Scudder Oration lecturer links changing training paradigms to growing discomfort outside of specialization

Gregory J. Jurkovich, MD, FACS
Gregory J. Jurkovich, MD, FACS

As specialization becomes more commonplace in medicine, so too does the refrain, “I’m not comfortable with this.” Gregory J. Jurkovich, MD, FACS, will explain why this perception has become so prevalent and the ramifications of this growing mindset in the Scudder Oration on Trauma: I’m Not Comfortable with This at 1:00 pm CDT, Tuesday, October 6.

Dr. Jurkovich is 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. The lecture will be available for on-demand viewing through the virtual Clinical Congress meeting platform through December 31.

“We used to never hear this, but we hear it all the time now regarding patient care: ‘I’m not comfortable with this,’” Dr. Jurkovich said. “As trauma surgeons, we get a lot of that as a referral, a call from an outside hospital that says, ‘We’re just not comfortable taking care of this.’”

The discomfort being expressed is code for not wanting to take on the work involved at the moment, or for not wanting to deal with the hassle or risk being presented by a particular patient, who may lack good hygiene or insurance coverage, he said. In short, it’s code for wanting somebody else to take care of the patient’s needs.

“It’s a terrible disease in medicine—physicians refusing to provide care, and they’re doing it under the banner of saying, ‘I’m just not comfortable doing this now,’” Dr. Jurkovich said, acknowledging this strong, negative statement is likely to resonate with many trauma surgeons. But, he continued, it might not be entirely true.

Instead, he asserts this phrase is one of the costs of new training paradigms moving toward super-specialization and the better outcomes realized through the skill refinement of a surgeon doing high volumes of a single procedure. He said most trainees—80 percent—now go this route.

“Their primary reason is they’re just not comfortable going into practice when they’re done with their residency training, and to get comfortable with it, they end up doing a fellowship in a specialized area, and then they focus their practice on that specialized area,” he said.

Two generations ago, following the Korean War and the Vietnam War, large county hospitals were the bastions of medical research, training, and education. Typically, the roster of doctors was relatively short because it was all the hospital could afford, Dr. Jurkovich said, but that cadre did everything that was needed.

This is the model under which Dr. Jurkovich received his training. Upon completion of his residency, he recalls feeling like he could do anything, unlike many current graduates. To regain this mindset, he asserts a need for generalists.

“We still need the people who are willing to take care of 90 percent of the issues and only send away 10 percent,” he said. “The only place we can really train those people is in much smaller, more rural training centers [rather] than the large tertiary academic centers, where all of the role models are super-specialists.”

As surgery has become more specialized as a profession, Dr. Jurkovich explains, it has become increasingly challenging to find the right person to take care of a specific problem. This, in turn, leads to long transfers of patients, delays in patient care, aggravation and frustration, and an uncomfortable working relationship within the field.

True discomfort with providing patient care, Dr. Jurkovich contends, it is a reflection of a health care system that has become too specialized or is dealing with unprecedented circumstances like the COVID-19 pandemic

“Early on, there was a great deal of discomfort even providing care for COVID-19 patients, and that is so anathema to being a physician,” he said. “Much of that has abated now with better protective equipment and a better understanding of aerosolized treatments.”

The Scudder Oration on Trauma honors Charles Locke Scudder, MD. A founding member of the American College of Surgeons (ACS), Dr. Scudder is known for his major contributions to the surgery of trauma. The lecture is sponsored by the ACS Committee on Trauma.