After-hours coverage of cardiothoracic critical care units by non-surgeons: process and value issues

Abstract

One article [1] and three commentaries in the January 2013 issue of the Journal discuss the coverage of cardiothoracic surgery (CTS) intensive care units by non-surgeons. Motivations for the paper by Skinner et al are: an increasing pressure to reduce the cost; a shortage of junior CTS surgeons and decreased interest in CTS critical care. The study’s stated objective is to ‘reduce staffing cost’, based on assumptions that non-surgeons can replace surgeons in the same job, for ‘significantly’ less money, with ‘somewhat equal’ results and ‘acceptable losses’; because ‘it is not rocket science’. While cost-cutting is often the ‘easy way out’ to increase value in healthcare, the more demanding task of increasing quality by improving safety, effectiveness, appropriateness, equitability and accessibility is what truly and reliably leads to an enduring, costeffective health-care system, on a local or national scale [2]. Deficiencies in the broad-based education, abbreviated clinical training and limited skill sets of non-surgeons seriously impair their situational/environmental awareness and processing of information, their decision-making process and the implementation of decisions, as in the proposed ‘emergent resternotomy in the ICU’ protocol—an often challenging situation for experienced CTS surgeons. Therefore, non-surgeons are not properly qualified to be the primary decision-maker in the high-risk environment of cardiothoracic surgical critical care (CTSCC). Moreover, ‘telephone management’ causes delay in information processing and increases the risk of errors [3]. A flight attendant safely landing a commercial airliner based on remote instructions happens only in a Hollywood film (http://www.imdb.com/title/tt0071110/). Ethically, patients treated by surgeons during ‘normal business hours’ while by non-surgeons in the ‘after-hours’ raises serious issues of trust between the patient and the physician, upon which rapport, agreement and consent are based. Patients can have the impression of being ‘abandoned’ by the physician and their care delegated to a ‘professionally inferior’ or a ‘less qualified’ practitioner. Professionally, professional governing organizations (such as specialty boards) have their mission as the only authorities regulating the specific education, training, proficiency requirements, examination, certification, licensure, scope of practice, duties, responsibilities and expectations, accountability and disciplinary action for all practitioners in any clinical field [4, 5]. The solution for staffing issues in clinical environment should be based on sound scientific principles that take into account the projected clinical needs in the community; the expected output from medical and allied health schools and training programmes; established, evidence-based standards of care and the appropriate education, training, skill sets, certification and credentialing of specific classes of clinicians. The shortage in surgeons cannot be remedied by drawing from another pool of clinicians that is also severely limited in number and suffers from the same ‘brain drain’. Measures to address the persistent shortage of surgeons and applicants to surgical programmes should be based on providing more incentives for medical school graduates to choose specific areas of practice as career goals. Changes to the work hours and shifts may also be beneficial in this regard. These decisions, which impact on professional standards and practice, should be made by the relevant clinical professionals, and never left to administrators or politicians.