Wednesday, May 20, 2009

After finishing the book...

The Final BLOG Question: After completing this book, do you think changes should be made in the way surgeons are trained? How important is it for surgeons to “practice” on real patients? Would you want to be operated on by the Intern, the Attending or the Chief Resident? Why? Why not? What challenges are faced by surgeons today?

23 comments:

  1. I think that there is a reason why this method has been adopted by hospitals. It seems to be one that works. Surgeons are humans and humans make mistakes, but they also must take risks in order to improve the health of a patient. I don't think there is any other way to gain real experience other than actually performing surgeries on real people. Also, I feel that the people in charge are good at what they do and can decide well which newbies should be doing which surgeries. I would be fine with an intern doing a surgery on me, because I feel that the head resident would have them properly supervised. I think people have to realize that whenever they have any kind of surgery they are taking a risk. No person is infallible; no surgeon will ever have a mistake free career. These are the inherent risks of human surgeons. There is no around this.

    ReplyDelete
  2. It is a good system! I think having interns do actual surgeries themselves is unavoidable, because how else are they to receive effective training? Instruction in the abstract is no good for training real-life surgeons doing real-life surgeries. And interns are never assigned the most exotic and critical surgeries; they work their way up from routine procedures. And their supervision usually protects from egregious mistakes. So it is a system that I feel comfortable with.

    ReplyDelete
  3. I definitely agree with the two people above me. Unless we performed all surgeries mechanically, it would be impossible to eliminate errors. Humans are obviously not perfect, but they are capable of performing surgery capably and efficiently most of the time. I think it's important for interns to gain experience by actually operating on patients, as long as they are adequately supervised so as not to put the patient at risk. If we do not train our doctors of the future properly today for fear of their mistakes, they will never evolve to become better surgeons. Personally, I would probably rather be operated on by the Chief Resident, but as long as I wasn't aware that an intern was operating on me, I wouldn't know the difference..I'd be nervous if I heard an intern were "practicing" on me because I'm a wuss, but in theory, I think it's so important for young surgeons to be able to put their theoretical knowledge into practical use early on in their careers.

    ReplyDelete
  4. I think it's very important for surgeons to get experience working with real patients in order to perfect their skills. As long as they are under supervision, there should be no risk for the patient, and the intern learns through practicing. I wouldn't mind an intern operating on me as long as he or she was supervised for safety. It would be good practice for the intern to learn what he or she is good at and what needs to be improved. One problem facing surgeons today is that they are not perfect and do make mistakes. Sometimes their patients' deaths are inevitable, and the surgeons can't do anything to prevent it. People need to accept the fact that the surgeons are human and will mess up once in a while.

    ReplyDelete
  5. I think that you can't replace 'practice' on real patients, but I'm not saying that the new surgeons should just be thrown in without aid. It's so important to have them at least doing something with careful supervision so that they really learn something. It's one thing to study diagrams and dissect cadavers in med school, but when the EKG is beeping and the person is still breathing, it's so different. You're cutting open a person who's still alive and can actually crash. Surgeons should, naturally, start out easy and build their way up- but you can't skimp on practice- that's what makes a good surgeon. I suppose it wouldn't matter to me, as long as the person is a capable surgeon- I don't want someone who's completely unsupervised and never done a real surgery before. I suppose I would be nervous going into a surgery with a complete newbie, but it really can't be helped- every surgeon started out new, and they had to have their first surgery on someone! Just as long as they're supervised by someone capable, I suppose I would be okay- as long as it's a fairly minor surgery. I don't know if I would want a complicated transplant or heart surgery done by a completely new surgeon.

    ReplyDelete
  6. I think the system seems to work pretty well because as a result of it many good surgeons are trained. However, using the word "practice" in this way is kind of weird because it makes it seem like it doesn't count or that it's not the real thing. I don't think that should be the attitude of a surgeon because each person, even if it is the intern's first operation, is still a real person, and what happens counts--it's not like practicing on a corpse where the person is already dead. I do think it's really important for interns to do surgeries though because they will have to do a first surgery at some point, and it's better to do it sooner rather than later because it leaves more time to gain experience. But as easy as that is to say in theory, I wouldn't want an intern doing their first operation on me. Actually...I would be fine with it as long as the results were ok, but I wouldn't want to know that it was an intern until after the surgery, because after reading about the interns' first surgeries in this book, it would just make me nervous. Some challenges faced by surgeons could be when they know a patient is going to die: should they tell them? Their family? Or in a situation like the man who was in a coma and developed pneumonia, should the doctor give antibiotics if they know the person won't leave the coma? Dr. Nolen wrote about these examples but they probably apply today as well.

    ReplyDelete
  7. This comment has been removed by the author.

