Summer 2015

Outgoing President Dr. Terry Hicks Encourages New Surgeons to Meet Challenges of Modern Medicine

Dr. Terry Hicks

Dr. Terry Hicks delivers his Presidential Address, “The Colorectal Surgeon in 2015: The Missing Pieces.”

By Dr. Terry Hicks

With a bow to the past in his Presidential Address and a focus on the external influences impacting the modern colorectal surgeon, Dr. Terry Hicks challenged his younger colleagues to find solutions to three key issues that are shaping medical training and practice in the 21st century.

Using the analogy of a jigsaw puzzle to represent modern practice, Dr. Hicks explained that three pieces of the puzzle are currently missing: changes in the way residents are educated, the state of medical malpractice, and the lack of physician autonomy. Each of these puzzle pieces represents an obstacle that has the potential to affect patient care, job satisfaction, and teaching effectiveness, so each needs to be addressed to complete the puzzle.

Postgraduate training has changed significantly since Dr. Hicks did his residency at the Louisville General Teaching Hospital. In those days, he said, expectations were “crystal clear.” Residents could be dismissed from a program for laziness, were responsible for studying and learning on their own, and were held to an exacting standard for patient care. Trainees who met these expectations learned from experienced surgeons who brought them along gradually during a 5-year maturation process – from a great deal of supervision during the intern year to increasing surgical independence as trainees progressed in the program.

That training model can no longer be followed, Dr. Hicks explained, because of “restrictive requirements on supervision of surgical residents, duty hour restrictions, reduced volume of surgery, and increased reliance on post-residency training.” Not all of the external factors that have brought about these changes are negative; they range from government regulations to important advances in medical care. But the result, Dr. Hicks said, is the realization that “we could no longer teach surgery as we had done in the past when repetition was the key to gaining surgical skills, almost like going through a difficult football practice. As educators, we realized that we had to transition into the new world where residents are taught with computers, simulators, and robots.”

To illustrate the current “medical malpractice crisis,” the second missing puzzle piece, Dr. Hicks cited the bankruptcy of the nation’s largest malpractice insurer, the fact that many OB/GYNs no longer deliver babies, the threatened closure of a trauma center in Las Vegas, and the astronomical costs of coverage. “The effect that fear of malpractice liability has on clinical decision-making is significant,” Dr. Hicks said, and leads doctors “to practice what is known as defensive medicine.” This, in turn, leads to “unnecessary testing, referrals, increased cost, and decreased access,” but the current medical liability climate is “not linked to quality and safety improvements,” Dr. Hicks pointed out. The majority of cases have no merit, and the real financial winners are the attorneys and experts. The process is “purely ex post facto financial resolution” that represents “one of the great challenges for medicine,” Dr. Hicks asserted.

As with the other challenges facing the modern colorectal surgeon, a number of disparate factors have contributed to the third missing piece of the puzzle: diminishing physician autonomy and job satisfaction. Health care reform has brought increased costs to operating a practice, time-consuming regulatory burdens such as the transition to ICD-10, and the paperwork associated with preauthorization required for insurance reimbursements. Another challenge is the transition from fee-for-service to value-based care, a process that is proving to be a difficult one because “value” is not easy to define, Dr. Hicks pointed out. Consequently, “defining the value of service is a moving target.” Effects from the malpractice crises – particularly related to a physician’s ability to exercise independent medical judgment without nonclinical personnel interference – are also related to the deterioration in physician autonomy. Even the Maintenance of Certification process is “cumbersome and time consuming, and the expense adds to surgeons’ frustrations,” Dr. Hicks said.

Despite the many challenges facing modern medicine, Dr. Hicks expressed confidence in the next generation of surgeons’ ability to resolve these issues and “to provide the highest quality of care to our patients and to evolve as teachers, researchers, and surgeons.” He encouraged his colleagues to keep the change process in perspective and used a note from a 5th grade student named Ian – a note that has been in his desk drawer for almost 25 years – to illustrate the point. The note from that student thanking Dr. Hicks for a presentation to his class affirmed, “Your job is probably the best job in the world.”

“So despite all the frustrations we face practicing surgery in 2015,” Dr. Hicks told his audience in closing, “never forget that Ian had it right: You have the best job in the world.”

 
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