Monday, June 08, 2009

I see Jimi in the mirror!

A sticky wicket has been picked up.

A thorny problem has popped up out of the weeds.

Pandora's box has been breached.

A sh*tstorm will fly.

Got the idea? Then you know how I felt when I read a recent study in the May edition of the Journal of the American College of Surgeons. Entitled Trauma Surgeon Mortality Rates Correlate with Surgeon Time at Institution, this is a retrospective review of outcomes in trauma patients with a comparison of seasoned versus less experienced trauma surgeons. This is a very provocative paper, and comes from the University of Miami Miller School of Medicine in Miami. In essence, the authors took a close look at their own data to see if trauma surgeon experience played a role in how major trauma victims fared in their institution. From the abstract:

Using our prospectively collected database, we compared our results with mean mortality for high-volume American College of Surgeon–certified trauma centers reporting to the National Trauma Data Bank. Mortality rates for our 11 trauma surgeons were correlated with years of experience as faculty surgeons at our institution during a 2-year period.
That's a pretty honest look in the mirror. What did they see? Overall, their trauma center mortality rates were excellent, and were significantly better than the mean rates of the National Trauma Data Bank for patients with all levels of injury. However, despite such good numbers,
...there was a significant correlation between years of experience as a surgeon at our institution and improved outcomes for patients with an Injury Severity Score ≥ 35 (weighted linear regression, p < style="font-weight: bold;">It took, on average, 7.9 years of experience at our trauma center to reach benchmark mortality rates.
Wait a minute. That means.....yes! Experience makes a difference! Us old guys do have something to offer after all. Of course, common sense would tell us this any way, but it is nice to be "validated" every once in a while.

Oh. Wait a minute. This means......experience makes a difference. In other words, despite the best instruction in residencies and fellowships, it takes a while before even the most well trained trauma surgeon has enough accumulated knowledge and experience to reach the level of his more seasoned colleagues. And that means, well, I'm not so sure --- but I'm pretty sure that some folks would demand to only be cared for by the most experienced trauma surgeons.

One of my favorite expressions comes courtesy of my program director:
Good judgment comes from bad experience.
Bad experience comes from bad judgment.
I know that today, after 15 years in practice, that I have better judgment and better experience than I did after 1 or 2 years in practice. That has come from a whole bunch of nights on call, time spent with patients, time spent with colleagues, time spent reading......and just a whole lot of time period. The same can be said for any occupation, it's just that physicians are held under the microscope a bit more closely than most.

I suspect that if this type of study were applied across all aspects of medical care, similar results would be found. Surgery just tends to lend itself to more spectacular problems when there are errors in judgment compared to, say, dermatology. But there simply are not ever going to be enough fully experienced surgeons on call at every institution in the country every single night. I think we have to expect that there will be an ongoing learning curve for new surgeons, but we need to encourage newly minted surgeons to put themselves into positions that allow close interaction with older colleagues who can provide much needed help as well as mentoring.

However, with the average age of practicing general surgeons in this country being ~ 56, I'm not sure the mentors will stick around to pass along the wisdom they have gathered if plans for major upheavals in health care in this country actually come to pass. And that would be a huge loss in institutional experience.

We'll see.