Morbidity and Mortality Rounds

What follows are my views on the organization and conduct of morbidity and mortality rounds.

The principal reason to conduct M&M rounds is: To review an individual patient's poor outcome in detail with all members of the treating team and in this way try to determine what led to the poor outcome and discuss ways to prevent a similar event from happening again.

In cardiothoracic surgery, the outcomes to be discussed are principally mortality. To discuss all morbidities is not practical. It would be ideal to discuss major morbidities, although in a referral centre with a high volume of complex and ill patients, this may also be impractical. The surgeons may agree on a certain list of morbidities that they wish to present on a consistent basis. For example, deep mediastinal wound infections, ARDS, anastomotic leaks, or "massive" blood transfusion, etc. Discussing only mortalities allows for a more detailed discussion of fewer patients, rather than a superficial discussions on many patients.

It is important that M&M rounds concentrate on individual patients in significant detail. The presentation describes the unique events and circumstances that led to that patient's death. Subsequent discussion is around what could have been done differently, identifying things that could be changed or improved. Things that can be "changed and improved" may be about an individual or a system. Instituting solutions to problems identified may be complex and difficult so they can seldomly be completely addressed in an M&M forum. If the problems are significant enough, the division chair should take definitive steps to make effective changes at a later time.

As stated, M&M rounds should be about individual patients. Collection, presentation and discussion of data on groups of patients and their outcomes are to be addressed on a different occasion and in separate forum. This type of outcomes meeting does not replace or substitute for the M&M round, but in fact, should complement it.

Another very important component of the M&M conference is the attendance. Attendance of all surgeons in the division is essential. The division chair should lead by example is this regard. I believe that as many other physicians and surgeons should be involved. This includes medical students, residents and fellows, whose attendance should be mandatory. The forum should be open to any MD in the community interested in the patient or the discussion. This adds transparency. At a minimum, all the MDs involved in the patient's care should attend: surgeon, requesting consultant, primary care doctor, anesthetist, intensivist and any other consultants that were involved in the patient's care. The larger group and varied backgrounds should lead to a diversity of opinions and perspectives which, in theory, yields a more fruitful discussion.

In order to intelligently discuss the poor outcome of a patient, one must know as best as possible why the patient died. For this, an autopsy is essential and should always be requested in the event of a patient death. This also means that a pathologist with experience it thoracic diseases and autopsies is an integral part of the presentation and discussion at the M&M conference.

It may be argued that by having an open forum the discussion may be inhibited because of embarrassment or competing/conflicting political interests. In an open forum, people would be less likely to give honest opinions. Therefore, it may be argued that these conferences should be held "behind closed doors". I believe that a policy of openness and transparency is better and in the long run helps the credibility of a division. Furthermore, if a division is composed of competent and skillful surgeons, there should be no concern when discussing bad outcomes. They occur even in the best of hands. The point is what is to be done to try and prevent it from happening again.

The M&M conference should be held once per month in a large auditorium with audiovisual capabilities. Two hours should be allotted. One week before, a summary of the each case should be made available to all the consultants involved with the patient. This allows them to think about and review the case. The case is presented by the consultant surgeon and discussion takes place between the consultants only. Residents and fellows do not participate despite their attendance. This is a 'business' round and not a teaching round, although there can be much learned by everyone.

Finally, I would like to mention a similar type of conference that discusses "near misses". It is similar in spirit as the M&M round, yet the structure and conduct are different. Dr. Chaim Locker reminded me of the importance of this sort of discussion within a division. He used an airforce analogy when he told me that, although it is important to discuss the catastrophes, it is sometimes more useful to discuss the near-catastrophes.

The "near misses" conference can be held once per week and should involve only surgeons of the division aswell as residents and fellows. All should participate in the discussion. The meeting should be a no-holds-barred critique of cases. The discussions will tend emphasize aspects of the surgical care of the patient so participation by others is not critical.

