On the treatment of the young: Part 2 of 2

If a trainee is fortunate enough to find a consultant's position, usually they will be ill-equipped to deal with the difficulties and hazards of starting a practice. Very little is taught in this regard during training. If you are fortunate enough to work in a group, salaried practice, most details may looked after for you. The reality is that most will go into some sort of "private", fee-for-service setting.

In many circumstances there is little systematic help provided by other consultant colleagues, or the institution, to help a new consultant set up a practice. Details abound, including how to hire and pay a secretary, setting up a structured office, taxation issues, billing, etc. You may get occasional curb-side advice, but there is very little investment in helping you set it all up.

Another situation that demonstrates the poor treatment of new consultants is the inequitable distribution of call. The "new guy" often gets more call days or more weekend call or more holiday call. What is the justification for this? If a group has taken on someone just to be another set of hands to lessen the workload, then the priorities of that group should be reviewed. I believe that call should be distributed equitably and fairly among all the consultants in a practice group, regardless of seniority or academic status.

Operating room time and cases should be distributed fairly among all the consultants in a practice group. The "new guy" may get less operating room time without any justification given other than they are more junior in the group. This is the pay-your-dues attitude that is pervasive and, in my opinion, not justified. Colleagues should help the individual fill his/her operating room time by sending them cases. This is providing a helping hand to the one that is starting out.

The distribution of cases is a more problematic discussion. If a surgeon was hired because of special expertise in a certain field, this expertise should be supported by sending appropriate cases. However, more experienced colleagues, especially the division head, should watch out for the less experienced. In cardiac surgery, for example, a reputation and career can be destroyed if someone has a high morbidity and mortality early on in practice. Therefore, "easier" cases can be sent to the new consultant, for them to gain experience. Furthermore, when more difficult cases are encountered, they should be assisted in the decision-making and the execution of these cases. This in no way should undermine their authority as the consultant on the case. Help should be provided as just that, help. They continue to be in charge of the case. The relationship between the senior and junior consultant should be one of mentor-student and not one of supervisor-subordinate. Assistance can be provided to a junior consultant, while giving respect for their earned position and title.

What may happen is that a junior consultant is given only the easy cases. This does not allow for professional growth. The other end of the spectrum is that the junior person is give all the undesirable cases. These may not be necessarily difficult, but may be undesirable for other reasons. Again, this is unfair. A potentially disastrous scenario occurs when the junior person get the most undesirable cases because they a the most difficult and complicated and no one else wants to do them. This is the most insensitive and callous behaviour on the part of senior colleagues.

Income should be distributed fairly. There is no justification that a junior consultant earn less simply because they are "junior". Again, this is a "pay your dues" attitude.

The arrogance and misplaced pride that some senior consultants have and direct towards the young consultant who can only be met with contempt and disdain. Is it a form of insecurity or jealousy on their part as they observe young new talent surpass them?

The young new consultant should be supported. They are an investment in the future of the "company". Help them establish their practice; be egalitarian; protect them from their inexperience; treat them with respect, as they have worked hard to achieve their position.

Professionalism Part 4: The patient encounter

Here are some "do's and dont's" when a patient is seen in an outpatient setting. In-patient encounters should ideally follow the same principles, although the circumstances may dictate the conduct of the interview and the examination.

Do's

Do arrive on time for your appointment.

Do dress professionally (see previous weblog for details).

Do review all the relevant notes and investigations PRIOR to visiting with the patient. Speak to the referring clinician, if possible. This may save invaluable time and may clarify the question to be answered by your consultation, in addition to providing insight into the clinical case. It is professional to appear knowledgeable and informed about the patient's condition. Shuffling through papers and being unaware of results while speaking to the patient and their family does not instill confidence in you as their surgeon.

Do introduce yourself and state your title; do the same for anyone accompanying you.

Do shake the patient's hand and aswell as family member's. This acknowledges everyone's presence.

Do sit down.

Do allow the patient to speak about their problem. You really should already know what their problem is and this is mostly for the patient's benefit. However, this may give the surgeon a sense of the severity of the symptoms, which is important in your clinical decision-making.

Do examine the patient. The laying-on of hands is expected from a doctor. Again, this is mostly for the patient's benefit, although it may actually be useful in certain clinical situations.

Do explain to the patient what the problem is and what can be done about it. (Teach them and be better than the internet.) This "counseling" is the main purpose of the visit and most of the encounter should focus on this (including informed consent). In fact, in cardiothoracic surgery, the surgeon needs to spend little time obtaining new information from the patient (other than to get his/her own sense of disease severity). If the physician has done his/her job, all the relevant clinical, laboratory, radiological, and pathological information are already elucidated and available.

Do draw a picture.

Do show the films to the patient, if possible and practical.

Do use understandable language for the patient and their family (a platitude).

Do answer all their questions. This is a simple statement, yet it is perhaps the most important aspect of the whole patient encounter.

Do obtain true informed consent.

Do allow the patient to end the visit when they are satisfied that all has been explained and all questions have been answered.

Do have a clear plan that they understand and a concrete next step for them to take.

Do shake their hand as you leave.

Do say you are available to meet again and answer any other questions, if required or desired.

Do dictate a note immediately after the visit.


Dont's

Don't arrive late. If so, say "I am sorry to keep you waiting". Explain that you had an emergency to attend to. No one can argue with this.

Don't stand.

Don't review the clinical record while interviewing the patient, except to specifically check a point of discrepancy that surfaces during the encounter. You should be familiar with the case PRIOR to visiting with the patient.

Don't answer the phone or pages during the visit, unless they are emergencies.

Don't do any billings, bookings, or any other paperwork during the patient visit, especially while the patient is asking questions. The patient should perceive that you are focused on them during the entire encounter, without being distracted or preoccupied by anything else.

Don't get up to leave until the patient signals that they are satisfied and ready to leave. If you have already gotten up and some other question comes up, close the door, take your hand off the door knob, face the patient and answer the question.

Don't gloss over informed consent. I have seen surgeons gloss over and rush through the informed consent process. This is a recipe for disaster.

Don't rush, even if you are in a hurry.

Don't put your hands over or on the back of your head.

Don't take any abuse from the patient or their family. If this happens it is your perrogative to end the interview and dismiss them. Your only responsibility is to ensure they have adequate follow-up elsewhere (usually back to the referring or primary MD).

Don't call patients by their first name.

Don't allow them to call you by your first name.


A few final thoughts:

Excess of time is not a requirement to achieve the things stated above. I have seen all of the do's and don'ts accomplished in 20 to 30 minutes and I have seen them violated in one entire hour. Also, "niceness" is not a priori. In fact, all I have stated is more about respect, politeness, and professionalism than about being "nice" and overly friendly with the patient. Again, I have seen the "nicest" surgeons perform some of the worst mistakes during patient interviews. Patients and their families will respect you for your knowledge, skill, expertise, and professionalism. This will gleaned from your interaction with them when you meet for the first time.