Sunday, November 26, 2006

Family Matters

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.


daco said...

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 not to operate on.

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.

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.

Sid Schwab said...

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...

Phoenix said...

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.

What a bloody stupid idea. There are many good reasons why this practice went out of fashion 50 years ago.

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.

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.

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.

shadowfax said...

Which is why the "cognitive" vs "procedural" divide that non-surgeons like to promulgate is so non-sensical.

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.

Anonymous said...

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.

Sid Schwab said...

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 Schwab said...

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 Schwab said...

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.

medstudentitis said...

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).

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.

Anonymous said...

I can confirm that, at least when I was in training a few years a go, unfortunately your observations would be spot-on.

The big push (from the government and from the teaching practices, anyways, and *lots* of other FPs) is to this idea of "comprehensive care."

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).

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).

But it stops us from doing our real jobs, and I agree wholeheartedly that it compromises patient care.

It's sad that we're made to feel like bad doctors for working within our scope of practice.

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.

I really like your examples. Thanks!

Big Lebowski Store said...

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.



#1 Dinosaur said...

As promised, here is my response.

Sid Schwab said...

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.

Anonymous said...

Hey Sid!

Glad to see ya again.

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.

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!!

Fortunately, for all the family docs that lack boundaries, there are more who do respect their training and mine.

Richard A Schoor MD FACS said...

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.
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.

Anonymous said...

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?

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?

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.

Sid Schwab said...

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.

PS: I don't have a daughter. Or friends.

Dex said...

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.
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.

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.

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.

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.

TheTracker said...

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.

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 one of our own employees came in with a crushed hand, an on the job injury.

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.

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.

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 second year cardiology fellows and above could pull the lines. So in summary, you had to have:

13 years of K-12 education
4 years of med school
3 years of internal medicine, and
>1 year of a cardiology fellowship

>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.

Mindless specialization is not the answer to incompetence. Good, standardized training and quality control are the answer to incompetence.

Sid Schwab said...

Don't disagree with anything you said. "Mindless" specialization would be particularly egregious, especially if it were a universally accurate characterization.

Would that there were such a thing as good standardization, and reproducible measures of quality control, too.

TheTracker said...

Yes, there are no easy answers to ensuring medical competence.

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.

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.

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.


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