The COVID-19 pandemic has infected nearly 30 million people worldwide and caused more than 1 million deaths. Meanwhile, the U.S. is experiencing a massive health care worker crisis as these frontline personnel are exposed to the virus as they provide care. An estimated 150,000-plus hospital and nursing home staff have been infected with COVID-19, and more than 700 have died. It’s enough to make anyone uncomfortable, says Gregory J. Jurkovich, MD, FACS, distinguished professor of surgery, Lloyd F. & Rosemargaret Donant Chair in Trauma Medicine, and vice-chair of the department of surgery, University of California, Davis, Sacramento.
Dr. Jurkovich delivered this year’s Scudder Oration on Trauma: I’m Not Comfortable with This on Tuesday, October 6. The lecture will be available for on-demand viewing through the virtual Clinical Congress meeting platform through December 31.
“Here we are as trauma surgeons, exposed to a large number of patients every day, from every walk of life, and at highest risk of getting infected,” Dr. Jurkovich said. “I don’t want to be infected. I don’t want to infect my family. I don’t want to get sick. I don’t want to be a vector. And I certainly don’t want to die. I am not comfortable with any of this, but how can we just walk away? Who is comfortable in today’s trauma centers?”
Statements of surgeon discomfort predate the pandemic, but COVID-19 has given them new life. “It seems that whenever confronted with the challenging, the inconvenient, the undesirable, the underinsured, or maybe just when overwhelmed with a new-found anxiety, our colleagues and peers have begun to utter the phrase, ‘I am not comfortable with this,’” Dr. Jurkovich said.
Instead of explaining a lack of ability, knowledge, or training, the line is utilized as a shield against unwanted, unpleasant, and inconvenient tasks.
“Perhaps saying this phrase is just a matter of practicing defensive medicine,” Dr. Jurkovich suggests. “Defensive medicine may motivate doctors to request more consults to limit liability and responsibility, referring to different specialists for each symptom, with the thought that once a referral is made, responsibility is pardoned. Difficult patients are placed on a referral merry-go-round, seeing one specialist after another without any clear, concise plan of treatment.”
The ubiquitous use of this phrase also may be borne out of a restructuring of the health care system that has stripped away three pillars supporting the professional’s intrinsic motivation and psychological well-being: autonomy, competence, and relatedness, he contends.
“Doctors used to want to give patients the time and support they need, and they wanted the system to value and recognize their efforts to provide this kind of care,” Dr. Jurkovich said. “While much lip service is given to the phrase ‘patient-centered care,’ many doctors feel that the system is increasingly driven by money and metrics, with rewards for those who embrace these priorities rather than the patient–doctor relationship.”
Dr. Jurkovich is not comfortable with this trend. He ponders whether the net effect of seemingly rising discomfort is growing apathy among doctors, which will ultimately lead to poor care for the sickest patients. He proposed the enhanced training paradigm of acute care surgery as the solution.
“As originally proposed, this two-year, post general surgery fellowship would incorporate surgical critical care, trauma and emergency general surgery, and bolstered, enhanced training in the management of vascular, hepatobiliar, and thoracic issues,” Dr. Jurkovich explained. He contends exposure to patients with these surgical issues has been hampered by specialists in those academic arenas denying access to these cases under the defense of having to train their “own” fellows, and he wants to see this change.
“We must find a way to train acute care surgery fellows so that they are comfortable with the broad array of surgical diseases that populate their consult list,” Dr. Jurkovich said. “We must make this happen if we are to remain the galactical pilots, or the complete surgeon, or even the one last group of surgeons who will not say, ‘I am not comfortable with that.’”