Sunday, March 02, 2008

The "A's" Have It

Back in the Dark Ages (i.e., when I was in training) it was said that the most important attributes a surgeon could have in order to be successful were:

  1. Availability
  2. Affability
  3. Ability
Specifically, ability was felt to be the least important of the requirements for a referring physician to send a surgeon patients. Sort of sounds backwards, don't it? Well, let's ruminate a little.

AVAILABILITY -- from the adjective available (American Heritage Dictionary):
  1. Present and ready for use; at hand; accessible
  2. Capable of being gotten; obtainable
  3. Qualified and willing to serve or assist
In the surgeon's world of the past, this meant being readily on hand, reachable, and quick to respond when asked to see a patient. "Capable of being gotten" means keeping your beeper on -- and answering it. And, of course, being "qualified and willing to serve or assist" should be the hallmark of a good general surgeon.

AFFABILITY -- from the adjective affable:
  1. Pleasantly easy to approach and to talk to; friendly; cordial; warmly polite
  2. Showing warmth and friendliness; benign; pleasant
Hmm. "Showing warmth and friendliness." "Pleasantly easy to approach." Sort of a non sequitur with the words "Aggravated DocSurg " -- what am I supposed to be, a golden retriever? Well, let's be honest. These are not terms generally applied to most surgeons, but they are critically important. Let's face it, would you rather be operated on by an extremely capable jerk, or a capable and caring one? Most referring physicians certainly choose the latter. Being pleasant to referring physicians, nurses, and referring docs is not only good for everyone involved, it also makes plain old good bidness sense.

ABILITY -- the least important of the "3 A's":
  1. Power or capacity to do or act physically, mentally, legally, morally, financially, etc.
  2. Competence in an activity or occupation because of one's skill, training, or other qualification
  3. Abilities, talents; special skills or aptitudes
"Capacity." "Competence." "Special skills" -- sort of like the kind Napoleon Dynamite wanted. In short, you gotta be able to operate your way out of a paper bag, or you are in the wrong field!

OK. All three of the "3 A's" are important, and are likely to remain so for the foreseeable future. In exactly the same order.

"WHAT!!??? I'm shocked! Why DocSurg," you ask, "with the overwhelming push to measure patient outcomes, evaluate complication data, and compare costs generated by physicians are the "3 A's" likely to stay in the same order?" One would expect that a surgeon's ability -- his skill in caring for patients, his cost-effectiveness, his shorter-than-average length of stay, or whatever yardstick with which one chooses to measure -- would inevitably rise to the top of the list. In fact, one could argue that ability should already be numero uno, and for goodness sakes, why hasn't Ms. Hillary already made it so?

Sit back and let the Aggravated One explain it all to you. The reason that availability is so important to referring physicians is that when they need the assistance of a surgeon --- right away --- the guy that will answer the call ASAP will be the answer to their prayers. A busy internist, family practitioner, or gastroenterologist doesn't have the time or patience to try to track down a surgeon; this is especially true today, when these docs are busting their humps with a huge load of patients in the office just to make a living. Traditionally, being available for emergencies, "curbside consults," or questions was subsequently rewarded with elective surgical business. Think about it this way --- ever had a major leak in your house? The plumber that answers the call and comes quickly to help is the guy you are going to call when you need a new water heater or sinks replaced when your wife decides it's time to redo the bathroom.

Affability? Using our plumber analogy, if the "emergency plumber" turns out to be rude and obnoxious, you're probably going to go back to the Yellow Pages next time.

What about ability? This is the trickiest to explain. I know a little about plumbing, but I'm no plumber. If my favorite plumber does some work at my house, and it looks good, I'm going to trust that he did a pretty good job. And if what he is working on started out as a disaster, and there are a few problems along the way, I'll pretty much feel the same. I could say the same about a cardiologist or a neurosurgeon. That's the way it is for most busy internists and FPs, especially now that few of them come to the hospital any more.

"But! But! But DocSurg, Ms. Hillary and Mr. Obama and Mr. Stark and Mr. Grassley and Mr. McCain and all of the yahoos that run insurance companies promised! They promised you would be graded, evaluated, measured, probed, and rated at each and every turn! Surely, ability will soon be at the top of the heap!"

Er, no. Not really. Because of the fourth "A" --- adaptability:
  1. The ability to change (or be changed) to fit changed circumstances
You see, the successful surgeon of the future --- nay, the successful physician of the future --- must be imminently adaptable. Quick on their feet to make sure that they are fully compliant with every mandate passed by Congress and any other Borg-like regulatory agencies. Nimble enough to dance to the tune of a slew of paper-pushing high school graduates who will churn the numbers of a myriad of physician "quality measurements" (trust me, they are not going to hire a fleet of high priced CPAs, economists, or even math majors to evaluate your physician's care). And ready and willing to keep their own statistics, to ensure that any perceived deviation from local, national or regional arbitrarily determined standards can be demonstrated to be false.

Adaptability will last, for a while, at the top of the list, with "ability" relegated to fourth place. But, I'm sad to say that with a continual loss of market forces, of which only a pittance remain, any emphasis on quality of care will be in name only. We are driving down a road which now has almost no exits left, where I suspect ability, availability and affability will soon be sacrificed to the ultimate "A":

And then we are all, well you get the picture....