    ReplyDelete
  8. Like some many of the people who responded before me, I do not think that it is necessary to change the system. While it may sounds weird to be "practicing" something on a human being, in actually, a surgeon is just gaining experience. I think that interns should have the opportunity to perform surgeries as long as they are accompanied and assisted by some one with more training (such as an Attending or Chief resident). Surely, the residents gained their experience by practicing on patients during their intern years. Dr. Nolen is a good example of a surgeon who started out shaky but became knowledgable and confident. If I needed surgery, I would be fine having an intern perform the surgery as long as they were assisted by a Chief resident so that if something were to go wrong, the Intern could be helped.

    ReplyDelete
  9. I forgot to answer the challenges question. From the chapters at the end of the book, I learned that one challenge that surgeons face is how to tell a patient that they are going to die. I think that Dr. Nolen's system of telling certain patients but not others is interesting. I can see how some patients may take the bad news better than others, however, I think that the patient deserves to know the truth. Another challenge is the decision-making process. If a surgeon is unsure about to do with a patient, it is difficult to decide on which procedure should be done, or whether anything should be done at all. In this case, I feel that collaboration is critical so that one person is not making the decision on their own.

    ReplyDelete
  10. It is extremely important for surgeons to practice on actual patients, because as Dr. Nolen describes it is through this direct, hands-on, real-life experience that the surgeon transforms from a student to a professional. This type of practice not only improves the surgeon’s technical skills, but more importantly it develops his/her confidence and sense of judgment, which are more “mental” strengths. Personally, I would want to be operated on by the attending doctor because s/he has had the most experience, having already completed their residency. Alternately, according to Dr. Nolen the chief resident makes all of the decisions as long as all the patients are taken care of well, so I may not mind being operated by him/her. Today, surgeons continue to face the challenges of inevitable or unavoidable misjudgment and mistakes. Surgeons are humans, and no one is perfect 100% of the time, no matter how experienced or knowledgeable s/he is. The difficulty is that these errors affect patients’ health and lives, and in some unfortunate instances even cost patients their lives or leave them with permanent disabilities. Another challenge that surgeons, particularly those that also do research, may face is in the way they “focus” their studies or procedures. In academic research, a lot of professors feel compelled to pursue research that is “popular” and receive a lot of funding rather than what they are truly interested in (unless it happens to be what is popular). Similarly, surgeons may face similar challenges in balancing their personal interests and motivations (and conscience..?) with what is funded well or prestigious.

    ReplyDelete
  11. I don't think that there should be changes to the way surgeons are trained. It is neccessary for surgeons to be able to practice on real patients because otherwise, the surgeons will never get the experience they really need to be able to operate without their textbooks. Although it may seeem unnerving to let an intern do operations, I feel like it is alright as long as he or she is supervised. Hypocritically though, I would prefer to have the Chief Resident operating on me only because the Chief Resident would naturally be more experienced and have a higher success rate. Some challenges faced by surgeons include the pressures of being responsible for the deaths of patients. Like the death of Maria Chavez in the book, many people are counting on the doctors to not only save themselves so that they can live longer, but because those people are also responsible for taking care of others like children or parents. The doctors have a large responsibility to be able to do what they believe will work. However, deaths are always going to happen and mistakes are always going to happen. Because humans are humans, the least the doctors can do is try to limit the deaths as much as they can.

    ReplyDelete
  12. I believe that “real” practice for interns is critical to their success, and yet I agree with Manasi in that preparations must first be made. Even though young doctors must have patients to practice on, the patients are still human beings and care must be taken. On a personal level it would be hard to have my doctor still be more or less a student, yet I do understand that that is the way the system works, and I don’t know a better way for it to be structured. Also the system is set up to let the interns succeed. They aren’t supposed to dive in with the hardest surgery first, and their superiors are regulating there actions. And although it is a scary idea to have your life in the hands of a beginner, even though there are still students they are well versed in medicine from years of studying, and the residents are there to help them succeed, anyways, the residents were interns at one point as well.

    ReplyDelete
  13. Regarding the way surgeons are trained, I would only change one thing, which is to allow interns more time on the operating table. I think surgeons, especially at private hospitals, don't give their interns enough time on the operating table to learn how to become great surgeons. Our current system obviously provides 'enough' time for surgeons, but I think a little more training couldn't hurt. This is because the importance of operating on real patients is essential to a surgeons success. As the book says numerous times, things in a text book are always much simpler than in real life. One example in the last couple of chapters was when the surgeon removed the gall bladder and didn't drain it. Thus interns need as much time operating as possible.
    Regarding whom I want operating on me, I think it depends on the surgery. If it was a routine surgery, even if the intern hadn't done it before, I would be okay with them doing it as long as there whoever was scrubbing was a practiced surgeon. But if it was say a triple heart bypass surgery, then I think I would want someone a little more practiced operating on me.
    I think the biggest challenge facing surgeons today is the mass amounts of people that sue. This is hinted to occasionally in the book. Every once-in-a-while, Dr. Nolen would mention wanting to try a new technique, but how worried he was that if it failed, he would get chewed out. He said that if the patient had died from the routine methods, he was much less to blame; but if they died whilst he was trying a new routine, he would be in trouble. This would cause surgeons not to try new things that could save a patients life. They might be more preoccupied with not getting sued than treating the patient as best they could.

