Hanlon, C. Rollins

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The Linacre QuarterlyVolume 29 | Number 2 Article 5May 1962Who Should Get Surgical Privileges in Hospitals?C. Rollins HanlonFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationHanlon, C. Rollins (1962) "Who Should Get Surgical Privileges in Hospitals?," The Linacre Quarterly: Vol. 29 : No. 2 , Article 5.Available at: http://epublications.marquette.edu/lnq/vol29/iss2/5a numbers game. Until the sci­ences of psychology, sociology. theology and others give us a more definitive picture of the nor­mal family for optimal rearing of children as mature human beings 1� seems we should be wary of simply arithmetical solutions. 8. Finally, and this is a note that applies to the moral order, it seems superficial to think that the issue between liberal and orthodox moralists is only a matter of means: artificial birth control ( contraception ) vs. periodic ab­stinence (rhythm). Surely the whole question of ends and pur­poses, motivation and intention and values, is involved in th� determination of the circum­stances, which make it wise or un­wise to effect birth reduction in indi:!dual families or groups of families. The history of mankind records how frequently we suffer when we pit our dated knowledge and thinking against nature's ried and tested wisdom or a, inst God's providential order. ,· hen we have deviated from na re·s nor�s. we have experience na­ture s capacity to strike ba< . It is, therefore, most incumbent ipon us first to obtain and utilizt 3.de­quate knowledge of nature i Jud­ing ;'Ilan's nature, as a pr�] e to a wise approach to populal n in those ar_eas where populatic ex­plosion 1s actually occurrinp The foregoing is an abstract of public t�lk given by Dr. Ratner under ,' aus· p1ces of the Newman Club, Univ ity of �,ssouri, last December. He is c full­time director of the Oak Park, linois, Department of Public Health. Sir. 1942, Dr. Ratner has served in the De ·tment of Public Health and Preventive I •dicine of Loyola University School of ·dicine and now holds the rank of assoc: e clin-1cal professor. He is on the f, ihy of the St. Albert Magnus Lyceun. of the National Sciences of the Dominic, House of Studies, River Forest, lllin, ,. Dr. Ratner IS a weil-known lecturer n biol� ogy, medicine and marriage; he , medi­cal adviser to the Cana Conferer of the Archdiocese of Chicago. A single free copy of an informal critique on d d' · Ratner, �.D., as interviewed by Donald MacDo'::�Jdrf:rmth IClne �y Hernert acter Series of the Center for the Stud f D . e �·�•can (.har· for the Republic may be obtained b d.Y o . emocratic Inst1tut1ons, I "nd on Medicine to 'the Center for the �tudectufgO reque"! for T_he _lnteniew 4068, Santa Barbara, California. Y O emocrat1c lnst1tut1ons, Box LINACRE QUARTERLY WHO SHOULD GET SURGICAL PRIVILEGES IN HOSPITALS? C. ROLLINS HA:slLON, M.D. THIS important and difficultquestion is answered in wide­ly different ways by various seg­ments of the medical profession. For example, the American Acad­emy of General Practice holds that the family doctor should be entitled to surgical privileges. while the American College of Surgeons maintains that the prac­tice of surgery in hospitals should be limited to qualified surgeons. What is the background of these confficting views? The controver­sial issues may be indicated by four· propositions. There are a number of important side issues. but · let us examine these four propositions: Surgical problems can be / divided into "major," "mi­, nor," and "intermediate.''This appears at first to be a reasonable statement of fact, sup­ported by logic as well as by long tradition. Excision of moles or warts is performed by many phy­sicians who would not dream of attempting a gastrectomy; they act on the obvious presumption that gastrectomy is a larger and more difficult operation than removal of a mole, and associated with a greater morbidity and mortality. Equally true, but much Jess evident is the possibility of fatal complica­tions from an inadequately treated mole that turns out to be a malig-MAY, 1962 nant melanoma. Such an instance illustrates forcibly the danger and artificiality of dividing surgery into "major" and "minor." We still have textbooks of "minor sur­gery." but the authors generally stress in the preface the virtual impossibility of establishing a divi­sion from "major" surgery. With this in mind, it is apparent that "interm�diate" surgical opera­tions defy analysis; indeed. the whole idea of such categories is based on the false premise that the only significant factor in the sur­gical experience is the operation itself. This is not to deny the im­portance of the operative proce­dure; if done badly. the patient may die despite masterful pre-C. Rollins Hanlon, M.D., has been sur• geon-in-chief of St. Louis University's Firmin Desloge Hospital since 1950. Anative of Baltimore, Md.. Dr. Hanlon came to St. Louis University from Johns Hopkins Hospital, Baltimore, where he received his M.D. degree in 1938; was an intern in surgery from 1938-39; and a res­ident in surgery from 1947-48; and sur• geon from 1948-50. A member of numer• ous medical, surgical and educational societies, he was recently elected as a representative of the Section on Surgery of the A.M.A. for a six year term. A consultant in surgery and cardiovascular surgery at the Veterans' Hospital, St. Louis, Dr. Hanlon was certified by the American Board of Surgery in 1946. He is currently a member of the American Association for Thoracic Surgery. the American College of Surgeons, the Amer­ican Surgical Association and many .:>ther organizations. Dr. Hanlon is a member of the St. Louis Catholic Physicians' Guild. 