To conclude, our actions as surgeons should be transparent when it comes to a poor patient outcome. This is the first step towards the critical assessment of what could have been done differently; and this will lead to changes that may prevent a death under similar circumstances. If we are competent and skillful, and then honest about our outcomes, our colleagues and patients will judge us fairly. We will also have their respect.

On the treatment of the young: Part 1 of 2

I have watched with despair the little-to-no help some cardiothoracic surgical trainees are given when they approach the end of their training and it is time to look for help and guidance to obtain a fellowship and/or employment. Similarly, I have seen the way junior consultants are treated appallingly poorly by more senior consultants and institutions when starting out in practise. It reflects poorly on some in positions of influence in the cardiothoracic surgical community. To use a favorite theme of mine, these behaviours are highly unprofessional. I will discuss these two situations in separate postings.

I believe that it is the responsibility of the staff at teaching institutions to help residents approaching their final years of training to find a consultant's position or an appropriate fellowship. This happens to a lesser or greater degree, sometimes with zeal, but more commonly not at all.

The first step in the process is guidance and counseling. First and foremost, teachers and mentors must be honest about what they believe should be the best path for the resident to choose. Not all residents are researchers or exceptional technicians. They should be counseled accordingly. If there is agreement on the path chosen, teachers should take an active role to help the resident get there. This should not be done informally or inconsistently. It should be part of the commitment taken when training a resident.

For example, if it is agreed by all that, based on abilities and goals, the best thing for the resident is to go into a non-academic, community practice, the resident should not be left alone to seek out a job. Everyone at the training institution should help in the process. Surgeons know what is going on in the job market. Positions opening are not much advertised. This information should be used for the benefit of the resident. In addition, scheduled and regular meetings should be held with the resident, along with the program director or a mentor, to discuss and act upon issues such as lettres of application, CV writing, reference lettres, interviews, advice on salary negotiations, requesting priviledges, licensure, etc. Formal discussions should take place at divisional meetings about the progress of the 'job hunt' and document this in the minutes. All these efforts should be taken well in advance of the end of training and not be an eleventh hour scramble.

The same effort and use of resources should be applied to search for the best fellowship, if that is the path to be chosen.

Sometimes a resident wishes to go into practise right after training, but his mentors may feel he/she should pursue more advanced fellowship training, because of good inherent potential. In the end, the final decision will be made by the trainee. However this should not negate the support given, as described previously. The opposite situation is more problematic. This occurs when a resident wishes to pursue further advanced training, yet his/her mentors feel that the trainee is not the best candidate for this. In fact, this path may not be in the best interest of the resident and the profession as a whole. And even occasionally, it may be felt that the resident would benefit from additional training at their own institution. This is a pedagogical quandary I cannot solve in these pages. All I must insist upon is that the teachers be honest about their impressions as early as possible during the resident's training.

A variant of the circumstances described above occurs when a division is interested in recruiting one of it's residents. The division head should have a formal discussion with the resident. The conversations should detail the direction of the division and how the trainee, as a consultant, can be a part of this vision. It should also detail what the division would want from the resident, specifically related to further clinical and/or research training. If there is agreement in principle, efforts should begin, with the resident, to arrange for fellowship training, as described above. In addition, there should be financial support for the endeavour, and furthermore, lettres of intent exchanged.

I have never seen the degree of support I describe above given to any resident, but I have seen it come close. This has been in the context of getting a fellowship and returning to work at that institution. However, this has been the exception. It strikes me as odd the degree of apathy teachers can have towards their pupils' future, when they have invested so much time and effort in there training.

The overwhelming and unfortunate reality I have seen is that residents receive very little help or guidance to find a job or a fellowship, other than the occasional phone-call. Many go away to do fellowship training with vague and non-committal statements of interest and very little promise of anything at the end of it all. There is a cloak and dagger attitude to recruitment: 'Go away and do your fellowship; keep in touch and we'll see', while backroom and hallway discussions take place. Eventually, last minute offers begin to surface. I find all this very disturbing. It is in no way supportive of new young surgeons and it is certainly no way to treat a future colleague.

