Dr. Luis Quinonez's Weblog

During my two years as a fellow in Cardiovascular Surgery at the Mayo Clinic I have learned inumerable operative skills, advanced clinical decision-making, and advanced clinical judgement. However, this is only half the story. I have also learned about professionalism and have witnessed a culture of service towards patients that is not rivaled by anything else I have experienced before in a Canadian setting.

A culture of service is reflected in the mission statement of the institution. But it goes beyond this. The founders of the Clinic set the tone for it's future: "The needs of the patient come first" or "The interest of the patient is the only interest to be considered". However, it goes even further that words. What struck me most about the Clinic is that these words are paractised on a daily basis by all levels of employees of the clinic. Everyone is pleasant; everyone is helpful. I felt that there was truly a "culture" of service. It has a feel to it; it is in the corridors of the hospital and in the walls of the clinics. Patients tell you about it, as they express their pleasant surprise about how "different" things are here.

To be fair, much of this stems from the profit-based medical practise in the USA. A culture of service is a useful business model to attract and retain patients. It works in the hospitality industry and applies well to medicine-for-profit. However, I think that this should not detract form the benefits it provides the patient and their families. I believe that we should try to emmulate this "culture of service" in our Canadian health care system, despite our resource limitations.

Resource limitation is a reality in Canadian medical practise. It leads to healthcare worker fatigue and burnout. This is perhaps one explanation for the lack of culture of service, which I have witnessed. However, there are attitudes and behaviours that are not resource dependent. We can all be more polite and less rude to our patients and to each other. Pages and phone calls can be answered more promptly. Phrases such as “how may I help you” or “can I do something for you” should be said more often. Regardless of who we are, we can answer questions or find someone who can. Pain should be treated more expeditiously (there is no shortage of morphine). Call lights should not go unanswered. And it all comes from the top, down. If a consultant is the one who first goes to help a family member waiting at the nursing station, quickly others will follow.

Our attitude should change from one of “this is not my problem” to “how can we help this patient”. Nurses should say less “I am not looking after that patient” and more “let me find someone who can help you”. Doctors should say less “this is not a problem in my specialty” and hang-up the phone. They should say more “I think this is not a problem in my field, but have you considered…Maybe you should consult…What about trying...”. Our frame of mind should not be one of relief when a patient does not have to be admitted to our service, but one of concern that the patient have a proper diagnosis and get the appropriate care.

We have also shifted our minds into cost savings rather than patient care. I believe this has had the largest negative impact on the potential development of a culture of service in the Canadian healthcare. There are glaring situations that typify this attitude. For example, there is the request for radiological investigations at night, when resistance is encountered and questions as to whether or not the patient truly needs the investigation. The underlying attitude here is the protection of a microbudget, rather than the best interest of the patient. What is worse is that the determination of need is being made by someone over the phone who has not even assessed the patient. Another example is the guarding of intensive care unit beds. Whether or not a patient gets admitted to an intensive care unit should be criterion-based and not on arbitrary judgments that are influenced by bed availability. Again, the interests of the patient should be the only interest considered and the system must adjust accordingly. In essence, a culture of service should take into account that the patient takes priority over the existing budget.

By no means am I suggesting that resources should be over-extended. Judgments about the true need for an investigation or an admission to an ICU bed should be made at the consultant level given the limited resources that exist. These decisions should not be left to residents, nurses, or administrators. And if a consultant is going to withhold a resource that has been requested by another consultant, it is a reasonable expectation that they see the patient and the reason for the denial be documented by them in the clinical record.

How does one reconcile a culture of service with the limited resources of the Canadian health care system? American-style for-profit health care is not the answer. It can be done within the existing structure by accepting the FACT that resources ARE limited. We, as consultants, can change our attitudes and behaviours to reflect our belief that the needs of the patient and their families do come first. Others will follow. If the quality of the care you deliver is in direct relationship to the amount of government funding, you should not be a doctor. Furthermore, the “triage” of resources is too important to be left to anyone less than a consultant. As consultants, we should be at the patient’s bedside making the critical determinations about their care. Patients and their families should see and know that we are in charge of their wellbeing. It is here that the culture of service begins.

