Wednesday, June 25, 2008

Food For Thought


Wedging a little update, for public interest, between my previous and tomorrow's (final?) post, I thought I'd mention a meeting I had recently. Some readers will recall I said I'm considering resuming, part-time, my surgical hospitalist gig. In discussing details, some interesting issues came up which go to themes about which I and other bloggers have written severally: namely, the changes going on in training programs and the products thereof.

I talked with two surgeons; one was of my era, the other much younger but having finished training just before the invasion of the eighty-hour work week. They have big concerns. Having just hired a couple of the recently minted, they are finding the need to establish a mentoring program, because the newbies seem neither to have the skills nor knowledge to manage completely on their own, despite looking great on paper. This, of course, is exactly what I've written about. In fact, I've suggested such a mentoring program will need and ought to be a formalized requirement of all new trainees, given their limited experience compared to those much decried days of yore (and myre.)

The ramifications are many. For me personally, and others like me, it might suggest a future premium: who better to mentor the fresh faces than the old and grizzled and recently retired? And for me personally, and for you, let's hope we never need surgery. At least until the full effects of the recent changes are realized and dealt with. Which would be, oh, another couple of decades. So good luck with that.

The warnings are out there, in this blog and comments thereon, and in many others, as well as in a trickle of papers on the subject. I've been saying there's trouble ahead; it may or may not be as bad as my worst fears. I'm certain there are highly-qualified people being cranked out. The questions are, how many, qualified for what, and willing to do how much? And how to separate the sheep from the goats.

Meanwhile, were I to finalize the job arrangements (not yet certain), there might be food for further thoughts down the road.

24 comments:

scalpel said...

How does the newbies feel about the need for mentoring?

Sid Schwab said...

Good question, to which I don't have a specific answer. From the discussion I inferred it wasn't unwelcome. Having done some mentoring not too long ago for a person just out of training (actually just before the 80 hour week), I can say in that case at least it was appreciated; mutually, in fact, in that I enjoyed imparting a few tricks and being told "wow, that was really slick!"

rlbates said...

Seems like that would give you many new stories to tell us. :)

Kristi said...

Peer-to-Peer mentoring is always a great idea, but can I take it a notch?

Expand on it. Make it a group effort. Experienced O.R. RNs and surgical technicians can be an invaluable source of information, tips and techniques.

Respectfully,

The Former OR RN who was known to send new Residents scrambling for "sterile fallopian tubes, STAT!!". =)

Mary said...

You mentioned that 2 surgeons hired the "newly minted" doctors. Is this a physician owned facility? Otherwise, I would imagine that most new doctors are hired by hospital recruiters who are trained in business, not medicine. Without the insight and concerns expressed by the doctors in your example, it would seem that most hospital recruiters would feel free to award surgical automomy to these new doctors based solely on "what looks great on paper".

Pity the poor patient who unwittingly becomes a stepping stone for the new surgeon's climb to practical proficiency.

Sid Schwab said...

kristi: excellent point, and I agree entirely. All it takes is for the young hands to realize the great source of info they have; swallow their egos a bit. I used to think how many times I went from bottom to top and bottom again: grade school, big eighth grader; freshman in hs to senior; freshman in college to senior; first year med school to fourth; intern to chief resident. The pinnacle. Then, new kid on the block. It takes getting used to.

mary: I'd say it's still the case that most docs are hired privately and not by a hospital. I can't say for sure, nationwide.

Annie said...

Since you already mentor right here on the blog and through your other writing, I think you'll be pleasantly surprised at how much you enjoy it back in the clinical setting. The new kids, I'm guessing, will be extremely appreciative, as this isn't a fellowship or residency with a set endpoint.

I used to love to mentor grad students because they came with their own agendas, were licensed and practicing under their own credentials, and so, we engaged on subjects of mutual interest. All of the fun without most of the headaches.

I'm happy for you and hope that it provides you with what you enjoy: patient contact, surgerizing, teaching and stories (to tell us, I hope)!

shadowfax said...

Ha! I'll be bummed if you stop blogging, but hey, if I get to consult you in the ER, that's a win for the home team as far as I am concerned!

Anonymous said...

The new crop of interns started orientation today. They look very young, very excited, and not scared enough. I always thought a good sense of fear of screwing up was a helpful thing to have during residency (and now!)

Sid Schwab said...

shadowfax: not that we know where you work. Wink, wink.

anonymous: fear (sense of your own limits and warning bells not to exceed them) is the essence of a safe doctor; and, given the potential harm surgeons can do, it explains, in my opinion, at least some of the more harrowing aspects of (at least old-style) surgical training. Having those sense of limits and of responsibility and commitment is imperative. Traditionally, part of the method was haranguing. I can't say other ways wouldn't be as good; but when the stakes are as high as they are for surgeons, I felt, in the main, it was justified.

Anne said...

Perhaps if we take the focus off of, well, everything (publishing papers, doing research, volunteering. . .etc.) we would be better able to focus on what we really care about. You know how it goes - "Jack of all trades. . ."

Patrick said...

And for me personally, and for you, let's hope we never need surgery. At least until the full effects of the recent changes are realized and dealt with. Which would be, oh, another couple of decades. So good luck with that.

Umm, gee. Thanks for the good luck bidding. I think.

Let's assume for the sake of discussion that maybe some of us don't care to rely too much on luck, and would prefer to stack the deck in our (or our loved ones') favor. If you were asked to produce a list of things that you think a patient should look for when choosing a surgeon, what would be on that list?

(And while we are assuming, let's ignore the trauma patient, since the only factor patient should be concerned with is proximity.)

