August 2012 issue of Plastic and Reconstructive Surgery Journal had an editorial by Drs. Rorich and Sullivan. In it they discuss changes in medicine. They start by asking a simple question,
when someone comes to see a plastic surgeon, are they paying for the
service the doctor provides,
for the experience and knowledge of the surgeon,
or both?
They divide tasks into 2 categories: physical and intellectual. Physical examples are things like mowing the lawn and digging a ditch. Physical activities do not require intellectual effort after they have been performed a few times. Intellectual activities require little physical effort: things like teaching and writing.
So what is surgery? It is physical: we cut, move, and sew. And it is intellectual: where do we cut? how much do we cut? how do we move it? which surgery is best? how are things different for this patient? Age, skin tone, patient desires, and other issues come into play.
As the authors state, “Changes in medical care over the past two decades have transformed the balance of the equation. Not long ago, patients initially came to their physicians in general (and surgeons in particular) because physicians had knowledge and clinical experience. Physicians had the intellectual acumen to make a correct diagnosis, and patients relied on and paid for such knowledge. Based on that knowledge, the physicians were then able to provide appropriate treatment—a service—as guided by knowledge. Although there was a balance between knowledge and service, the patient-physician relationship initially relied on the physician’s knowledge and on subsequent skill based on that knowledge.
Trends in modern medicine have begun not only to alter the equation but are showing signs of actually reversing the equation. Today, the procedure involved, the service rendered, and the knowledge that lies behind the skill have been regarded as if one does not need knowledge to have skill! Yet they are intimately related if the patient is to have a good outcome in the hands of a competent surgeon. Often, the professional knowledge is not only separate but is also not rewarded in any way. Frankly, this trend is not correct, as all physicians should be rewarded for achieving excellent outcomes as the end result of the successful combination of their experience and skills.”
I know few people will read this blog, but I thought it was insightful. With everyone calling themselves “plastic surgeons” despite training in other areas like internal medicine, dermatology, ob gyne, and others, how do patients choose? Take liposuction as an example. Many doctors do liposuction. But do they do it equally well? Do they know how much to take (and when not to take out fat, particularly if skin tone is an issue)? Do they counsel well (for example, if they cannot do a tummy tuck, will they liposuction a patient who really needed a tummy tuck)? Do they recognize when a complication is occuring?
We true plastic surgeons train as surgeons. I trained in the days before caps were placed on how long you worked. I spent the decade of my 20s in a hospital. If you have read “Outliers” by Malcolm Gladwell, you will hear of 10,000 hours. You reach a level of insight and excellence at 10,000 hours. For patients, I think the takeaway is to not focus just on the procedure and cost, but focus on the training and experience of the surgeon as well.