Author Affiliations: Department of Surgery, University of California Davis Medical Center, Sacramento.
The environment of health care delivery is responding to a variety of external forces that are changing the practice of surgery. Only when we look back at this period can any assessments be made to determine whether the changes were beneficial or detrimental. The observation that surgeons are retiring at an earlier age may be a reflection of the negative effect of the changing culture of surgery on career satisfaction. As a young surgeon who anticipates an additional 20+ years of a surgical career, these changes are important to me and will clearly affect my practice as well as my satisfaction. This special article provides my personal perspective on some of the current and anticipated changes in surgery that are a manifestation of cultural changes in health care delivery.
Charles Dickens introduced the changes occurring just before the French Revolution in his novel A Tale of Two Cities by noting:
It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us.1(p1)
Change is an ongoing phenomenon that accompanies progress. However, the tempo of change is rarely constant; advances usually occur in starts and bursts. Unfortunately, in these periods of rapid change, not all aspects of the progress are embraced with enthusiasm. The practice of medicine is in ongoing upheaval, with many forces acting to produce a significant change in the way medical care is provided in the United States. These forces include, but are not limited to, technological advances, the method of surgical education, generational differences, increased expectations from the consumer, and health care economics (both the available monies as well as the allocation of these financial resources). Claude H. Organ, Jr, MD, editor emeritus of the ARCHIVES, asked for the perspective of a young surgeon (I finished my training in 1998) on the influence of these forces on the changing culture of surgery. The following discussion is purely my opinion and is inherently biased by my experiences, my lack of knowledge of the details involved in the forces at work, as well as my limited foresight of the future.
There is no doubt that medicine in general, and surgery specifically, is undergoing a technological revolution.2 The following 3 major technological developments have significantly altered the way surgical services are provided to patients: the microprocessor chip, the development of minimally invasive surgical tools, and the complete sequencing of the human genome. Residents who are completing their training take these first 2 developments for granted; the effect of molecular medicine derived from the Human Genome Project will likely be realized in the next 10 years. Younger surgeons assume that medical records are stored electronically; radiographic images are viewed in digital format; and information is 1 click away through accessing the Internet. Electronic information regarding a specific patient is much more easily accessed that leads to a more efficient use of time for the provision of medical care; poring over a 3-volume medical record or digging through an x-ray film folder containing hundreds of film images is no longer required. However, there is a perception that surgeons have become less interactive with patients since medical information is no longer acquired from direct physician-patient interaction but from a computer terminal.3 There is resistance to the loss of some of the personal aspects of the provision of medical care; whether this is an acceptable compromise for the more rapid, accurate acquisition of information required for surgical decision making has yet to be decided.
In addition, libraries have changed from shelves of books and stacks of journals to a bank of computer terminals. An informal survey of third-year medical students at the University of California, Davis, Sacramento revealed that most no longer purchase textbooks but acquire their knowledge from sources stored electronically. Information is immediately available from the Internet, although whether the access to information leads to better-educated physicians or better decision making is unclear. The ease and rapidity of information access is a double-edged sword; patients have the same access to the Internet and medical information Web sites. It is estimated that more than 30% of patients will access the Internet and obtain information about their medical condition prior to seeking medical attention; patients feel empowered and more active in medical decision making when armed with this Internet-accessed information.4,5 Despite the development of various groups such as MedCIRCLE that screen the Internet for medical accuracy and offer certification to those sites meeting its standards,6 there is a wide variability in the accuracy of many of the Web sites that leads to the acquisition of inaccurate information by the patient. In a survey of 1050 physicians, Murray et al7 reported that nearly one quarter of the practioners felt that information brought by the patient was inaccurate. Furthermore, only 38% of the physicians thought that the acquisition of this medical information from the Internet was beneficial to the physician-patient relationship. Surgical decision making can involve lengthy reeducation if the patient has spent a significant amount of time on the Internet prior to the first encounter with the surgeon; this can contribute to mistrust and, ultimately, may compromise the appropriate provision of health care. A little knowledge truly is a bad thing!
The upsurge of minimally invasive surgery (MIS) has clearly altered the provision of surgical care.8 Beginning with the first description of a laparoscopic cholecystectomy to the use of robots in the operating room, technological changes have clearly altered the performance of surgical procedures. Minimally invasive surgery has become the standard of care for the treatment of certain diseases within just a decade of its development. The current generation of young surgeons continues to expand the implementation of MIS; instruments are smaller and more functional; the diseases to which MIS can be applied have expanded exponentially. As a transition surgeon (ie, one who started training before the widespread implementation of MIS but who has incorporated these techniques into his practice), it must be recognized that MIS has an established role in the provision of surgical services, but should not be adopted to the exclusion of standard procedures or established surgical principles. Minimally invasive surgeons are general surgeons first and foremost and should not exclude patients, procedures, or diseases from their practice because of their expertise and preference for performing MIS. Furthermore, not all diseases should be approached with a laparoscope, nor should established surgical procedures be modified to facilitate completion using MIS techniques unless equivalence or superiority is demonstrated. Pushing the envelope of technology and MIS should be encouraged, but I am not sure that robotic surgery is necessary to perform hemorrhoidectomies!
