675295
research-article2016
HANXXX10.1177/1558944716675295HANDIngraham
Editorial HAND 2017, Vol. 12(4) 325–326 © The Author(s) 2016 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1558944716675295 hand.sagepub.com
Quadrigia and Productivity John Ingraham1
Abstract Financial productivity in academic surgery is important and deserves great emphasis, yet it is but one of many vital elements of a healthy practice. Productivity must be carefully balanced with many other vital goals such as maximizing patient safety, maintaining excellent outcomes, optimizing resident and medical student education, and earning outstanding patient feedback. The following editorial explores this elusive balance and the importance of not swaying too far in the direction of revenue. Keywords: productivity, efficiency, surgeons, quadrigia The perception of productivity in academic surgery implies money-making ability. As so defined, it can be compared with that of the airline industry in which many tasks, such as taxiing with only one engine, choosing altitudes with better tailwinds, and deviating around only the worst of weather, are specifically done to save fuel, and therefore money. Just as pilots are responsible for their passengers’ safety, so surgeons are for their patients. Just as pilots are paid for what they do, so are surgeons. The connection between a pilot and his or her passenger, however, differs from the sacred bond that exists between a surgeon and his or her patient. In this context, productivity must be carefully balanced with many other responsibilities. A surgeon’s efficiency can be thought of in terms of extrinsic factors (eg, quick operating room turnarounds between cases, access to patients, or the use of physician extenders). Extrinsic factors can and should be maximized, much like fuel efficiency, through objective, system-based modifications. Intrinsic factors, factors unique to each individual surgeon, also affect efficiency, but are much more variable and therefore more challenging to regulate. These factors can also improve, but must be fairly assessed in light of each individual surgeon’s strengths and weaknesses. For example, a carpometacarpal arthroplasty performed safely and competently by different surgeons may vary significantly in terms of operative time. If the slower surgeon is pushed to be too fast, patient safety, surgical outcomes, or resident education could all suffer. The faster surgeon, who may be praised on paper for more cases and higher relative value units (RVUs), must still ensure as much attention to education, outcomes, and safety. If one accepts that having some intrinsic differences between surgeons is inevitable, consideration must be given to how much variation defines acceptable versus substandard. Productivity—defined as money-making—must be carefully and thoughtfully assessed
as one of many important measures of an academic surgeon’s success rather than the only important measure. Not infrequently, a patient of mine has come to clinic with an unexpected issue that I felt deserved far more than the allotted time: one lost a sibling to suicide the day prior; another was freshly divorced, just lost his parent to cancer, and would soon receive from me a presumptive diagnosis of osteosarcoma; yet another was a recovering alcoholic 1-month status post microsurgical reconstruction secondary to trauma who was just realizing his low point. I had no reservations about devoting extra time to each of these patients, even in the context of at least 2 potential sacrifices: (1) that the more straightforward patients who saw me walk in late to their appointments would score me lower on their Patient Satisfaction surveys; and (2) that somewhere, in some way, the amount of time I spent with those pre-op, consult, and post-op patients, respectively, would reflect poorly on my productivity. Should a surgeon be penalized for doing what he or she feels is ethically and professionally best for each patient? Should productivity be granted so much clout that it trumps ideal patient care? In his address, The Pursuit of Happiness,1 at the 1991 American Society for Surgery of the Hand Fellows and Members Luncheon, Dr. Paul Brand touched on this perspective in discussing a sailboat race he once experienced:
1
The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA Corresponding Author: John Ingraham, Assistant Professor of Surgery and Humanities, Division of Plastic Surgery, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, 500 University Drive, H071, Hershey, PA 17033-0850, USA. Email: [email protected]
326
HAND 12(4)
We started well, but the wind was light and we had a heavy boat. It was a handicap race, so we started ahead, but we watched the fleet of sailing boats overtake us one by one. Then our skipper called me to him and quietly told me to get hold of our light kedge anchor, which was secured by a rope rather than a chain, crawl unobtrusively to the prow, and lower the anchor gently by hand into the water . . . . Mystified, I did as I was told, and soon felt the anchor hit the sand and the rope tighten as it took hold. To my astonishment, the rope angled forward, not backward. To my still greater amazement, we suddenly found ourselves gaining on all the other boats . . . we forged ahead.
it to our patients to avoid this quadrigia effect. Productivity cannot be allowed to pull so hard on one finger that the hand drops what it holds so dearly, namely our patients’ trust, well-being, and satisfaction and our educational mission.
