the best doctor

Monday, December 7, 2015

The Heisman Trophy watch has begun, with hundreds of voters now deciding who might be the best college football player in the nation. It’s an interesting exercise, trying to explain why the best player is always the one that touches the ball and not necessarily the one who blocks or tackle; those people who without their work and skill allow the stars to shine. As the NFL has proven repeatedly, there are many underappreciated college players who star when given the opportunity to play with the best blockers. But the Heisman is meant to recognize a college career, not a professional potential.

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Rating the best individual in a team sport also happens in medicine. Every frequent flyer magazine found in the back of an airline seat contains full page ads touting the best orthopedic surgeon, plastic surgeon or internist in New York, LA or Chicago. And who decides who is “the best”? No doubt, there are a few superstars in medicine who are more intelligent and have taken advantage of their education and training to develop skills that perhaps outshine their colleagues. But these are the few. Most of the best do not advertise and their patients find them by referral from their primary care provider.

There is a downside for being considered the best in medicine. The most complicated patients tend to arrive at their doorstep because they have failed to be diagnosed or cured elsewhere. Sometimes it is because the diagnosis is too obscure or because there are underlying medical conditions, like heart disease or infection, that make surgery much too risky. The star surgeons may have higher complication rates because they take care of sicker patients, but often they perform at the highest level because of the team that surrounds them.

Good results happen when a solid routine is developed to care for the patient. Better outcomes, few complications occur when a team is assembled and kept together, just like in any sport. Infections in the operating rom don’t magically go away because of surgical technique, though that skill is an important contributor. There must be a solid housekeeping crew that cleans the operating room before a procedure begins. The surgeon depends upon the technicians in central supply to sterilize the equipment needed to invade the patient. Circulating and scrub nurses needs to understand the sequence of events (the equivalent of play calling in football) to make certain that the surgeon and their assistants have the instruments needed at his fingertips at the time they are needed, to prevent delays. Longer anesthetic time may increase complication rates. It is also a reminder that the anesthesiology team plays a critical role in caring for the patient. It’s easy to put a patient to sleep; it’s tougher to keep them there and wake them up at the appropriate time.

A superstar doctor surrounds themselves with a star team of their own, understanding that the doctor touches the patient for only a short period of time during their medical care. An orthopedic surgeon depends upon the physical therapists to spend hours with their patient, before and after an operation, to return the repaired body part to normal function. A diabetes specialist has nutritionists and diabetic educators teaching patients about the balance between food and insulin, how pumps work and what to do when blood sugars get out of control. The same can be said for cardiologists and their cardiac rehab physiologists, pulmonologists and respiratory therapists and most other specialists. Even family doctors depend upon their nurses to help patients with many of their questions regarding a child’s fever or how best to treat diarrhea.

Once upon a time, the patient expected the doctor to be the sole source of medical knowledge and for handholding through the diagnosis and treatment process. Historically, the doctor’s skill was in making the diagnosis, since there were few cures and treatment available. The world of medicine has changed dramatically. Once diagnosed, an illness or injury may have many treatment options and the doctor is responsible to lead the patient through the decision process as to which path to take, but now depends upon many other team members to make those treatments happen. Regardless of the brilliance of television doctors like House and ER, the real world knows that it’s all about team.

Again this year, the Heisman will be awarded to a quarterback who has thrown for dozens of touchdowns, or a running back who has rushed for a thousand yards. As they stand on the stage to accept their award, they should be flanked by the linemen who blocked for them and the receivers who caught their passes. In football, as in medicine, it takes a team to make a superstar. Next year, the winner will have moved on to the NFL and the challenge of playing against better competition. Another player will step into their shoes and the linemen are I still there and the team intact, there may be a new star that shines as bright, just like the player they replaced. This year a superstar doctor will retire and they too will be replaced.

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