    ReplyDelete
  14. I think the current system is probably the best way to train surgeons. The only way to gain sufficient amounts of experience and proper judgment is by being thrown in headfirst. The only way an intern or a soon-to-be-surgeon can be prepared for the future is by practicing in real situations with real consequences and complications, but with the support network of more experienced surgeons. As a patient, I would probably want one of the attending residents to operate on me. The attending residents are better-trained than the interns, and they would also probably be less stressed than the chief resident. They also have checks on one another and therefore can usually be counted on to come up with the right decision by discussing amongst themselves. Surgeons have to learn to balance logic with compassion. They must make difficult decisions every day and learn to deal with the consequences. With the continuing progress of medicine, they must also stay up-to-date on new research that may help their patients while remaining cautious about implementing new methods. They must always strive to make the best decisions for their patients

    ReplyDelete
  15. I agree with most people in that the current way surgeons are trained is the best we can do right now. Maybe technology will elimante the need for human surgeons but that will not happen any time soon. The interns need to get god hands on experiance and the only way they can do that is by preforming surgery. There is no way around it. Personally i would want a more experianced surgeon preforming surgery on me. Although i did just say interns do need experiance i would rather not have their first surgeries be preformed on me. Surgeons still face many problems today. Surgeons still face death all the time and it is not easy to deal with.

    ReplyDelete
  16. I feel that until technology has made some rather remarkable advancements into the fields of virtual technologies and synthetic organic tissues, the training of surgeons in the manner described in MOAS is a necessary inconvenience. While I would personally rather have a more experienced surgeon performing complicated procedures on my body I would at the same time understand that in less serious or more common surgical processes it is valuable to let a less experienced surgeon gain experience by having a go at it. One day we might be able to give a studying surgeon the opportunity to operate on a fake human that could develop the same problems a real case might, but, although technology is definitely more advanced now than in MOAS, we have still not rid ourselves of the need for real practice on live human cases. Like others have said, it is of course wise to have an Attending or Chief Resident there to supervise, and to take over if complications arise or if the task is a very dangerous or unusual one, but in general I feel that allowing the less experienced surgeons to hone their skills is a good way to continue making sure there are people to perform these valuable tasks. That said, I would still be a little scared if an intern was operating on me, so I might prefer that they not tell me exactly what was going on. This way I dont have to be hypocritical of the ideals I just discussed, but can also maintain a trust in the surgeons who are taking care of me.
    Aside from the obvious challenges of having an extremely difficult, strenuous and unforgiving profession, I think surgeons today still suffer from similar problems to those at Bellevue. These being especially a desire to do good work without the necessary personnel or supplies to carry out every procedure the way it should be done. It is sadly the nature of our current health care system that those doctors and surgeons who wish to help patients truly in desperate need will end up with little funding and second rate facilities because those they are helping are most likely poor and without health care. Working with what the state provides, the modern surgeon must work hard to be resourceful and efficient if they are to be successful in making a difference.

    ReplyDelete
  17. I think it’s very important for surgeons to be able to practice on real patients. How else are they going to learn how to operate on “real” humans? Of course it is critical that these surgeons have the proper training before hand and that there is proper supervision. I’m such a baby, so I would personally want a chief resident to be operating on me (I know… totally hypocritical). But I feel that almost everyone would feel the same way. Everybody wants to know that they are being taken care of in the best way possible and that the surgeon operating on them is the best at his job and has had plenty of practice. It’s hard to imagine having someone operating on you as “practice.” As long as I didn’t know that whoever was operation on me was new at the job, and that this operation would be considered practice, I think I would be fine.
    One of the challenges facing today’s surgeons is being surrounded by death. I know I wouldn’t be able to deal with it. Knowing that someone died in your care seems like such a big burden to carry on your conscious. I know that it isn’t the doctor’s fault when a patient dies, and that in operating that is always some degree of risk, but I don’t think I could personally bear the ordeal of knowing that I was involved in somebody’s death. On top of that, there is the burden of telling the families. Surgeons are extremely brave people. They must focus on all the good they have done and all the lives they have saved, rather than the deaths they have seen.