Finally one or two of the smarter skippers recognized what we had done. The rope ahead of us told them how we were winning. They saw that they would have been smarter, if, instead of watching each other to see who was getting ahead, they had thought about their progress in relation to the unchanging contours of the earth beneath us. They would have realized that we had all been going backward because the tide was pushing us faster backward than the wind was pulling us forward . . . .
Ethical Approval
In the tide of productivity, the wrong perspective puts our mission at risk of drifting further and further from the most important destinations of safe, caring, and thorough patient care, consistent and meaningful education of future surgeons, and honest, pressure-free billing. Whether or not the winds are light or in our favor, we owe it to our patients to be among the wise skippers who know to measure success in reference to these sacrosanct goals, even if it means dropping an anchor to get ahead in the journey. In hand surgery, we know that if one flexor tendon seemingly outperforms the others and gets its finger to the palm first, even when the same muscle is pulling on all the flexors, the wrong race has been won—it’s not one finger against the others that’s most important, rather all the fingers working together to achieve that greater goal. We owe
Acknowledgments The author wishes to thank Kimberly Myers, PhD, for her invaluable editing advice and Charles Verheyden, MD, PhD, for his thoughtful encouragement. Both authors have given permission for the acknowledgment.
This study was approved by our institutional review board.
Statement of Human and Animal Rights This article does not contain any studies with human or animal subjects.
Statement of Informed Consent Informed consent was obtained when necessary.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Reference 1. Brand PW. The pursuit of happiness. J Hand Surg Am. 1992; 17(4):593-597.
research-article2016
HANXXX10.1177/1558944716675295HANDIngraham
Editorial HAND 2017, Vol. 12(4) 325–326 © The Author(s) 2016 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1558944716675295 hand.sagepub.com
Quadrigia and Productivity John Ingraham1
Abstract Financial productivity in academic surgery is important and deserves great emphasis, yet it is but one of many vital elements of a healthy practice. Productivity must be carefully balanced with many other vital goals such as maximizing patient safety, maintaining excellent outcomes, optimizing resident and medical student education, and earning outstanding patient feedback. The following editorial explores this elusive balance and the importance of not swaying too far in the direction of revenue. Keywords: productivity, efficiency, surgeons, quadrigia The perception of productivity in academic surgery implies money-making ability. As so defined, it can be compared with that of the airline industry in which many tasks, such as taxiing with only one engine, choosing altitudes with better tailwinds, and deviating around only the worst of weather, are specifically done to save fuel, and therefore money. Just as pilots are responsible for their passengers’ safety, so surgeons are for their patients. Just as pilots are paid for what they do, so are surgeons. The connection between a pilot and his or her passenger, however, differs from the sacred bond that exists between a surgeon and his or her patient. In this context, productivity must be carefully balanced with many other responsibilities. A surgeon’s efficiency can be thought of in terms of extrinsic factors (eg, quick operating room turnarounds between cases, access to patients, or the use of physician extenders). Extrinsic factors can and should be maximized, much like fuel efficiency, through objective, system-based modifications. Intrinsic factors, factors unique to each individual surgeon, also affect efficiency, but are much more variable and therefore more challenging to regulate. These factors can also improve, but must be fairly assessed in light of each individual surgeon’s strengths and weaknesses. For example, a carpometacarpal arthroplasty performed safely and competently by different surgeons may vary significantly in terms of operative time. If the slower surgeon is pushed to be too fast, patient safety, surgical outcomes, or resident education could all suffer. The faster surgeon, who may be praised on paper for more cases and higher relative value units (RVUs), must still ensure as much attention to education, outcomes, and safety. If one accepts that having some intrinsic differences between surgeons is inevitable, consideration must be given to how much variation defines acceptable versus substandard. Productivity—defined as money-making—must be carefully and thoughtfully assessed