One has to invest in the future and this means supporting the young. This includes helping them take the final steps towards a productive professional life. We should strive for them to be better than we are. Their achievements should reflect the investment and care that was taken to train and educate them. In the end, their success is our own.

I would like to acknowledge Drs. André Duranceau and David Sackett, for planting the seeds that led to many of the ideas I discuss above.

Professionalism Part 2: Consultations

As part of an ongoing discussion on professional behaviours, I would like to submit my views on what I consider professionalism when asking for, receiving and doing consultations. Not all consultations are the same. They may be formal or informal; urgent or routine; hospital or outpatient. I would like to address the various circumstances in which consultations may occur in cardiothoracic surgery and how I believe they should ideally be handled.

Before delving into consultation "etiquette", there are some basic principles: There is no such thing as a stupid question; when someone asks for help, be helpful; whenever possible, take the opportunity to teach; be polite.

I believe that it is more difficult to ask for a consult than it is to answer one. To ask for a consult one must formulate a clear question; one must be humble and have enough insight to know and accept that others may be more expert than you on a subject; one must be willing to take advice; and, very importantly, one must know when to apply and when to reject the advice given. All of this may be very difficult to do, especially in a life or death situation.

When asking a consultant to see your patient in hospital, it is best to do a formal request. This should be in writing and, ideally, should be communicated directly to the consultant by you. This allows the opportunity to discuss the important issues about the case and communicate precisely what is the question to be answered and in what time-frame. Additional tests may be requested in advance to make the consultation more efficient. If the consultation is informal, one should never write the consultants opinion in the medical record, or the fact that the case was discussed with the consultant, because you have not given them the opportunity to review the case in it's entirety. If their opinion is relevant enough to the case, a formal consult should be requested. After the consultation has been done, call to thank the consultant and to ask any relevant questions. It is very important to realize that you are not obligated to follow a consultants recommendation, but you must be very clear as to why.

Requesting a consultation on an outpatient is not too dissimilar in principle, however, much of the verbal communication may not be necessary, unless there are specific concerns that are best addressed with a phone call. When requesting an outpatient or office consultation, a formal lettre of request should be sufficient. This should be a dictated note and all the relevant information and investigations should be made available to the consultant, to avoid wasting the patient's and consultant's time.

When answering a consult, it should be done in a timely fashion. Urgent consults should be answered ungently, regardless of the time of day. Routine consults of inpatients should be answered within 24 hours, even when no final opinion can be given at that time. Routine outpatient consults vary in time-frame. I believe that patients with cancer should be assessed as soon a possible. Similarly, patients who are very symptomatic must be seen promptly. The timing may depend on the resources available, but necessary adjustments should be made in scheduling to accommodate these cases.

When giving recommendations on an in-patient, write them down in the progress notes only, or write them down as suggestions in the order sheets. Dictate a note. Communicate directly with the requesting consultant to discuss them. Allow them to execute your recommendations. Respect the fact that it is their patient and they should know what is best in the overall picture of their care. Be assured that if you demonstrate competence in your knowledge and skills, it is only exceptionally when others will not follow your suggestions.

Consultations on outpatients may come with some implicit or explicit requests. You may be asked to simply give an opinion or you may be asked to go ahead and take over the patient's care if the need for surgery is evident. One must be sensitive to this difference and if there is any doubt, communicate directly with the requesting doctor. Dictate a note within 24 hours of seeing the patient and send it to their primary and consulting doctors. If they need to know something sooner, call. For the most part, routine outpatient consultations can be handled without directly speaking with the requesting M.D., but the threshold to pick up the phone should be low. Document this communication. It is also very important to make it clear, verbally or in writing, what will be your level of involvement in the patient's care. Remember, you are a specialist and not a primary care provider.

In general, one should never refuse a consult and one should never view a consultation as trivial or stupid. Whether formally or informally, someone is asking a question because they may need support for an opinion already held; they may need help with a complex problem; they really do not know what to do; or for reasons you may not really understand. When answering the consult, give your honest opinion as an expert. However, take the time to reassure if they are doing the right things; acknowledge the complexities and difficulties being faced; and take the opportunity to teach if this is appropriate.

