Recently I’ve been asked to write about rural surgery, what it’s like, what’s good about it. Everything has its ups and downs.
First of all let me say that whatever your job is, the money you get paid to do that job is for the crappy part, and every job has a crappy part. The trick is to find a job that has a crappy part that you can tolerate. Remember Mikey? His brothers didn’t want to try the cereal, so they decided, “Let’s get Mikey. He hates everything.”
Mikey eats the cereal that everyone else hates, and he gets paid big bucks for it, too.
So what is it about rural surgery that I get paid for?
I trained in a tertiary care hospital, as most residents do, and in that world, you have everything, all the time. (At least that’s the way it was — perhaps not the case anymore.) We had specialists, and all the newest, latest, greatest technology. And it was all available all the time. Need to order an esoteric test that you just read about in some obscure journal article? Write for it, you’ll have a result by tomorrow. Need 20 units of blood for one patient? Coming right up. Simultaneous brain and great toe transplant? Call the fellow — they’ll schedule it for next week. The corollary to this is that what you do — whatever your special little slice of surgery happens to be — that’s what you get to do. Need something outside your niche? Call somebody, and they’ll come do it for you.
Well, then you get out into the real world. Here’s the bad news. No specialists. Want an ultrasound at 4 p.m.? Too bad. The only tech in this county has already gone home, and his schedule tomorrow looks pretty full, too. How about a cortisol level? Want that? Well, you can’t find it in the order section of the museum piece they call a computer around here. You’ll have to call the lab. They want to know: How do you spell it? Would that be hematology or chemistry? Are you sure that’s actually a test, or maybe you’re playing a practical joke perhaps? Funny, Dr. Amantine!
Or how about when the ED calls because there’s a guy with a peritonsillar abscess. I explain that I am the general surgeon on call, there must be some mistake, they should call the otolaryngologist. I am then advised the otolaryngologist is the only one in this county, and he takes call every third night, and tonight is not that night. Therefore, the peritonsillar abscesses go to the general surgeon on call when the other guy is not available.
So here’s where it gets ugly. I have to take care of the patient. I cannot send the patient away. And I have to do something that I’ve never even seen done. The typical surgical education quip is “See one, do one, teach one,” but I haven’t even seen one.
So, I get the book off the shelf. I read about peritonsillar abscesses. I look at the pictures. And on this particular occasion, (yes, this really happened, years ago), I called my senior partner, who said he’d show me this time, but next time I was on my own. And so it went — I learned how to drain a peritonsillar abscess. And, in fact, I did drain it. No sweat. Well, maybe a little.
Fast forward to the present. There are 1,332 critical access hospitals in the United States. They are located in rural areas, and up until now they have been maintained to sustain essential health care services in rural communities. But today, forces are at work that may unravel the financial support that allows these hospitals to stay open. Additionally, the trend in medicine and especially in surgery emphasizes clustering patients by illness or by procedure to one specialty “center of excellence.” You want to have your carotid artery surgery done excellently, with the lowest possible complication rate? You should go to somebody who does only carotid surgery. Colonoscopy? Knee job? Hernia repair? Don’t settle for any less than the best. Even if that means you will be driving for two hours to get there. The media talks, and people listen. Need a breast biopsy? You need to go to a specialist. Got appendicitis? You really need a robot.
And on the delivery end, the specialists recognize that statistics are influencing patients’ choices — and they will market aggressively to get the most hangnails or earlobe reshapings or tongue resurfacings or whatever market it is they intend to corner — the more the better.
I’m not saying that assembly lines are a bad thing. Henry Ford did a wonderful job with them. Of course, he was making cars. Human beings are not cars.
As I re-read all this, I think, wow! I must be crazy to have gone into medicine, and surgery! What was I thinking?
So here’s the good.
You know that ultrasound tech, the only one in the county? His name is Bert. I call him, the next day, and I say, “Hey Bert. It’s Dr. Amantine. (How ya doin’, doc?) Can you please do this ultrasound for me?” And he’ll squeeze it in.
That cortisol level? Guess what. Nobody in the history of medicine ever died because they didn’t get a cortisol level. Pretty sure on that. In fact, I can do without it.
That peritonsillar abscess? If I’m in a pickle, I can do what I need to do to take care of that guy — because the principles involved in human physiology and saving a person’s life do not change from moment to moment. They don’t even change when we elect a new president, or create new computer programs to encode what we did electronically for the statisticians to analyze.
And finally, that patient who needs the breast biopsy? Yeah, there’s a guy in the city who does breast biopsies and nothing but breast biopsies, and he’s done a billion of ’em. He does ten in a day. But when Mabel needs a breast biopsy, she asks me one thing: How many have you done? And I tell her, oh, I dunno, maybe only four or five hundred. And then she tells me: You did my cousin’s biopsy, and she loved you. She told me to come see you, and you’d take good care of me, just like you did for her. And at her post-op visit, she brings me a scarf that she knitted, and it’s soft, with lovely colors in intricate patterns, and she made it just for me. Because she’s not a car. She’s a human being, and so am I.
So in answer to the question, “What is rural surgery like?”, it’s a job, just like any other. I get paid to do stuff that nobody else wants to do, just like every job. It is never dull. Sometimes it is stressful, sometimes heartbreaking, sometimes intellectually challenging, always rewarding.
I can’t imagine doing anything else.
“Hope Amantine” is a surgeon who blogs at Simple Country Surgeon.
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