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If You’re Uncomfortable, Change is Occurring, and with Purpose – It Should be Good
As a young kid, my grandfather took me to see a wonderful respected golf pro in Austin with the purpose of teaching me to be a better golfer. His name was Harvey Penick, he was famous then and only became more so with time. For those of you deprived of knowledge of this great game, he taught some greats named Nicklaus, Crenshaw and Kite, and a woman named Whitworth , to name but a few. With me, he had quite the challenge. He watched me hit for a while and said nothing, then he asked me to make changes in my grip and swing, I did, and after hitting a few, he asked how it felt? The reply was “awful”, and his was “wonderful, it means we are effecting change”. Change is always that way, but his efforts and my own allowed me to progress fairly well as a golfer, but alas, I still need a day job. It brings us to the approach we need with many of the changes in medicine. The mandatory requirement for an eighty hour workweek has dramatically changed the concept of training programs forever. As a product of the prior training effort, we all struggle to grasp the wisdom of this paradigm shift. In coming to grips with this change, a focus has been once again been placed on the need for the application of sound business principles in time management and communication to the practice of medicine. But with that focus, we should become better at what we do.
Thoracic Surgery has since the time of the late Dr. John Kirklin’s ICU algorithm development been aware of the need for systems to best manage our patient. Dr. Kirklin’s unit strived for an efficiency of care in the ICU from the near infancy of cardiac surgery. His unit used algorithms to direct administration of volume, blood, potassium and other interventions well ahead of its time in an effort to improve care. The STS database has led a charge in medicine for collection of data and use of same to affect our “best practices”. CT surgeons and their programs over the years have been innovators of change and models for the use of data driven decisions in applying therapy for the best in patient outcome and care.
As the eighty hour work week is clearly on us and not ever to go away, we must once again strive to use it for our patient’s advantage and to the example of how to best provide care for all of organized medicine. This challenge is not easily met. However, our profession over the years has attracted some of the brightest and most motivated talent medicine has ever known. Thoracic surgery has trained some of the best critical care physicians the world has known to date. Our ability to make persons sick and then bring them back from the edge of death to become highly functional members of our society is unrivaled in Medicine today. Our level of technical expertise is some of the most highly developed ever. All of this has been based on a traditional model of working for over 100-120 hours per week for years on end to mold the talent and individuals described. Those of us trained in the mode where “the best place to find a helping hand”, as told to me innumerably by the late J. Kent Trinkle, “is the end of your own arm” must realize things have changed in some ways. Still the best way to get something done right is to do it yourself, but we must learn to trust and embrace systems which do more than reinforce our need to be present day and night to the benefit of our patients. Some practices of the past will sadly be leaving our profession, but the opportunity to do more for our patients by embracing and developing systems of care which will create the communication and continuity patients as ill as ours require must be seized.
In our practice, this is just becoming evident to our entire group. We are like so many struggling with how to create ownership of a patient and their many critical problems in an environment no longer of sole proprietorship, but one of fractional owners and timeshares. The need for our faculty to check out patients to the person on call has never been greater, and the need for a system to check out all of the various organ systems and issues with each patient while not being too tedious or insufficient in detail is obvious. We have begun to adopt a charting system that captures their problems, displays their presenting symptoms and anatomy or physiology in a way that someone new to the case is immediately familiar with the significant nuances of the individual. Systems such as these begin to solve at the science and facts of our profession, but one of our unique aspects of our profession is the humanisitic component remains an art as much or more than it is a science. More than science and data must be involved.
In our group, we have been fortunate to have a reasonable group of communicators who interact with patients and their families in an excellent way. This is no accident, as it has been a priority for our group from its inception with such great mentors and doctors as Fred Grover and Kent Trinkle that practiced the Art of our discipline in its highest form daily in addition to bringing science. For our profession to thrive, hopefully regain, and add to its place of esteem within our communities, we must again ensure we communicate and listen to patients and their families. Our therapies should be directed to their needs and wishes as we once again “minister” to the patient and their family in a way our profession did long ago. They must feel that we are treating them as we would our loved one and that we are explaining things to them in an honest and compassionate way no matter what the gravity of their affliction.
The eighty hour work week has changed the way we can teach young doctors our trade. No longer will the time spent in the hospital provide the immediate feedback to them as to what worked or did not, and outcome databases will not allow for the see one, do one, and teach one kind of program anymore. We once again have almost come full circle to a position of apprenticeship where a young intern is best taught by spending time with a master clinician in the discipline of their choosing. We cannot turn them loose on a particular population such as an indigent or governmental captive audience and we should likely never have, it is an opportunity to do so much more. The eighty hour week gives us only the time to have them carefully proctored in a highly structured way. They may have ample time for procedures, but they must be taught under a very short leash.
For those of us trained in the men-were-men-and-dinosaurs-roamed-the-halls era of Thoracic Surgery, this change is difficult to accept, but we must not only accept it, we must once again lead the charge in the education of our residents and developing a model that all others can be envious of. The problem is always one of time, and this is no different.
In our group, creation of specific teaching modules has been done and each faulty takes a turn at it daily for the medical students. Work hours has made morning rounds more difficult and time for them limited, so we have instituted an attending rounds that is later in the day for the benefit of those residents presenting for call that night and others leaving that day. Our TSDA has been instrumental in creating a web based curriculum that can be studied when “off of the clock” and more efforts to develop new teaching modes as this are needed. In the meantime, operative experience is being proctored for the interns by PA’s or an experienced older Thoracic Surgeon with special expertise in saphenous vein procurement and true interest in teaching these skills. Faculty perform more cases than they may have once done and the Thoracic Surgical resident case volume seems lower, but the quality and variety have seemingly increased. Time for research in a two year program of any meaningful kind has not been something that we have found a way to include, but time for “elective” Journal clubs and literature reviews have been created and increased.
All of these changes require resources, and in this day of decreasing physician reimbursement making these changes has been done at the expense of our pocketbook. With the example of so many others, our group has been successful in shifting appropriate burdens to the hospital for perfusionists, nursing support, PA support of lost resident service components, and help with patient flow problems. None of this is easy, and to do it well at times has seemed impossible, yet with good mentors and examples around to draw ideas from, it is all possible. The overriding principle that has allowed this to happen in our group has been one of doing and requesting things that clearly benefit patients while not overly inflating needs or costs in a way that seems to others to unfairly pad our CT surgeons’ bottom line. None of us live extravagantly, but we all live well.
Thoracic Surgery is changing rapidly and will not be what it once was ever again, but it remains a vibrant field with many challenges and one where the ability to change lives and hold a position of respect within ones community and peers has never been greater. If we work to confront head-on the challenges that work hours brings to our program and trainees, we can build a better system of care that will benefit our patients, our education programs, our hospital partners, and payors in a way never demonstrated before. The greatest outcome of this may just be the time we may be able to carve out for ourselves, our families, spouses and friends. For me, the outlook for Thoracic Surgery seems brighter than ever and the opportunity to do more for our patients has never been greater as we work to change ourselves in a way that makes us all better. It won’t be always comfortable, but we will get there…