Thursday, July 26, 2007

An Open Letter to Surgeons

It seems in the Medical Blogosphere, every specialty is writing open letters to every other specialty. Maybe some anaesthesiologist has already written one. I haven't looked. Here is mine.

Dear Surgeons:

I actually like most of you guys. At least I like you a whole lot better than most internists. Maybe because we work so much together there are a few things that piss me off.

1. Punctuality. Maybe I am a bit anal about being on time. I frequently arrive at parties at the acutal time the invitation says. However when the case is booked to start at 0730, I try to show up at least 15 minutes early, the nurses show up at least 30 minutes early, all so we can have the patient ready for you. But you consistently show up at 0745. Now if we start 15 minutes late, we rarely ever make up the time which means that we leave 15 minutes late. That is assuming we get to do the last case which is often cancelled if we are running late which hits me in the pocketbook, not to notice having to witness an ugly scene between you and nursing.

When confronted on this, your excuse consistently is, "but it's only 15 minutes". Next time you fly somewhere show up 15 minutes late and see if you get to board the plane.

Maybe 15 minutes isn't much, however when I finish 15 minutes later than I should have, that might mean I don't get to eat supper with my family, I miss my children's soccer game completely or I miss the meeting I scheduled at the end of the day.

And by the way. I cannot start the case until we know you are in the hospital. That is because you could be operating at another hospital, in court, or have died in your sleep. I am aware of all three scenarios happening. Quite often the patient wants to talk to you, frequently the consent has not been signed.

And having started the day, try to arrive on time for each subsquent case. If you can't because you are dealing with something in emergency or on the floors, why not call and tell me. If I know I have an extra 15-30 minutes, I can actually do something with the time.

2. Residents. Those surgeons who don't work in teaching hospitals can skip ahead here. Most doctors my age were junior house staff on a surgical service years ago and we know how hard surgery residents used to work and how completely soul destroying and uneducational it was. The current group of surgery residents are quite right to refuse to put in that amount of work. However... most of that work still has to get done. That means if the residents won't do it, you had better find someone else to do it; the nurses, yourself I don't care. The standard of care on most surgical services is disgraceful. By the way, you might want to ask your colleagues at non-teaching hospitals how they manage to provide pretty good care without residents.

Further while it is important to train the residents, the middle of the night or late in the day when you are already behind are not good times to teach. When I am letting a resident do something I make sure they try to do it as efficiently as possible, I come in extra early and I help them as much as possible so that they can do the procedure or get the case started faster.

3. "I really don't want to do this case but the family is insisting on it" God man, how many years did you train so you could be intimidated by Mrs. Jones' high school dropout grandson. To put it another way, I have as much training as you and do you ever respect my opinion? And isn't it funny how these discussions only occur after hours, never during your elective slate? Grow some balls, sit down with the family tell them how operating on granny will at best slow her demise, may likely hasten demise but will not prevent her demise.

4. Yes we don't work after we've been on call. Sometimes now we don't even work the day before night call. This is not because of some weakness but because we have learned that it is dangerous to work without sufficient rest.

Like the alcoholic who thinks he is witty and sexually attrative when he is drinking, you believe you can provide competent care without much sleep. We have watched you for years. Trust us, you can't and you don't.

5. We do emergency cases in the order determined by whatever protocol the hospital has decided for prioritizing cases. Surgeons presumably had some input into the process. If you feel your case is more urgent than the one ahead of yours, don't whine to us. Call your "colleague" and ask him if you can go ahead.

6. Oh and while we are on call or even in the course of our elective lists, we may have to go the ER, the ICU or the ward to intubate somebody. We may also have to do a labour epidural. This may delay you. We do these because we are physicians.

7. Try telling the truth for a change. Instead of saying you have to do Mrs. Smith right away because she has perforated, why not say,"I know Mrs. Smith can wait but the family is driving me crazy." We may still not do your case when you want it, but won't you fell better about yourself. Be truthful about the patient's medical condition, and how long you are going to take.

8. I don't know about the medical training of people recently but anybody who trained in my era had pretty good grounding in history and physical examination skills. Put those skills to use. Not just in the areas related to where you are operating. Currently when I read a chart, I get my best information from the nurses notes which is kind of disgraceful. Also you might consider writing the odd progress note. Like, say every day. Just so we have some idea about what happened to Mrs. Smith in the 5 days since she was admitted and why she is having surgery today.

