Ch. 2: WHO KNOWS ENOUGH TO CHOOSE AMONG THE OPTIONS?
How knowledgeable is the Primary Care Physician (PCP) who refers his patients to surgical specialists? Physicians trained before 1985 have minimal familiarity with contemporary techniques. Some observed some surgery in medical school or a rotating internship. Now, younger physicians have had almost no exposure to surgery after medical school. Even the knowledge of anatomy has been sacrificed to the rapid expansion in pharmacology, biochemistry and bacteriology. Time constraints in training are unavoidable but still have ramifications. How can primary care physicians understand the options, risks, benefits, advantages and disadvantages or expectations postoperatively? During education most non-surgeons witness only a few hernia repairs and do not see the newer laparoscopic type. How can one expect them to have more than a minimal understanding about anatomy, techniques of repair or the response surgery?
PCPs might select the surgeon for his patient with minimal knowledge of the surgeon’s skills or philosophy. Certainly most referring physicians have never seen that surgeon operate. The selection may simply be on the basis of a corporate Group affiliation. On the other hand a PCP may have a long relationship with a surgeon and detailed knowledge of the surgeons record of performance, which he will share with his patient. When exploring the possibility of surgery, a patient with a hernia should therefore benefit from the information in this book when querying his PCP.
Ask your PCP questions. What is your PCP’s experience with the surgeon? Do patients return with prolonged disability or frequent recurrences? What do patients report back after the surgical experience? Will one of those patients share the experience, first hand, with you? Does the HMO Plan dictate the referral being made to the best available surgeon or a surgeon? Are you getting all the choices reasonably available to you? You may be willing to pay out of pocket for a surgeon that you desire and you may have thought about having this choice when you purchased a slightly more expensive Health Insurance Plan. Get what you paid for.
If you decide to have surgery, you need to have enough information to make good decisions. Knowing what to expect will provide security and minimize anxiety. Ideally, your surgeon should satisfy himself that you have this understanding but frequently other people are delegated to be the educators.
The Surgical Resident is frequently the person that asks you to sign the consent form and writes postoperative instructions and orders. The younger Surgical residents are Doctors who are specializing in surgery or fields related to surgery and they are generally confused by inguinal anatomy and the various techniques. They have only a basic proficiency in describing techniques and expectations. They have not experienced the details of preoperative and postoperative care in this era of ambulatory surgery because hospital house staff infrequently sees the patient before or after the day of surgery. The resident rarely hears about the progression of pain, diet, bowel function, mobility, return to activity or work and may not be able to describe expectations and the detailed steps that will minimize discomfort and accelerate recovery. In Municipal Hospitals a patient may choose to have surgery by a surgical resident. The procedure will be performed under the supervision of an experienced surgeon, but the resident will manage the perioperative care, yet his experience managing that course is minimal.