If you do not know what to do or are unable to provide what is needed for the patient, it is your obligation to let the requesting doctors know. It is also your responsibility to seek out, or help them seek out, someone who will be able to help the patient with their particular problem.

And finally, the most important thing to be is polite.

Choosing the "right" fellowship for Canadian cardiac surgery

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.

Is the best interest of the patient the only interest to be considered?

"The best interest of the patient is the only interest to be considered."

"The needs of the patient come first."

Dr. William Mayo

One of the things that I admire most about the Mayo Clinic is it's commitment to the interests and needs of the patient. The spirit of the aphorisms of Dr. Will is one of the founding principles of the Clinic and it is reflected in their mission statement. And it is not just "talk". I see concrete examples of it every day from the people working here; and in the way the institution functions; and in the way the institution is organized. This attitude of the patient-first seems to permeate the walls of this place. It is inculcated from your arrival here at the Clinic, while making direct reference to the Mayo brothers and drawing upon it's rich, yet short, history. For me this is one of the pleasures of doing a fellowship here.

However, my question is: Can this be truly applied to the health care system in Canada?

As Canadians, we have the misfortune of geographical juxtaposition to the United States. This has become our point of reference for patient care. Immediacy of access and treatment is common in the US for those that have insurance or those who can afford it. I think that these expectations are unrealistic for us in Canada. We should remember that up to a third of population in the US does not have access to the quality of medical care we do. Dr. Will's statements may need to be have the caveat "if you can pay".

The Canadian health care system is publicly administered. It is universal, so all Canadians benefit from it and should have access to it anywhere in Canada. The system aspires to be comprehensive in it's services. All these goals are laudable and I believe, like many Canadians, that our system should be supported and maintained without the corrosion of privitization. However, this comes with a price. Resources are limited and priorities may need to be set to ensure the sustainability of our system.

The ideals of the Mayo brothers may not be entirely compatible with the Canadian public health care system. Although we believe that the patient's needs and interests are of paramount importance, we also must consider the needs and interests of society in order to keep our system alive. For surgeons this is not self-evident. We are taught that the interests of our patient come first, which is a direct link to the Hippocratic tradition. There is very little formal education or training which addresses the realities of limited resources in our daily practice. Limited resources may place in direct conflict the interests of society with those of the patient.

Take, for example, the limited number of beds available in surgical intensive care units and the limited amount of operating room time to perform cardiac procedures. As a result, in order to provide cardiac surgical services to all it's citizens, patients may need to be on waiting lists. I believe this is an acceptable compromise. As surgeons, we should not become frustrated with this situation. In fact, we should understand that we are able to provide care to all our patients, even if they have to wait for some time to receive it. Patients also need to be made aware of this reality. In addition, they must be reassured by knowing that urgent or emergent care will provided without waiting.

New technologies, and even established ones, may not be immediately available to surgeons and their patients. In many cases, their is no access at all. One must consider that many of these new technologies are costly and sometimes of questionable value to the patient. That is to say, there is lack of evidence to support their widespread use. Without being nihilistic, it is important to recognize that newer does not mean better, and a public health care system must consider the cost vs. overall benefit to the population when making these technologies available. Surgeons need to participate in the decisions of application and implementation, rather that just criticizing the government for their inablitity or unwillingness to provide access.

A good example of the problem of new technologies are the methods now being used to the surgical treatment of atrial fibrillation. At least one department in Canada would like to purchase a machine and start performing this kind of surgery. I would like to point out that the evidence for the benefit of this technology is not very good, when it is compared to the standard cut-and-sew technique. Also, much of the hype about atrial fibrillation surgery with these machines is industry driven. Finally, I would humbly suggest that rather that investing in a new machine, send a surgeon to learn the cut-and-sew technique, which is probably better anyway. It is certainly cheaper.