The sequencing of the human genome has expanded our options of tools to investigate human diseases, and we are just beginning to peek over the horizon.9 What if we could tell which 23-year-old patient with multiple trauma would succumb to SIRS (systemic inflammatory response syndrome), while another identically injured patient would leave the hospital without complications from his or her injuries? Or what if we could tell which patient with stage II colon cancer will develop hepatic metastases, and then identify the most appropriate and effective therapy? The genetic basis of diseases is well established, although the diseases that have been clearly linked to somatic genetic defects are uncommon syndromes, with names such as Li-Fraumeni and Sipple. The next generation of surgeons will use not only clinical and radiologic information for determining the most appropriate surgical decision, but molecular genetic profiling will also become routine. As a surgical oncologist, this is already part of what we do for breast cancer, but this concept of disease and patient profiling will become standard practice.10 I anticipate that the advent of molecular medicine will improve outcomes; futile care will be eliminated because profiling predicts that the patient is unlikely to benefit from therapy.
The time is long past when surgical mentors could spend hours in the operating room instructing the student on the technical complexities of a surgical procedure. Furthermore, the diversity of surgical techniques is sufficiently broad that we are unable to expose trainees to all potential methods, especially in the current setting of the 80-hour workweek. Finally, technological advances are sufficiently rapid that new procedures are being developed while other procedures are being cast aside as obsolete within a short time span. A surgeon of 20 years ago would easily finish training with sufficient mastery of surgery that would allow a steady practice without much change. However, current finishing trainees have significant gaps in their experience but are expected to be proficient as well as incorporate new procedures within a short time of completing training.
As a personal anecdote, I never participated in a laparoscopic adrenalectomy during my residency; however, within 2 years of my first clinical appointment, I had become adept at it and had incorporated it into my portfolio of operations for adrenal diseases. Clearly, the education of the technical aspect of surgical procedures has changed so that education in the operating room has taken a second seat to the use of simulators and artificial learning environments while the focus is more on skills development rather than procedural acquisition. The next generation of surgeons will begin their education with an established skills set that was acquired primarily in virtual settings rather than clinical-based experience11,12; furthermore, the established surgeon is unlikely to attempt a completely new procedure on a patient but instead gain experience through inanimate resources. A second force driving this change in education comes from the patients; they are simply tired and intolerant of being guinea pigs for the development and implementation of new surgical procedures. Patients now demand experience and expertise (see the “Consumer Expectations” section) and are hesitant to undergo a procedure in which the surgeon has no prior training.
The move from training in the hospitals and clinics to the virtual simulation laboratory clearly has its deficiencies. Direct observations of individual variations, responses, and outcomes from a surgical procedure are a wonderful source of education; this source of surgical education is no longer a primary experience among current trainees. Surgical training has evolved from continuity of care to shift work, and while there are many ramifications of these changes, one significant consequence is that patient experiences and outcomes are diminished as a significant source of the surgical trainees’ education. While clinical medicine has been promoting bench-to-bedside translational developments, there has been a significant shift from the patient bedside to the computer bench for the acquisition of skills and experience. Some of the most important lessons that I have learned have been from direct observations of patient’s clinical conditions, and we should continue to maintain a solid focus on education that occurs directly with the use of clinical sources, namely, patients.
The generation of Americans entering the workforce have been termed “Generation X,” with the “Nexters” or millennial generation following.13 There clearly are generational differences in core values as well as the composition of the group by sex, ethnic, and religious variables. I do not doubt that this group of physicians and surgeons has the ambition, drive, and ability to provide the highest level of medical care. However, the value differences may have a significant influence on the way medical care is provided. A major difference in Generation Xers is the basic attitude toward work; individuals in previous generations often chose careers committed to a single employer over a lifetime of long hours; personal success was measured by professional accomplishments. Generation Xers will not tolerate this lifestyle imbalance; personal and individual time is a significant priority and employment may be a means to accommodate nonemployment-related goals. Excessive workloads are not tolerated because this only limits the accomplishment of other goals and is not viewed as an achievement, or, at least, a reasonable compromise required to achieve other goals. Dedicated, outstanding surgeons will be found among Generation Xers, but the method by which these surgeons provide care will be different.