    ReplyDelete
  18. I definitely think that the way surgeons are currently trained is fine. It seems to work and produce great surgeons with lots of experience. I believe that it is very important that surgeons practice on real patients, however I also feel that it is very risky for the patient. As much as I want the practicing surgeons to have that experience I also do not want to put anyone at risk. An ideal situation, I guess, would be for the students to practice on some fake, very close to identical human…Yes, this sounds ridiculous, but if it could be made with precise detail it would benefit everyone. Surgeons, not only today but in the past and, I’m sure, in the future, will have to deal with the likely possibility of making mistakes. Patients will have to be aware of this possibility and take precaution. As of right now it doesn’t seem like anything can be done to the surgical process to make it as safe as it needs to be, but then again, will we ever be satisfied with what we are capable of?

    ReplyDelete
  19. I do not believe that there needs to be major changes in the way surgeons are trained. There is only so much someone can learn in classes without applying what they have learned in an actual situation. Since we have no way right now to synthesize an entire human body, there is no way to get any sort of "practice" in a situation that can be applied to a real one. Because of this, real patients must be used to gain this knowledge, since it is absolutely necessary that surgeons gain this knowledge to successfully complete their jobs. I really would not care what sort of surgeon operated on me, and I would not worry about them making mistakes. If they did happen to make a mistake on me, I would just accept it, even if it did happen to result in my death (in which case I would no longer be able to actually have a conscious feeling about it). I guess I do not really value my life that highly, and feel that whatever they did to me would ultimately be beneficial, perhaps not for me, but definitely for someone. I really have no idea what sort of problems surgeons face today, although I imagine that they are rather similar to those experienced by Dr. Nolen in his time at Bellevue.

    ReplyDelete
  20. The system hardly needs to be changed, really. Intern surgeons gain valuable experience, and it is only after rigorous training that they ever get to 'practice' on people. It is interesting, though, watching the technology for fully roboticized surgery develop, where the capacity for human error is reduced to a practical zero. Especially interesting is technology, currently in development, that would allow the surgery-bot to be operated by a human, but with parameters set, so that for example during any form of head surgery, the machine would be incapable of cutting outside of a given area, preventing the subtle twitches of a human hand from causing injury.

    ReplyDelete
  21. I am quite conflicted with this question. On one hand I think personal practice on a real human is a great way to learn how to do surgery. On the other hand, I personally would not want an intern to perform surgery on me. I know how important surgical operations are, and how large the risks are. I'm sure many people are comfortable getting surgery from a not so knowledgeable doctor. They are the ones who can get that kind of surgery, but count me out. Even though I would not volunteer myself, I think that firsthand learning would drastically increase an intern's skill. I also think it is very beneficial to work on a fake human, but many circumstances do not allow this to happen. For the most part real surgical situations are best to learn, but can be very harmful to a patient if anything were to go wrong. As long as there is very careful supervision, intern surgeries are probably safe and should definitely be done. There are still many people like me who would not be comfortable with this, so interns should only operate on willing patients.

    ReplyDelete
  22. I think that there definitely could be improvements to the teaching methods with new surgeons. However, it seems that surgery has come a long way and is now a very efficient procedure that can be done well and quickly. While there are complications in surgeries that is expected we are basically cheating nature by opening each other up and tinkering with our insides, so we cant say that surgeries should be perfect. I do believe that these complications should be limited as much as possible, but then again surgeons need to learn. This is a very complicated question and can have many different and varied answers. I think it is valuable to have first hand experience in the OR because this helps the surgeon build up a calmness and confidence in surgery. obviously, the first hand surgeries helped DOC NOLEN, but nolen also had a lot of mistakes that made situations a lot more complicated. This is a really tough one, but i think the first hand experience is more beneficial than the negatives. Personally, i would not want a newbie or an intern operating on me. I would want someone with experience on my operation and with a high success rate. I would want to know that my surgeon has completed this surgery before with efficiency and skill. Honestly, i think interns should be stuck to simple operation procedures. nothing costly that could seriously endanger the patient, once they assist on enough more complicated ones and move up the ladder then they should get a chance, but not until then.

    ReplyDelete
  23. I agree with Zoe that it is safer with the attending or chief residents standing by while an intern performs an operation. I believe it is ok for the interns to start with minor operations, because the margin for error is greater. As they gain more experience, they can move on to more difficult procedures, with the residents close by to intervene. I believe that surgeon training today is satisfactory, and there is no way to replace hands-on experience. Surgeons are faced with the difficult questions of whether to operate on someone, how to operate on them, and how long to wait. I believe that these hard lessons can only be learned in the OR and not in a classroom.

    ReplyDelete