as one of many important measures of an academic surgeon’s success rather than the only important measure. Not infrequently, a patient of mine has come to clinic with an unexpected issue that I felt deserved far more than the allotted time: one lost a sibling to suicide the day prior; another was freshly divorced, just lost his parent to cancer, and would soon receive from me a presumptive diagnosis of osteosarcoma; yet another was a recovering alcoholic 1-month status post microsurgical reconstruction secondary to trauma who was just realizing his low point. I had no reservations about devoting extra time to each of these patients, even in the context of at least 2 potential sacrifices: (1) that the more straightforward patients who saw me walk in late to their appointments would score me lower on their Patient Satisfaction surveys; and (2) that somewhere, in some way, the amount of time I spent with those pre-op, consult, and post-op patients, respectively, would reflect poorly on my productivity. Should a surgeon be penalized for doing what he or she feels is ethically and professionally best for each patient? Should productivity be granted so much clout that it trumps ideal patient care? In his address, The Pursuit of Happiness,1 at the 1991 American Society for Surgery of the Hand Fellows and Members Luncheon, Dr. Paul Brand touched on this perspective in discussing a sailboat race he once experienced:
1
The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA Corresponding Author: John Ingraham, Assistant Professor of Surgery and Humanities, Division of Plastic Surgery, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, 500 University Drive, H071, Hershey, PA 17033-0850, USA. Email: [email protected]
326
HAND 12(4)
We started well, but the wind was light and we had a heavy boat. It was a handicap race, so we started ahead, but we watched the fleet of sailing boats overtake us one by one. Then our skipper called me to him and quietly told me to get hold of our light kedge anchor, which was secured by a rope rather than a chain, crawl unobtrusively to the prow, and lower the anchor gently by hand into the water . . . . Mystified, I did as I was told, and soon felt the anchor hit the sand and the rope tighten as it took hold. To my astonishment, the rope angled forward, not backward. To my still greater amazement, we suddenly found ourselves gaining on all the other boats . . . we forged ahead.
it to our patients to avoid this quadrigia effect. Productivity cannot be allowed to pull so hard on one finger that the hand drops what it holds so dearly, namely our patients’ trust, well-being, and satisfaction and our educational mission.
Finally one or two of the smarter skippers recognized what we had done. The rope ahead of us told them how we were winning. They saw that they would have been smarter, if, instead of watching each other to see who was getting ahead, they had thought about their progress in relation to the unchanging contours of the earth beneath us. They would have realized that we had all been going backward because the tide was pushing us faster backward than the wind was pulling us forward . . . .
Ethical Approval
In the tide of productivity, the wrong perspective puts our mission at risk of drifting further and further from the most important destinations of safe, caring, and thorough patient care, consistent and meaningful education of future surgeons, and honest, pressure-free billing. Whether or not the winds are light or in our favor, we owe it to our patients to be among the wise skippers who know to measure success in reference to these sacrosanct goals, even if it means dropping an anchor to get ahead in the journey. In hand surgery, we know that if one flexor tendon seemingly outperforms the others and gets its finger to the palm first, even when the same muscle is pulling on all the flexors, the wrong race has been won—it’s not one finger against the others that’s most important, rather all the fingers working together to achieve that greater goal. We owe
Acknowledgments The author wishes to thank Kimberly Myers, PhD, for her invaluable editing advice and Charles Verheyden, MD, PhD, for his thoughtful encouragement. Both authors have given permission for the acknowledgment.
This study was approved by our institutional review board.
Statement of Human and Animal Rights This article does not contain any studies with human or animal subjects.
Statement of Informed Consent Informed consent was obtained when necessary.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Reference 1. Brand PW. The pursuit of happiness. J Hand Surg Am. 1992; 17(4):593-597.