Sid Schwab said...

Patrick: I get asked that a lot, both on the blog and in other face-to-face situations. (Like when I did readings of my book.) Back then part of the answer was the usual: where did you train? Are you board certified or eligible; are you a member of the American College of Surgeons. Where a person trains is probably not really revelatory, as is true with lawyers: my dad went to a night law school; my brother, to your locums. The memberships are perhaps more important. Nowadays I guess I'd wonder how recently trained, and if in the eighty-hour era, I'd consider risking insult by asking if there was or is any mentoring since. But mainly I always say this, partly because it's an artful dodge, and partly because I think it's sensible: if you trust your primary care doctor, then you have to trust that he/she would send you to someone competent. Transfer the trust from the one to the other. Or, even, ask your doc if the surgeon is the one he/she would have do the same operation on him/herself or family.

Patrick said...

Your answer seems fair. And and artful dodge.

Most states/communities have a listing of the "best lawyers," where best is determined by polls of practicing attorneys. While a high ranking may indicate professional ability, or it may indicate something else (like, networking ability) it seems like a pretty good bet that the nit-wit density on those lists is pretty low. Is there a comparable listing or publication for docs? I'm guessing the answer is no. Y'all seem pretty tight-lipped outside the club.

Also, there is one hell of a sentence inside your comment at 8:25, Sid.

It features a colon, a semi-colon, plus the words "locums" and "revelatory" . . . AND it makes a point.

If I wasn't convinced before that they don't make surgeons the way they used to, I am now.

Sid Schwab said...

There are some such ratings for doctors. I can't claim familiarity with them all. One with which I am familiar listed me as one of America's Top Surgeons. The first year it was done, it actually WAS based on a survey of physicians, asking them to whom they'd go themselves or refer family for various specialties. I considered it a mild honor; but the deck was a little stacked. I was in a large clinic; other local docs were on their own. Plus there's no saying who responded and why or why not. A very similar one has come out every year since: same look of the book, same notification to those mentioned in it, with an offer of a nice plaque for two or three hundred bucks. Since that first time they abandoned the peer criteria and use who knows what. Since I'm still listed as a "top surgeon," and since I haven't practiced for several years, one can only assume it's completely bogus. And, indeed, it is. I wrote about it here.

Bongi said...

in my country we don't have the different levels of certification like board eligible and board certified. if you qualify in out country you're on the roll which means you are fully qualified. if you qualified in another country you may have so called limited registration meaning you can only work in a state hospital. you then need to write our finals to become fully qualified. many of the cubans who defected from their contract did write these exams and are now fully qualified.

we're a bit behind you but there is a strong human rights move to make surgery training easier. it doesn't help that we have a shortage of general surgeons. they want to churn them our, despite quality. and they will be fully qualified so there will be no clear differentiation between the old style and new style surgeons.

recently i've seen and heard some things that really shock me. my master plan is to not get sick in my old age. otherwise i'm screwed.

Frank Drackman said...

Hey Sid, before you sign off forever, Did you ever scratch your ass during a case and neglect to reglove? I saw a Surgeon wipe his brow once and then go back to work sewing in an Aortic Valve...

Chrysalis Angel said...

I would think the mentoring would be appreciated. It isn't like you walk out of training knowing everything there is to know about everything. You would probably be perfect for this type of thing.

I hope there will be no final post for a long time!

Sid Schwab said...

Frank: I do recall a wayward scratch once in a rare while, but never without realizing it in time to reglove. And there's the grabbing of the light handle that isn't there...

Anonymous said...

how do you do this mentoring, particularly by non-physicians without undermining the authority of the new hires?
it seems like you are asking for trouble. it is one thing for a grizzled veteran to throw a couple pearls every now and then. it is completely another to establish a formal program to review competency rather than to inspire excellence. it creates an aura of mistrust rather than team, in my experience. rather like another residency/ fellowship for these guys. don't be surprised when they move on. after the first few months they will be insulted.

Sid Schwab said...

anonymous: your inferences have nothing to do with how it actually works. "Non physicians"? Who suggested that??? "couple of pearls now and then"??? What gave you that idea? "review competency rather than inspire excellence"?? We are so not on the same page. Can't imagine where you got your concepts...

Andrew said...

There are a few lists of "best doctors." I just saw the one for Honolulu, the town where I work. Some of the choices I would judge reasonable. Some, not so much.

Personally, I think the best doctor is the one that gets out of bed and drives to the hospital to see you at 3 AM when the intern calls because she thinks something is wrong.

Somebody that does great technical operations, but only when the sun is up, probably isn't the right person for me.

I've also always thought that a good surgeon should be as interested in NOT operating on you as he/she is on operating on you. Just because you are sent to a surgeon should not mean you need or get an operation. I've seen more than a few cases done for fairly dubious indications.

I am always amazed that patients meet me, have about 20-30 (clinic is slow) minutes to talk to me about their hernia/gallbladder/etc, and then are booked for an operation if needed. There's a lot of trust that is put in you (me) and I'm constantly awed that it happens like that.

Sid Schwab said...

andrew: I agree completely and I've written as much here several times. It's an amazing thing that people entrust us with so much, with so little real information. I'd also add that the great surgeon is the one who knows how to avoid trouble in the first place (which also includes knowing when not to operate) rather than the one who is always making a great "save." As I said in my book, it's like the great outfielder who knows the pitch count, the game situation, and positions himself always to make an "easy" catch, as opposed to the one making a diving catch. That can't always be avoided; but more often than people recognize, it can.

SnowLite said...
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