With this issue of Alberta Doctors Digest, we are pleased to introduce a new series: Foundation Stones of Medicine
When walking across the floor of a building, we may not be aware of the foundation stones that keep it in place. Similarly, patients travelling across the health care system are usually unaware of the intricate structure of specialty care that lies beneath what they see on their individual journeys.
Over the next year, we will feature articles highlighting some foundational specialties. We think the perspectives of these colleagues will be illuminating for the public and perhaps even for members of the profession.
For September/October, we introduce: General Surgery.
General Surgery
Mention the term “general surgery” to most patients and they’ll have little idea what it means. Ask anyone who works in a hospital setting and they’ll know exactly how essential general surgeons are in the day-to-day work of caring for patients.
“General surgery is essential to the backbone of hospital care and the mother of all surgical specialties,” notes Dr. Anthony Gomes, a general surgeon based in Lethbridge and the president of the AMA’s Section of General Surgery.
So what does a general surgeon do? Simply put, almost everything. As Dr. Gomes explains, general surgeons handle most surgical situations that come through a hospital. “We look after all the big trauma that crosses all the different specialties. If you've been stabbed or you have a bleed into your brain from trauma, the general surgeon will fix it. The leaders of the trauma teams in many Alberta hospitals are general surgeons. We do a lot of things that save people's lives in extreme circumstances.”
General surgeons also handle most cancer surgeries including thyroid cancers, breast cancers, intestinal cancers and melanomas and will triage patients and help make a diagnosis. “Half of the colonoscopies done in Alberta are done by general surgeons,” notes Dr. Gomes. “So if you're screening for colon cancer, there's a good chance you're going to see a general surgeon or a colorectal surgeon, who is a specially trained general surgeon, for your colonoscopy.” In addition, general surgeons do a range of other intestinal work including gallbladder and hernia surgeries.
What’s in a name?
The breadth and depth of the work done by general surgeons has led many to wonder if they shouldn’t consider a name change. Dr. Gomes says, “We've actually had a debate among colleagues across Canada about whether there could be a better name for general surgery. We do so many things that we can't really come up with one that's descriptive enough. When you see shows on TV, they don't say ‘get the general surgeon.’ They say ‘get the trauma surgeon’ or ‘get the emergency surgeon’ or ‘get the vascular surgeon,’ but the fact of the matter is that general surgeons get pulled into doing all of that stuff. It’s just when you say trauma surgeon, it sounds so much better.”
Increasing intensity
Like many physicians working within our health care system, general surgeons are facing challenges that make it harder to do the work they are trained to do. Dr. Gomes says, “It’s a very broad field, and it's also very high intensity. A lot of sick patients in the emergency room end up being general surgery patients. We always have sick patients pre- or post-op in the intensive care units.” With the growing pressures on emergency rooms, driven in part by a primary care crisis that has resulted in upwards of 650,000 Albertans living without a family doctor, that intensity has increased.
“Not surprisingly, we feel over worked and under appreciated. By the nature of our work, we’re expected to be able to deal with all those emergency things – we cover call at night while doing all the things a general surgeon would do during the day.” A lack of health human resources is one of the biggest challenges currently facing the specialty.
Dr. Gomes explains that the team is essential to general surgeons, who need a resident or a clinical assistant to be able to provide support in the operating room and coverage in other areas of the hospital when the surgeon is operating. “When a general surgeon is by themselves in a particular hospital, it’s simply not safe. It’s a huge frustration when you're a surgeon and you have a problem you know you can fix, but you don't have the support staff with you to be able to safely take that patient to the operating room.”
Improving understanding and changing how things are done
Dr. Gomes stresses that it’s important to improve the understanding of general surgery as an underpinning specialty in a hospital that has to be protected and resourced. “There are some things you could run a hospital without. In fact, lots of hospitals don't have neurosurgery. In a large city, only one hospital may have a cardiac surgeon or only one hospital has a vascular surgeon. But if you don't have general internal medicine and obstetrics and gynecology, it's not a hospital. Without general surgery, it’s like having an army without an infantry. You're not going to get anything done. You need boots on the ground, and general surgery is boots in the hospital.”
In order to keep our hospitals operating, we need to find ways to retain existing general surgeons and attract new physicians to the specialty, something Dr. Gomes points out will require making general surgery less demanding and more diverse. He knows the demands of general surgery make it a tough sell for many medical learners. “People know general surgery is hard. You’re up all night and you’re running around. And when you're alone on call, the next day you’re completely done and cannot function.”
Dr. Gomes notes that he and his colleagues have recently made changes in Lethbridge, managing to attract enough new surgeons that they are able to offer a better work-life balance. “I've worked most of my career with three to four general surgeons, so every third night you’re on call, and when someone goes away, you’re on call every second night. But this summer, we’re up to nine surgeons, and we’re finding ways to manage our practices together so we can go home after the night on call. Having a team around the general surgeon to provide that care and to provide continuity for patients is key. The team goes on. The surgeons change, but you are still providing excellent seamless care for patients while giving surgeons a better quality of life.”
Dr. Gomes stresses that it is also important that those on-call services are recognized financially. “We negotiated a stipend back in 2013 that allowed us to say here’s a specific site and we're going to park a general surgeon in our hospital for 14 hours a day. They're not going to leave. When you call us from the emergency room, we will come right down. When you need an emergency scope done, we'll come right over and do it. It streamlined care throughout the hospital. And it's improved care because that one surgeon in the hospital looks after all the patients that were admitted or convergently.”
He notes that a payment model like this creates stability that makes it easier to recruit and retain surgeons. “It’s allowed us to hire more people and cover calls more consistently. We never need locums in Lethbridge … it's a win-win for everybody.”
As he looks to the future, Dr. Gomes emphasizes the importance of developing compensation models for qualified people to make the specialty as attractive as possible. The work, which is both interesting and rewarding, will do the rest. “You can meet a patient who is really sick, and you can help them be better in a few days, sometimes even in just a few hours. That’s one of the things that I think brings people into general surgery – you make a huge difference.”