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Opinion SCOPES II
jcontinued from page 35 response would be to make training “harder� rather than easier, so that when confronted with difficult surgical pathology, we don’t feel like the Asiana pilots approaching a sea wall at 150 mph. Graduates need to know how to get the nose up in a hurry when it counts. A good nap and an A grade in citizenship will not cut it. Feeling coddled and protected by “the team� doesn’t cut it either. Neither does a learning environment that refuses to reward excellence and punish failure. Like it or not, fear motivates. Unfortunately, this does not appear to be the direction we are headed. In this post-evolutionary world, there seems to be a conscious attempt to make surgical training as unthreatening as possible. When I began my internship, I thought everyone was better, smarter, more skilled and harder working than I was. I was told, in no uncertain terms, that I had entered a dog-eat-dog world where it was survival of the fittest.
GENERALSURGERYNEWS.COM / GENERAL SURGERY NEWS / SEPTEMBER 2013
Surgical pathology was uncompromising and unforgiving, and the training to learn how to deal with it would reflect that reality. It was a harsh but exciting world. The ground rules appealed to me. When my mom dropped me off at my Little League games, she said “drag their———in the dirt.� I was ready— and remain convinced to this day—that the culture of surgical training drew everything I had out of me. I thought my professors of surgery were gods. I wanted to act like them. I wanted to be like them, whatever it took. No doubt this view was partly inaccurate and a product of youth, but it motivated me to be more than I otherwise would have been had the message been to relax and enjoy life on the level playing field where all reasonable needs would be accommodated. In retrospect, it was clear that surgical culture made a choice to maximize the skills and attributes of people like me even if it meant weeding out others disinclined to subject themselves, or their families, to such an intense experience. Somewhere along the way, the leaders
of surgery, pressured by the norms of the outside world, changed their minds, and now they are finally being confronted with the consequences of that decision. Unfortunately, technology and automation have not come quickly enough to disguise the lack of readiness in surgery graduates. Program directors and department chairs find themselves in the unenviable position of certifying surgeons not yet ready for prime time. Ultimately, however, blame goes beyond program directors and department chiefs and resides with surgical leadership that endorsed the 80-hour workweek. They sent the signal that surgery, once the mighty discipline, was ready to capitulate to all the norms of the post-evolutionary world that endorsed accommodation over adaptation. The “Me Generation� would not find surgical training a stressful experience and did not have to choose dermatology to achieve work–life balance. How ironic that the quest for work– life balance has now extended surgical training by one, two or three years just to achieve competence. Extending
surgical training would not be necessary if programs had the same intensity as they used to. An honest debate about the root causes of the general decline in surgical training is not even permitted. Disguising failure that results from declining standards has become a growth industry in the United States. There will be no retreat from the groveling obeisance to the level playing field no matter what the consequences. Giraffes with short necks will thrive. It has been decreed: Evolution is dead. Intelligent design has constructed for us all a happier, less judgmental place where we all can thrive. Only our patients are at risk. For those of you who read this and disagree, kindly express your displeasure in a warm and nurturing way. —Dr.Cossman is a vascular surgeon in Los Angeles, Calif.
khorty@mcmahonmed.com.
Letters to the Editor
Hat or Miss To the Editor: I read with interest [Dr. Lauren Kosinski’s] article, “CMS Directives: Hat or Miss� [ July 2013, page 1]. Some years ago I wrote an essay on this very subject. I think it was when a state surveyor had directed us to get rid of the hats and replace them with bowl covers. We did until he was gone, and then replaced the surgeon’s hat on the shelf next to the bowl cover bouffants. There is not one shred of scientific evidence that shows the bouffant is safer. In fact, the skullcap allows for a better use of headlights and loupes, which do not stay in place as well on a bouffant. There is a reason for the CMS [Centers for Medicare & Medicaid Services] rule. It started years ago when the much-desired takeover of the practice of medicine began. It started with doctors being lumped in with lab techs, venipuncturists, nurses and everyone else in anyway involved in patient care. We all became health care providers. This took away our specialness as well as some of our power. With every new rule and regulation we gave up power and position. The removal of the skullcap makes the surgeon like every other doctor, and was necessary since we all know surgeons are more cantankerous and obstreperous than other doctors. This [CMS mandate] has nothing to do with safety and everything to do with control. Who knows what could be next. Perhaps the internists should be wary of draping their stethoscopes around their necks on their way from ICU to the supermarket! Larry Monn, MD Indiana
To the Editor: My hospital recently tried to do this in one day and failed due to a massive uprising. It was in part pushed by a need to explain an infection that supposedly had a
hair in it. Somehow the fact that the patient had a ruptured colon was overlooked. It was an example of who really is driving the ship we are on. Surgeons were kings and queens not long ago, and there is no way this would have been attempted 25 years ago. I agree with Dr. Kosinski’s comments that being disengaged only hurts us in the end. However, we as a group have grown soft. Leadership is protection—protection from the administratively insane. Garth Olds, MD, FACS Bozeman, Montana (MCW General Surgery Grad 2001)
To the Editor: I was astonished to read the article by Dr. Kosinski echoing my feelings on the useless rulings and mandates that continuously pour from the mouths and pens of bureaucrats from the various agencies that presume to supervise and regulate us. In my experience, there are no better champions of patient care than surgeons. For each law written, a liberty is lost and these bureaucrats obviously have no idea how these seemingly tiny mandates add up to decreased quality of life for surgeons and physicians and increase the burden of care of individual patients. Kudos to Dr. Kosinski for relating this so eloquently. Craig Swafford, MD LCDR (SEAL) Ret. Assistant Professor of Surgery UT College of Medicine Chattanooga
The Dangers of Prescription Painkillers To the Editor: I’m writing in response to a recent report on prescription painkiller overdoses from the Centers for Disease
Control and Prevention. The report, which showed that more women die from prescription painkillers than from car crashes, is alarming. It is imperative that physicians and patients explore alternatives to narcotics for pain management. Many people are aware that prescription painkillers cause serious side effects such as respiratory depression, nausea and vomiting, and mental confusion. Prescription narcotics are also associated with the development of dependence and addiction in some people. And although opioids are frequently prescribed for postoperative pain management, a real risk for the development of narcotic overuse does exist. Physicians need to minimize this risk for their patients. In addition, many patients are already asking for alternatives to prescription narcotics for pain management to avoid the negative effects of opioids. In response, many hospitals are implementing narcotic reduction programs that use innovative alternatives to opioids for postsurgical pain management. One option is a portable pain pump, which can help manage postsurgical pain by delivering an automatic and continuous, regulated flow of a non-narcotic, local anesthetic through a catheter near the surgical site. Options such as these help reduce the reliance on opioids to relieve pain after surgery, and can also reduce many narcotic-related side effects, speed recovery and improve the overall patient experience compared with narcotics alone. Hospitals benefit via a reduction in adverse events, shorter hospital stays, fewer readmissions and improved patient satisfaction. This report sheds light on the dire need for alternative solutions to treat pain. It’s critical that physicians educate their patients, involve them in decisions about pain management and give them options. Rita Hadley, MD Dayton, Ohio Dr. Hadley is a speaker for I-Flow, manufacturer of the On-Q Painbuster Post-op Pain Relief System.