The changing demographics of the young surgical workforce is probably one of the brightest beacons on the horizon of health care. Women represent more than 50% of the applicants to medical school.14 There is increasing ethnic diversity among the medical school applicants that is beginning to represent the demographics of the United States; 7% of applicants were Hispanic, 8% were African American, and 18% were Asian. This expanding diversity will allow for medical care that incorporates issues specific and relevant to these subpopulations. Using a translator to review a disease process and obtain informed consent inserts an additional barrier to the development of a trusting, interactive physician-patient relationship. In addition, the projection of personal values into the decision-making process can be destructive when the physician and patient harbor different beliefs based on ethnic, racial, or gender biases. The broadening diversity of American surgeons will likely increase the provision of appropriate health care; this concept has been termed “cultural competency.”15 The next generation of surgeons will possess this cultural competency and eliminate health care disparities of the past based on barriers of mistrust caused by racial, gender, or religious differences.
Individual responsibility for the care of a patient has long been the mantra of surgical disciplines. Along with the responsibility of patient care also comes the accountability for clinical outcomes.16 An Institute of Medicine report on medical errors—To Err Is Human; Building a Safer Health System17—opened public and political analysis on the method of health care delivery in the United States. There has been increased scrutiny of the methodology of health care delivery with increased recognition of preventable adverse outcomes. This goes well beyond the systems of health care delivery but has increasingly focused on individual providers, who are responsible and accountable for procedure-related outcomes. In fact, for selected specialties and regions, these outcomes have been tracked and made publicly available, although to what end this reporting of outcomes improves health care delivery remains largely unknown.18,19
Whether we like it or not, responsible reporting of outcomes is part of the current landscape of health care delivery. Both patients and health care insurance groups are demanding these data for individuals as well as groups of providers. This has been most clearly manifested by the organization of the Leapfrog Group, a conglomerate of large companies that is responsible for obtaining health care insurance for a significant fraction of employed Americans.20,21 The goals of this group are altruistic; the prevention of medical mistakes and improvement of the quality of health care. However, secondary goals, such as rewarding physicians and hospitals for improving outcomes and collecting data for responsible and informed health care access choices, will clearly affect the individual and group practices of surgeons. What is not stated is that surgeons who obtain outcomes below the standard set by this group may be financially punished and that patients would be discouraged from seeking health care from these providers. While I understand that concentrating health care into the hands of experts will reduce preventable medical errors, I question whether this is truly feasible. For example, as a young surgeon entering practice, it may be difficult for me to develop expertise in areas in which inexperience leads to poorer outcomes, such as in the sentinel lymph node biopsy for breast cancer. In this circumstance, it has clearly been shown that up to 53 procedures should be done with concomitant axillary dissection to establish an accuracy rate that has been deemed acceptable (although luckily not by the Leapfrog Group).22 If a patient has access to 2 surgeons, one who has completed his or her learning curve and one who has not, then these outcomes-based referral guidelines should prevent the inexperienced surgeon from ever gaining proficiency. While I believe that the goals of the Leapfrog Group will improve the quality of health care delivery for certain diseases and procedures, there is also the potential to significantly stunt the development of young surgeons by shuttling these cases away to the experts. Who will become the next generation of experts?
The goal of transparency of outcomes is an important aspect of the Leapfrog Group, and patients are learning to demand this. When asked how many times I have performed a procedure, the response of “time and again” is an unacceptable way of saying 2. Part of the informed consent process involves communication of potential outcomes, and these truly can be judged by experience. I believe that most patients are grateful for the honesty that has been a founding principle of surgery (primarily manifested by morbidity and mortality conferences). This is no longer just a matter of individual patient outcomes but rather, a matter that includes historical results from single providers as well as groups of providers. While not all patients will use these data for health care choices, others expect and demand it for use in the process of informed decision making. We cannot hide our poor outcomes and transparency of outcomes is here to stay.
As Bob Dylan sang “the times, they are a changin’,” various forces are changing the way surgical care is delivered as well as the entire culture of medicine. The economics of health care delivery was specifically avoided herein because I am not sure what system will be in place in 20 years, though it clearly will not be the current model. The forces enacting these changes are powerful and will effect both good and bad alterations to the provision of health care. While I am enthralled by certain components of the future, I also wished I could have experienced some of the times of the past, lamented by my mentors. However, the changes are not as important as how we adapt to the change, and the current generation of young surgeons has demonstrated leadership abilities that will guarantee continued excellence in the delivery of surgical care to Americans.
Correspondence: Richard J. Bold, MD, Division of Surgical Oncology, Suite 3010, University of California Davis Cancer Center, 4501 X St, Sacramento, CA 95817 (firstname.lastname@example.org).
Accepted for Publication: November 30, 2004.
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