During one of our first patient rounds for surgical residents at the University of Cincinnati, our department chairman said to us, with emphasis, “ A surgeon is an internist (internal medicine specialist) who does surgery.” He was true to his word. We were asked to do our own white cell counts, hemoglobin and hematocrit counts. We were expected to interpret our own laboratory chemistry findings. We looked at our own xrays and interpreted them according to our clinical knowledge of that patient. We did our own EKG’s and learned to interpret them. We did our own arteriograms and biopsies. We did our own preoperative assessments to determine if that particular patient was ready to go to surgery, or needed further preoperative study. We took care of our own patient’s needs postoperatively in every way. We did not ask a hospitalist, an intensivist or any other variously called specialist to provide that care for us. Every need of that patient was our responsibility. Those patients knew that too. They knew if that they had a problem, we were going to do whatever it took to meet that problem for them. It was a very personal relationship every surgeon had with each patient. We were taught that there was nothing more important in our lives than taking care of that patient’s needs.
And all of that is now gone. I do not know of any surgical residency anymore which does not rely heavily on other medical disciplines to provide care for their patients. Whether they are being taught urology or orthopedics or otolaryngology, or any other surgical discipline, all of them are taught to be masterful in their surgical procedures – but not to take care of all the patient’s needs. Surgeons now send all their patients to a primary care physician or internist for “surgical clearance.” If there is any kidney problem postoperatively, a nephrologist is called. If there is any heart problem, a cardiologist is called. If there is a diabetic problem, an endocrinologist is called. If there is some form of neurologic deficit, a neurologist is called. If there is a mental problem, a psychiatrist is called. Patients find themselves seeing a stream of physicians coming in their room every day, each of them concerned about only a narrow part of their whole being. Each of them charges significantly for their services. If that patient gets into severe trouble, he or she is sent to the ICU, where an intensivist does most of their care. Why has the cost of medical care in hospitals skyrocketed? It is not just all new expensive tests; it is the structure of health care in our health care system at this time. We have turned surgeons into mechanics, who are very good at what they do, but unable to cope with any other patient problems. Each specialty has become insular, unable to provide whole care for anyone.
It would be a mistake to say that all of this is bad. Patients are getting the advantage of specialty care for all of their problems. They are getting the very best knowledge and training for all their problems. The appropriateness of all their care has become excellent. It becomes problematic, however, to determine just how much we are willing to pay for all that excellent care. The problem is that each of these specialists who are seeing every patient, orders their own set of tests and investigations. Our patients are getting poked and prodded incessantly, running all over the hospital for various diagnostic studies and procedures, and finding themselves surrounded by a sea of beeping, alarming, pumping, dripping, poking things, while an army of people run in and out of the door. It is impossible to rest or contemplate. Our hospitals are not exactly torture chambers, but in some respects there are significant similarities. There is all this sleep deprivation and physical invasion that occurs during that hospitalization, and then there is that monetary punishment that occurs after that hospitalization is done. It is a great double whammy.
I don’t think we are going back to surgical care as it was in 1965. I am pretty sure that what we see now is going to continue. Surgeons will gradually become more and more glorified mechanics. Family physicians and Internists will no longer make hospital rounds. All hospital care will be provided by insular specialists, hospitalists and intensivists. There will be no other physicians who go to the hospital anymore. We have almost made hospital care a factory line, in which every patient is treated as a certain diagnostic complex and run through the appropriate testing and treatment for that particular set of diagnoses. It is simply a business. It is no longer personal care. If we allow this trend to continue, medical care becomes rote and unfeeling. I do not like that at all.
I think two things have to change, to make hospital care become again personal and patient oriented. One is that we must emphasize primary care. There must be one physician who knows that patient personally, considers him or herself responsible for all diseases that this particular patient has, is responsible for all decisions as to what testing is done for that patient, and decides to which specialist that patient needs to be referred, a person who immediately assumes total responsibility for their health care as soon as that patient is out of the hospital again. There has to be that one person who is “my doctor,” who is always there to take care of me. As far as hospital care is concerned, I believe that every patient should have a clearly appointed “captain of the ship.” There should be one hospital physician for that patient who is responsible for overseeing all care for that patient, whose decision can overrule anyone else’s, who can decide if this or that test is needed, and who can correlate those tests and those treatments between specialists, a one person in the hospital who is “my doctor.” We are not going back to medical care in the past. We need to accept with gratitude all the new things we can do for our patients. But if we do not do these two things to make medical care personal again, we are not doing our job.
How would each of us like to be treated, if we were the one laying in that hospital bed, sick and in pain? I am begging for personal care to come back into medicine again. I am begging for surgeons to once again become doctors first, and surgeons second. I am begging for the patient to always come first. These are people who are completely depending on us, for their health and their lives. They deserve the best that we can give.