It may be argued that by accepting waiting lists and the lack of access to newer technologies (and a myriad of other things), we are just bowing our heads and becoming complacent and complicit to the problems in our health care system. I disagree. By doing so, we accept that public health care has a price and balance must be found between the needs of the patient and those of society. To contribute within these confines, we all must find ways to become more efficient and less wasteful and we must pause before trying to introduce innovation. We also need to educate the public on the challenges we face and reassure them that they are being cared for well.

The purpose of this discussion is not to propose a solution to this problem. I only want to bring to the forefront the fact that it exists and acknowledge the difficulties it creates when treating patients. By ignoring it we bring about frustration in our own professional lives. Furthermore, by not educating the public about this, patient's expectations are becoming unrealistic. I certainly do not have educated or comprehensive knowledge about the structure and function of the Canadian health care system. My point of view arises from my own frustrations and my own experience in dealing with the system that I so much value and want to preserve.

Professionalism Part 1: Dress

This entry will be one of many addressing issues of professionalism in the practice of cardiothoracic surgery. It is difficult for me to define professionalism, however, I am able to recognize it. Therefore, I will attempt to describe behaviours that I believe reflect it. Choosing a particular appearance in the way we dress is one of these behaviours.

I have come to believe that the manner in which we dress is very important. Although, initially during my training I was less impressed by this. I felt competence could overcome sartorial transgressions. Of course, competence is more important that appearance; nevertheless the latter re-inforces the former and thus both are complimentary.

During the clinical encounter, competence is initially assumed by the patient. This is the benefit that our title affords and is granted by social contract. The initial impression we give by how we are dressed either re-inforces this assumtion or underminds it. Subsequent and consistent 'professional' appearance further re-inforces our competence and instills confidence and trust, which is comforting to our patients.

There is an expression in spanish: 'Como te ven, te tratan'; literally translated: 'How you are seen, you are treated'. What it means is that your apprearance dictates the way in which other people perceive you and thus treat you. In this way, dressing professionally leads to respect. Patients, I believe, want and respect a surgeon whose outward appearance reflects his/her knowledge and experitise.

I think that a lesson can be taken from the bussines world on this subject. In that sphere, professional dress or business attire may be tied to productivity and success. Would you trust a banker wearing jeans and a t-shirt. What would you think about his/her competence as a finacial consultant? Would the CEO of a large company be respected as much if he worked in slacks and a golf shirt? These may be obvious examples. But why would this not apply to surgeons?

One may argue that this point of view is elitist. Dressing professionally means dressing well. This does involve spending a significant amount of money, especially if you are a resident or fellow. This well-dressed appearance usually correlates with socio-economic status, and in this way may be viewed as elitist. If the surgeon uses his appearance as an extension of his status for others to see, this may also be viewed as vain. In the context of eliticism and vanity, some may interpret the surgeon-patient relationship as paternalistic. This is all very true. However, it is what we say and do that will determine whether the way we dress is merely a reflection of an internally inflated ego, or another way to communicate to our patients that we take their care seriously enough to look professional.

In my opinion, dressing well and professionally equals (for a male) a suit or jacket and tie. It also means being clean shaven (especially post-call). As surgeons we have the advantage that we can wear scrubs with a lab-coat and still look professional. However, this should be minimized. Going to a clinic in scrubs is sometimes necessary, but not ideal.

All of what has been mentioned applies also to surgeons-in-training.

As a final thought, I note that the male dominated history of CVT surgery has a long tradition of suits, ties and other formal dress-amenities. This symbolized their status in society; they were respected and admired. Some still percieve surgeons in this way. I believe we should exploit this for the benefit of our profession and, more importantly, for our patients.

The Issue of Salary

Salary vs. fee-for-service. There can be much debate as to why one vs. the other. I have seen the debate get quite passionate, usually by those suspiscious of institutions and those that believe in free enterprise.

Prior to completing my residency in Cardiac Surgery, I took some time off and was in private practice in General Thoracic Surgery (St. Joseph's Hospital, Hamilton, Ontario, Canada) for 9 months. My views on the subject are quite coloured by this experience. What I am seeing at the Mayo also influences my opinions on the subject.

