu...I wish I understood this post and the comments, but I'm too stupid and lazy to read it carefully or to understand it properly.<br /><br />best,<br /><br />FleaBig Lebowski Storehttps://www.blogger.com/profile/09131330425557709407noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-45698724614121513792006-11-27T19:39:00.000-08:002006-11-27T19:39:00.000-08:00I can confirm that, at least when I was in trainin...I can confirm that, at least when I was in training a few years a go, unfortunately your observations would be spot-on.<br /><br />The big push (from the government and from the teaching practices, anyways, and *lots* of other FPs) is to this idea of "comprehensive care."<br /><br />Idea being, as you've pointed out (much more eloquently!!) that somehow I'm not doing my job if I don't also deliver the kids, assist in surgery, provide psychotherapy, (fill in the blank with something even more specialized).<br /><br />As you said, maybe this all made sense when we were the only game in town. And when things were way simpler (b/c noone knew any better).<br /><br />But it stops us from doing our real jobs, and I agree wholeheartedly that it compromises patient care.<br /><br />It's sad that we're made to feel like bad doctors for working within our scope of practice.<br /><br />There I said it, scope of practice. We need to hammer this into trainees who've been taught there's no scope, or an infinite scope.<br /><br />I really like your examples. Thanks!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-63832330831421726972006-11-27T09:42:00.000-08:002006-11-27T09:42:00.000-08:00Where I'm from there are extra training programs (...Where I'm from there are extra training programs (a third year of residency) available for family docs to learn new skills i.e. tubal ligation and they spend a year learning from people in OB. I have to say that for people working in the north where access to specialist services is limited, many people couldn't get these elective operations if family doctors didn't do them. I agree that if the resources are available they should be utilized, but what about communities that are a sea-plane ride from a tertiary care center? The family doctor is a valuable member of the surgical team in many of these communities. Especially when it comes to surgical assisting - many docs do a few days a week of surgical assist (whether it's their patient or not). <br /><br />I see where you're coming from, but I think there is a place for family docs in other care areas when availability to specialist services is limited. I do agree that these docs require extensive extra trainig and should not be attempting these procedures with only a 2 year family residency under their belt.medstudentitishttps://www.blogger.com/profile/09740144837675438466noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-64260098277352419072006-11-27T08:38:00.000-08:002006-11-27T08:38:00.000-08:00Shadowfax, again: oops. In my above comment, I mad...Shadowfax, again: oops. In my above comment, I made reference to a post I've written but haven't posted yet. It's about, as you might guess, the use of the "coginitive." Stay tuned. And sorry if I puzzled you. Assuming you read followup comments.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-10690155916353576292006-11-27T08:10:00.000-08:002006-11-27T08:10:00.000-08:00emmy: I couldn't agree more with your point. Commu...emmy: I couldn't agree more with your point. Communication is key, and under-done. I can say that I've often had a hell of a time getting hold of the primary doc. Voice-mail and email help, as long as the need isn't urgent. It's also a hopeful sign that electronic medical records are becoming more commonplace. It's a fact that communication among various docs is often lousy; it's not always for lack of trying.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-21409658106640872182006-11-27T08:05:00.000-08:002006-11-27T08:05:00.000-08:00shadowfax: you may have missed my point. I don't d...shadowfax: you may have missed my point. I don't disagree that primary care is undervalued -- I said so several times. I was making a much smaller point: that the use of the word "cognitive" is pretty annoying. Whatever else is true about "procedurists" vs primaryists, the difference is not about "thinking." That's all. Small point, really. Or maybe not so much: if we want to be on each others' side in the fight, maybe we ought to find different ways to frame the argument. And I absolutely agree that the actual relative values are screwed up. It sounds like you get more for popping in a hip than I do for popping out a colon.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-20686374029303524272006-11-27T07:10:00.000-08:002006-11-27T07:10:00.000-08:00OK, I see your point. It does seem better to refer...OK, I see your point. It does seem better to refer to the most competent doctor in that field. But at what extent does the FP or the Internalist become involved after specialized care is started? I have a hell of a time getting my specialist to communicate with my Internalist, especially the ones referred to by another specialist. The problem being is that there is not one doctor that gets the whole picture, each just has his or her little part of the puzzle. I generally blame HIPPA for the whole mess, but some of it is just the doctors not taking the time to follow up.