9. If you have a problem with the way I work or the way a particulary case went down, talk to me first. In private, not yelling in front of the nurses. Before you write a letter or talk to my chief. Definitely befor you talk to the family. Aside from being courtesty, I may just be able to explain why I do something or what happened in that case. And please no sneaky progress notes that I will never read but that are in the chart forever.

10. No amount of lab work is a substitute for a legible history and physical documented on the chart. The more lab work you order, the more likely something is going to be abnormal which will lead to more testing and possibly the cancellation of your case. Also when you really need something stat like a PT INR, the lab can't do it promptly because it's queued up behind all the routine "baseline" PT INRs you and your colleagues ordered. There are specific guidelines for pre-operative lab work. Look them up and use them. Don't forget, some tests have a shelf life. Electrolytes done on admission don't mean much 2 days later in a patient who has been vomitting or hasn't peed.

11. Your responsibility for the patient doesn't end when you book the patient. Many patients need ongoing monitoring and rescuscitation in the few hours before they are booked and when they get to the OR. Don't tell me after the blood pressure crashes on induction "Oh he might be a little dry". That should have been taken care of before he got to the OR.

12. Yes we do get paid by the hour. Years ago somebody decided that was the best way to pay anaesthesia. It turns out they anticipated laparoscopic surgery. The downside of this is of course of income is limited by how many hours of work you and the hospital will provide us. Essentially we work when you want to work. That's the cross we have to bear. We do not however slow down cases to increase our income or to fill up an underbooked day. I must say, I am bemused and occasionally disgusted by how much time some of my colleagues take to get a case underway, but I actually have life and when I see the chance to finish early, I go for it.

13. No matter what your overhead really is (and it is much less than you always say it is), you make several times more money than the nurses. Please don't whine about how overpaid or lazy they are. Also please don't flaunt your lifestyle in front of the nurses or me. I know you work hard and have a lot of training. So do I. Also if you drive a Porsche, why the hell are you aways late in the morning?

14. I'm all for new technology but nights and weekends aren't the best time to try out the new orthopaedic hardware. Instead of franticly calling the rep and yelling at the nurses, do things the way it has been safely and effectively done for years or postpone the case. Also watching the rep walk you thru a case doesn't engender a lot of confidence in your abilities or judgement.

15. When I am on call, I have to miss things. Please don't use family or personal business to try and get your case done at a time of your chosing. Call up one of your colleagues and get him to do the case for you. I realise some of you are on call more often than me (some of you are also on call less).

16. When you "outsource" your easy cases to the private surgical suite or the community hospital please don't come and boast about how efficient it it there (especially when you show up at 0745 to start your 0730) case. It takes a lot longer to set up a radical neck than it does to set up a myringotomy. Secondly don't be surprised if we are a little surly when you bring your complications back to our hospital. Thirdly it is really good that you help mop the floors in your private suite. Why don't you ask the cleaning staff here if they want some help.

17. Before whining "it's on my card" make sure it actually is on your card. Also if a piece of equipment is so important why don't you, during the changeover that you complain about, make sure it is actually on the tray. We have nurses and techs who are supposed to provide equipment for us like laryngoscopes but we still actually check before the case that we have one that works.

Wow I didn't realize I had some much spleen (the metaphorical kind, not the organ that is bleeding under your retractor) to vent. I really like you guys and I know not all of you do any or all of the above transgressions. It's the 90% of you that give the other 10% a bad name.

See you tommorow (at or before 0730).

Bleeding Heart.

1 comment:

Sid Schwab said...

Pointed as they may be, your points are (mostly) well-taken. My idea of punctuality was to finish the first case by the designated start time (I could do it with hernias!) since I always was there half an hour ahead. I tried like hell to avoid the operation where a one-in-a-million chance is better than no chance. I rounded (and wrote notes) at least twice a day; more in the sickos. Can't do much about having to work after call, before it, and even when not on it. And, like scheduling my office in such a way as to (nearly always) run on time, I felt highly obliged to be realistic in my operative time estimates. I've always bemoaned the fact that orthopedic hours seem to have 120 minutes in them...