I believe that a fee-for-service system has a negative influence on the practice of surgery. The pressures of volume based remuneration lead surgeons to see more patients and do more procedures. In this model of practice, the patient is the one who suffers. Less time is spent with patients and families, whether on rounds or in the office, due to the time pressures inherent in such a system. I believe that part of the reason our profession has been devalued in the eyes of the public is that we do not spend enough time with our patients. When I was in practice, the cynicism of some made me cringe. I would book one hour for all new consultations for lung cancer. Some of my colleagues could not believe that I would spend so much time. They told me not to worry, that I would get faster! To me, this was not an issue of speed!!!

I am not suggesting that procedures are performed unnecessarily or hastily. This would be unethical. However, I do believe that procedural indications and performance are modified in such a way as to benefit the surgeon's purse. Two examples: During a CABG the intra-op TEE reveals a small PFO. Closure of the PFO is not unsafe for the patient and is easy to do. One can argue you are already there so why not? There is a theoretical benefit. However, PFO is a normal finding in an otherwise healthy part of the adult population, so you could leave it alone. If you were paid extra for the closure, what would you do if you were not placing the patient in any danger.

The second example is a drainage of an empyema as an add-on case. There is a premium for cases starting after 6 pm in Ontario. Your case is ready to go at 5:30 pm. Do you and your anesthetist drag your feet to start at 6 pm. It does not place the patient in any danger and it is easily done. I have lived this situation, and I can tell you that when you are starting out in practice and there are bills to pay....This is reality in a fee-for-service system.

There are numerous examples that can be given: some I have experienced first-hand; others I have seen and others I have been told (sometimes as words of friendly advice to a junior staff from those who know the system better). This goes on to a greater or lesser degree on a daily basis.

The other issue is that of dignity. I have seen so many surgeons 'nickel and diming'. They would chase after every cent they believed the system owed them for their sevices. I found this to be a pathetic spectacle. However, the system was set up to reward them if they did this. I have nothing but contempt for this behaviour and for the system that allows and encourages it to occur.

What about a salary-based system? I believe that surgeons would spend more time with their patients and families. It would encourage the performance of procedures for purely medical reasons, without the corrupting effect of volume-based remuneration. However, I think this system must come with a commitment from the surgeon to provide the best possible care, whatever the circumstances.

The danger of this system is the apathy that can develop when income is assured. For example, delays in surgery because there is no pressure to perform operations, which increases waiting lists. Surgeons need to provide a good service to society, and therefore must increase their volume of work as the need arises, even if their income is the same. Another potential issue is the performance of operations during "off-hours". There is no incentive to do this with a salary. Surgery needs to be done when it is needed by the patient, and not at the convenience of the surgeon.

In a salary-based system, the surgeon must rely more on his/her desire to treat patients well. The intrinsic value of excellence in patient care is paramount. Take the example of some cardiac surgeons at Mayo Clinic. What drives them to do the number of complex and difficult cases the do? However many, and however difficult, the patients they see, they will be paid the same. I believe that they is internally driven by the need for excellence.

I awknowledge that this system is not perfect. However, I am convinced that it is the most beneficial to our patients. In the long-term, it will select out young doctors that will become surgeons who's drive is less about money and more about excellence in patient care.

Friendship in the Trenches

The bonds of friendship during surgical training may be compared to those forged during military training or perhaps even armed conflict. My time at Mayo has had it's challenges. There have been high and low points. But I have had the priviledge of sharing this experience with two other fellows. As a trio, we have been frustrated and elated; we have been close to tears and murderous rages; we have laughed with our bellies held as only comrades can do; we have been kind and encouraging, while sharing our doubts and insights; and we have understood the other's joy and pain, as just yesterday they were our own.

I want to thank Drs. Calvin Wan and Chaim LekerLocker, friends and comrades-in-arms (or scalpels). Without their presence, Rochester would have not been the same.