Questions About Surgery - Is It Really Worth It? Are You Restrained By Working In A Public System?

[medhope15]

I apologize in advance if this was asked somewhere else! Also, I'm a med hopeful considering surgery (specifically general surgery or ortho). I've spent lots of time with docs and actually worked in another field which gave me exposure to hospital patients. So I have a basic idea of what surgery is "patient A tears knee ligament, gets referred to an ortho who does imaging and decides on OR", I know there must be much more to it; I know even though surgeons are sometimes really focused on one area of surgery (knees or spines etc) they actually have the tools to do all kinds of surgeries in their area of specialty, so I'm guessing there can be some variety in work.

Also, I've seen the cuts and job losses in health care first hand. I've seen the new culture to cut as many corners as possible to save money.

 

Interestingly last week I came upon the public website which discusses cases of people who sue OHIP when they decide to travel to the US to get a surgery which was refused by 3, 4, 5 docs in Ontario for various reasons, then they fly down to a spine clinic in florida and get their "inoperable" tumour removed, and live happily ever after. I'm assuming some of the refusal on the part of Canadian docs has to do with cuts to funding perhaps more so than with skills???

 

So how do surgeons feel working under OHIP?? I know it might be a juvenile example, but even when you watch Grey's Anatomy, someone shows up with a strange tumour and the surgeons plan some new technique or strategy to remove it. I've heard that under OHIP with the billing, you can only bill under names of techniques that are covered...so if there is some new thing you envision for the patient or some interesting technique called XYZ that you invent, you can't perform it because it's not a "standard" procedure like "CABG" or "Valve replacement". I guess I'm wondering if it is better to train in the US??? Is there more room for creativity? and use of skills??

 

Again, I'm very very naive to the details of the billings, the constraints the surgeons face. And I'm just looking to become enlightened.

[A-Stark]

Better to have an actual surgeon (or surgical resident) answer this, but yes, very naive! 

 

You seem to be asking about variety in procedures, something that will be entirely specialty-dependent. But most surgeons will tell you that every gallbladder is different. Similarly, with every CABG comes different anatomy, different grafts, different lesions, and different patient factors (they certainly don't all act the same once they reach CVICU!). 

 

Surgeons have different training and different experience. Some are more aggressive than others. Some are less tolerant of risk. You cannot go by info on a "public website" where people often don't have their facts straight let alone an understanding of the relevant underlying pathology. So don't worry about that stuff. 

 

Grey's Anatomy is fiction. Their ORs don't look like anywhere I've ever been (why do they operate in the dark??), and the behaviour of the characters descends into ludicrous histrionics all the time. In the OR! 

 

"Valve replacement" entails everything from a Bentall's to a minimally invasive MVR. The billing system accommodates most things. It is hardly the case that American surgeons have some sort of free reign with billing - they're arguably a lot worse off dealing with multiple insurers instead of a single provincial insurance plan (+/- WSIB, military, FNIHB).

 

But generally speaking you don't want to be a patient who's getting the more "creative" surgeon. TV shows always suggest that we encounter "strange" tumours that confound staff, often leading to a conflict where the "play-it-safe" surgeon argues with the "cowboy-risk-is-our-business" surgeon. In the end - usually - the riskier path always pays off, though often only after the patient nearly dies (or actually codes but comes back). 

 

That's just TV. In real life, high risk patients tend to do a lot worse. And sometimes the complications of certain ORs mean someone ends up with an open belly and multiple fistulas. Or necrotic tongues. (Okay I've only seen one like that...)

[medhope15]

Ok thanks for the feedback!!

The website i was referring to is actually a public government website, where pt vs OHIP cases are clearly available for all to read and regularly updated.

 

I just started to get the impression that the "risk" taken or the creativity with certain procedures that some docs "refuse to touch" in Ontario is an issue of billing in a public health care system? government not willing to cover something recognized as standard??

....not sure how to explain this ... as a fictional example, say you have a patient with a routine CABG but something about this pt is "odd" and the normal way can't be done, so the surgeon wants to try an alternative method that noone else has suggested which may involve some backwards approach or weird grafting or something that is seen as novel (again this is a fictional example). Will the government allow and bill this? or will they say "hey, you're doing something completely "different" and we aren't allowing it". Basically, can you be creative and novel? is there that room to grow to push yourself? (I seem to get the impression that in the US, yes there is that room to be novel, sure you face risk of lawsuit, but if you feel confident, go ahead).

[A-Stark]

Billing is dependent on the type of procedure, not the detailed specifics of the technique. It's pretty common for "new" techniques to be tried, especially as regards prostheses and specialized equipment. It's common enough to see Stryker reps in the OR to demonstrate/show off some new TKA system. 

[NLengr]

In the States, there are many surgeons willing to do all kinds of unproven procedures that are of little benefit, as long as you have cash to pay them. It can be like the wild west down there sometimes.

 

They also have access to some technology that's really good at attracting people to their hospital (and therefore gives the hospital more money), but provides no proven benefit over established older techniques. Again, in the US, if you have the cash, someone will gladly take your cash and do it for you. Here, since it's public money, the government generally wants to see evidence of benefit justifying the added expense of new technology.

 

In Canada, you generally have to prove a surgery (or medication) has some degree of value before the system will pay for it. In the US, they are quick to adopt all kinds of stuff, even if the evidence is terrible. At least part of that is profit driven (attract more people to hospital with fancy looking technology and the hospital makes more money).

 

There is still lots of room to push the surgical envelope in Canada, but if you are doing unproven surgery, you are likely an Academic surgeon doing it under the auspices of research, which may be funded in a different manner.

 

 

Also, Grey's Anatomy has very little to do with real life medical practice.