Posted by Luis Quinonez at 11:31 PM | Permalink

Whenever I tell someone that I am doing a fellowship in cardiac surgery at the Mayo Clinic the first thing they ask is what is my area of subspecialization. It is difficult to answer this because at Mayo there is no such fellowship. The training is in advanced adult cardiac surgery, which means that you participate in all aspects of cardiac surgery. This includes, for example, valve repair, aortic and aortic root surgery, atrial fibrillation surgery, adult congenital surgery, transplantation and assist devices, heart failure surgery, and so on; Not to mention the high volume of re-operative cases and the surgical treatment of unusual conditions such as HOCM, constrictive pericarditis, Ebstein's anomalies, carcinoid heart disease, chronic pulmonary emboli, and others. This is in addition to the usual CABGs, valve replacements, endocarditis, dissections, etc...Yet this amazing experience is not enough for some surgeons and even some cardiologists, who are wowed by new techniques and impressed by those that call themselves minimally invasive surgeons or off-pump surgeons or whatever.

After two years at the Mayo, I will not say that I am an aortic surgeon or a transplant surgeon or an arrhythmia surgeon or anything else. However, I would have seen enough of many kinds of cases to perform some of them competently. For example, I will be able to participate in a transplant program, but I would not venture into starting one; I would be comfortable tackling cut-and-sew mazes after some time in practice, but I would not call myself an arrhythmia surgeon; I would feel comfortable dealing with a primum atrial septal defect in an adult, but I am not a congenital surgeon. And if I choose to focus my practice in an area, I have the skills to do this. For example, I have performed some mitral valve repairs during my residency and as a fellow I have performed all the components of a P2 resection. But, more importantly, as a trained surgeon, I have seen all sorts of complex mitral valve repairs and, in time, I will tackle these cases. Yet I would not say that I did a fellowship in mitral valve repair.

I am not trying to be arrogant or cavalier. I am an average cardiac surgeon and I am aware of my limits (one also needs to be cautious and conservative during the first years of practice). I just want to explain, in part, the comprehensive training one gets at a place like Mayo. For those who have never experienced this, they will not understand how, and will have difficulty accepting that, this is possible. Nevertheless, many surgeons who have done these sorts of fellowships are the 'go-to' surgeons at institutions because they are willing to take on difficult and complex cases. They can draw upon a significant experience obtained during their fellowships and translate it to a variety of situations. Yet this type of training does not seem to be valued by some and is not what others think to be an acceptable and marketable fellowship.

What is sexy today is a fellowship in robotics, heart failure, minimally invasive, arrhythmia, or aortic stents, to name some. The assumption here is that basic skills have been obtained during residency and no further refinement is necessary or desired. The only skills that are valued are new and innovative ones, whatever the flavour of the day. Proponents of these fellowships will argue that by performing these 'advanced' techniques one can translate what is learned towards what is 'basic'. In addition, there is, in fact, exposure to other kinds of cases during these fellowships, making them not so narrow. Both are very valid arguments.

I believe that both types of training are valuable components for the development of an academically-minded division of cardiac surgery. And, importantly, a division head must have a clear vision in his/her mind of where he/she wants to take the division in order to develop a rational recruitment strategy. However, I believe that one cannot build a division with subspecialists only. In fact, a smaller division may need to concentrate only on the excellent delivery of basic general cardiac surgical care before even considering branching out into subspecialization. Subspecialization must rest on the shoulders of excellent 'basic' care.

By arguing the above, I am not trying to be self-serving. It is no secret that I am also looking for a position as a cardiac surgeon in Canada. What disturbs me is the impression given to me by some that a fellowship without subspecialization is less valuable or important. Subspecialization is nice, but solid excellent basic care is more important. The reality is that many, if not most surgeons, will not get to use their subspecialty skills. I know of surgeons who have done fellowships in transplant, pediatrics, robotics and do not have the opportunity to use these skills.

The reality of Canadian practise is that not every institution can be a transplant, robotic or pediatric centre, etc. It is an issue of patient volume and resources. Even some academic institutions must accept this reality. We should not view this as a limitation. Our reaction should be to change our focus to those things that we can do well and with excellent results, and then build upon that.

Posted by Luis Quinonez at 03:48 AM | Permalink