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-11416538531705871372006-11-26T21:32:00.000-08:002006-11-26T21:32:00.000-08:00Which is why the "cognitive" vs "procedural" divid...<i>Which is why the "cognitive" vs "procedural" divide that non-surgeons like to promulgate is so non-sensical.</i><br /><br />Certainly it's nonsensical from a practice-philosophy perspective. Whether medicine or sutgery, it is all physiology, orthopedics excepted. (Oh, I joke!) But it is a very real divide from the reimbursement perspective and is one of the major reasons that primary care in this country is teetering on the brink of collapse. When I can bill $500 for resuscitiating someone from cardiac arrest and $1200 for popping a hip back in -- well, the system is just broken beyond repair. And the CMS/CPT divide between procedural reimbursement and cognitive reimbursement is the driving force behind the major dysfunction.shadowfaxhttps://www.blogger.com/profile/11648279307230813762noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-11998679714611990202006-11-26T14:47:00.000-08:002006-11-26T14:47:00.000-08:00Unfortunately for the British public, our governme...Unfortunately for the British public, our government (who prefer to spend healthcare money on making management consultants extremely rich than to actually spend it on health) are planning to re-introduce the concept of family doctors providing basic surgical care, with tertiary referral centres performing the more complicated procedures.<br /><br />What a bloody stupid idea. There are many good reasons why this practice went out of fashion 50 years ago.<br /><br />As a baby surgeon I loved operating, and I'll never forget the first few times I opened a belly to repair a perfed ulcer, performed a simple appedicectomy, or established a pneumoperitoneum. The reason it was such a buzz was that the boss was stood right behind me (or occasionally sat next door in the coffee room) and if I wasn't sure, I'd stop, and ask for advice. Safety first.<br /><br />I tutor medical students and junior surgeons in a surgical skills lab. We always emphasize safety, safety, safety. When a junior gets all excited about anastamosing a pig's bowel, we reassure him that it's okay to have fun, but to remember the priority is safety. If a junior can't tie surgical knots properly and safely at the end of a 3 day course (which many cannot, worryingly!) they're advised to think about another career.<br /><br />Young people die every year during uncomplicated surgery. Tonsillectomy is still a dangerous one, apparently. But our government are pushing to have these procedures carried out in the home, by family doctors who've been on a 3 day course. And if you're lucky, they'll be able to tie a knot.Phoenixhttps://www.blogger.com/profile/02888089682386053436noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-91094029283702873062006-11-26T13:50:00.000-08:002006-11-26T13:50:00.000-08:00Amen to everything you said! Lots of primary care ...Amen to everything you said! Lots of primary care docs see surgery as some sort of black box: send your patient, get him back. You well expressed how it's so much more. Which is why the "cognitive" vs "procedural" divide that non-surgeons like to promulgate is so non-sensical. Another post, perhaps...Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-33363361568915312562006-11-26T12:39:00.000-08:002006-11-26T12:39:00.000-08:00I heard an interesting comment from a speaker at a...I heard an interesting comment from a speaker at a surgical meeting a few years ago. I believe the subject was about the need for vascular fellowships. The speaker quoted his mentor as telling him that performing vascular surgery was not hard, he could teach him that in 2 months. However, it would take the speaker 2 years to learn who to operate on. And it would take 20 years to learn who <b>not</b> to operate on.<br /><br />Ever since then, I've felt that that was a good description of what practicing surgery is really all about. While certainly some operations are technically much more demanding than others, for the most part actually learning the techniques of performing surgery are not necessarily that difficult for a full-time practicing surgeon. But this is only a small part of what the surgeon has to do. The clinical knowledge needed to be a good surgeon is vast, and the clinical judgment necessary to be a good surgeon, both inside and outside the operating room, takes years to accumulate.<br /><br />My first exposure to this was upon beginning my 3rd year clerkship in surgery as a medical student. When I got my first look at a real surgical text (Schwartz in this case), I was very surprised by its contents. I had expected a straightforward diagrammatic volume showing how to perform different operations (and such volumes do indeed exist). Instead, the textbook proved to be just as large as the major medical texts, with a heavy emphasis on physiology, mechanisms of the diseases being treated, and discussions of the various surgical and non-surgical options for treating the disease processes in question. Surgery is far more than simple plumbing, despite our own jokes about it begin exactly that, and to expect someone who at most "dabbles" in surgery to be both proficient and safe is as unreasonable as it would be to expect me to be able to successfully treat a complicated cardiac patient by simply reading about it in a book.dacohttps://www.blogger.com/profile/06711585585464079682noreply@blogger.com