69 operative care. On the other hand t�e m�st deftly performed opera� it:°� will fail to benefit the patient it IS· unnecessary. incorrectly c�ose�. poorly timed. or associated with madequate preoperative and �ostoperative management. In the mterest of the patient, the only conclusion to be drawn is that allsurgery is of major significance and that the categories of "· t _ cl. .. m er me iate and "minor" surgery should be abandoned. From such considerations we come to the second proposition. Physicians can be divided 2 according to their capacity • �o und�rtake operations ofmcreasrng magnitude.. This proposition is based on the mco�rect assumption that surgery consists essentially of a group of small and large operative proce­dures. �. man �ith privileges to do certam major operations. such as_ appendectomy. may not be per­mitted by the medical staff to do bowel resection, because he is not competent to perform this proce­dure. But what happens when this m a� unexpectedly encounters a malignancy of the cecum during the course of operation for sup­posed �ppendicitis? Does he pro­�eed with the resection? Does heee? the patient under anesthesia w hile he sends out an emergenc • call for a specialist to come to hi: rescue! Or does he terminate the operation, send the P.atient back to bed and call in a specialist to do the b_owel resection later? And even _if he has a specialist as his techmcal assistant at the O · • I . . rtgma opei,atton, has the patient been #70 properly prepared for a bo· section? In any of the four, �f actio�. ?pen to the op-surgeon m such a misad" the patient takes all the ris; -1 re­,Jrses a ting 1ture, 3p of g of ative per-eless. this 'cians tining 1rrow es. It denly d rec-per-If surgery is not just a g. operations, then the grad phys1c1ans according to 0� procedures which they ha formed is improper. None there are many hospitals co.untry where certain ph without formal surgical have for years performed 0 range of operative procec' 1s not practicable to alter s this status quo, but one she ognize that the operatio formed by such practitio11 be associated with a demc, h.ig�er rate of complicatic similar operations perfor men .with specialized train s may trably � than :d by g. For example. an audit of �cords of some 9,000 patients w� had a tonsillectomy performed 1 1958 showed a postoperative ; mmor­r�age rate of 26 per thous .1d ton­sillectomy patients. W �n the operating doctor was a general surgeon, the rate was 24 i:, - r thou­sand; the ear. nose am: throat specialist had a rate of 19, and the general practitioner had 14 post­operative hemorrhages per thou­sand cases. In eight additional cases, the general practitioner re­admitted the patient to the hospital for hemorrhage, while the readmis­sion rate for general surgeons and specialists was less than five per thousand. These were serious h_emorrhages requiring transfu­s10ns in 11 per cent and return to the operating room in 27 per cent. LINACRE QUARTERLY The magnitude of the problem is obvious when we project the data from these 9,000 patients to the more than one million patients undergoing tonsillectomy each year in the United States. Some 10.000 to 15,000 additional patients with hemmorrhage present a strong argument against the contention that tonsillectomy is a "minor" procedure which the experienced general practitioner can perform as well as a surgical specialist. The physician should not em­bark on any surgical procedure in which his complication rate is alarmingly higher than the rate for the same operation by trained surgeons. Neither should he begin any "standard" operation such as appendectomy in which unexpect­ed findings may lead him beyond his technical competence to the serious disadvantage of the pa­tient. He should be able to handle adequately any surgical problem he encounters during an operative procedure, or he should not oper­ate. 3, Physicans rated as capable of performing "minor sur­_gery" may graduate to higher privileges by in­hospital training while con-tinuing to carry on a gen­eral practice of medicine. This proposition is advanced as � substitute for residency training m surgery,1 despite wide agree­ment that the best way to educate surgeons is by an accredited sur­gical residency program which schools the candidate in funda­mentals of surgical diagnosis. pa­thology and therapy in an inte-MAY, 1962 grated fashion with the gradual assumption of increasing respon­sibility under supervision. The improvement in the general level of surgical care since this plan has been widely adopted is apparent. Why then do some advocate a loose form of preceptorship train­ing? Simply stated, the standard surgical residency is "unduly burdensome and time consum­ing ."2 Moreover, in the case of a general practitioner, it "would place disproportionate emphasis on surgery"; in effect. he would be overtrained in one aspect of his diversified practice. Qualified surgeons would agree that a four-year residency training period in surgery would tend to convert a general practitioner into a surgeon. so that he would give "disproportionate emphasis" to the surgical aspects of his practice. The same surgeons would state that a man should not be half­trained or quarter-trained in sur­gery because a half or a quarter of his practice calls for surgical management. There is involved here the same basic misconception previously noted. that surgery con­sists of learning a number of tech­nical procedures, to be applied to patients in the same way one pre­scribes a drug or a hot waterbottle. It is true that surgical training is "burdensome and time consum­ing." but these burdens rest equally heavily on all surgical trainees, be they fresh from their 1 Thorpe, George L., "Surgical Training for the Practicing Physician," GP, XV: 147. March. 1957. 2 /dem: p. 148. 71 internship or securely established in practice. Indeed, one might argue that the established practi­tioner is able to withstand the fi­nancial and other stresses better than the young man whose entire career has been marked by finan­cial outlays so that he is increas­ingly involved in debt. But such an argument about degrees of in­convenience is irrelevant to the central issue, that one cannot edu­cate surgeons well on a painless, casual. learn-as-you-earn basis. A surgical residency is a full-time enterprise, and those who expect to achieve the same result by in­hospital preceptorships are closing their eyes to the necessary qualifi­cations of a modern surgeon. Let us examine what is offered as one substitute for residency training. The article previously cited describes an "active, working plan by which general practition­ers are gaining increased surgical privileges." After completing 25 minor operations under supervi­sion, the candidate may be granted "minor surgical privileges" and may then "proceed to higher cate­gories" without interrupting his practice. The further progress of the plan will be outlined only briefly. The aspirant to "advanced" surgical privileges must complete I 00 major procedures arising from his own practice; the fii:st 50 as assistant to a supervising surgeon and the rest with their roles reversed. After suitable assessment by the hospital surgical committee, the applicant may be granted addi­tional surgical privileges. •72This preceptorship type c ing falls far short of provid kind of surgical competenc can cope with any situati arises. Consequently, if t treatment for patients is ( terion, it is hard to just' standards of surgery in h where qualified surgeons a able. Recognizing that tf prenticeship" or "in-traini1 of surgical education is the American College of E forbids its fellows to tr; surgeons by this method. rain­g the vhich that best r cri­. two pitals avail-"ap-· type ferior.geons non-Re st riction of 1 privileges may be 4 in large urban' but is unrealistic 1community hospit. :gical ,stified spitals ,mailer Some have said that 1 rural areas with excellent hosp, I facili­ties,· the family doctor i� 1e only available surgeon. "It i, utile to discuss surgical residenc, . Board certification. pathologic ,, . its and hospital surgical privile, ; under such circumstances. If tr patient needs surgery, the fam, doctor operates. There is no p. ,cticable alternative."1 As convincing as this rriay seem at first, one cannot withJ,old the hard question: "Why can't the patient be sent to a nearbv hospital with qualified surgeons in attend­ance?" Modern transportation puts the most advanced surgical care within easy reach, ijenerally in less than an hour. If the best surgical management is our goal, are we going to sacrifice this to the convenience of the patient. the 1 Op. Cit., p. 71. LINACRE QUARTERLY relatives. or the attending physi­cian? In urgent emergencies. the initial operation may have to be done locally, but this does not pre­vent subsequent transfer for the specialized care that may be even more important than the operative procedure. Keeping the patient in an insti­tution close to home has been invoked to justify another perni­cious practice - that of itinerant surgery. The patient is operated on by a visiting surgeon whose sole activities may be the operative procedure and the collection of the fee. Even if he furnishes consul­tation and examination before operation, he fails to provide care and advice in the critical period after operation. All too often the door is opened to ghost surgery. with · the patient unaware of the identity of the surgeon, who ar­rives· and leaves while the patient is anesthetized. This article will not discuss the flnancial implica­tions of these improper practices. It is true that there are at pres­ent not enough "Board qualified" surgeons to staff every hospital in the country. In some of these hos­pitals there are physicians who by long years of surgical practice or by preceptorship and self-educa­tion have made themselves into competent surgeons. These men were formed in another era, before the widespread adoption of the residency system of training. There is no desire to legislate against such men or to quarrel with the statement that some ex­cellent surgeons have been pro­duced by the apprenticeship sys­tem. Today that system is not only unfeasible. it is manifestly inferior to residency training. Its continued advocacy as a means of changing general practitioners into surgical practitioners by a painless. learn­as-you-go mechanism is a back­ward step in improving the surgical care of patients. Who should get surgical privi­leges in hospitals today? Clearly it should be the qualified surgeon. as recognized by eligibility for. or membership in the American Col­lege of Surgeons. Reprinted from Hospital Progress. St. Louis, Missouri, December, 1961, with kind permission of the Editors. MAY, 1962 73 

Who Should Get Surgical Privileges in Hospitals?

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Who Should Get Surgical Privileges in Hospitals?

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