The Internet has progressively changed how patients select their surgeons, though I am not sure in whose favor the balance works better. Instead of relying on local recommendations and word of mouth within a community, patients now find “experts” online, research their backgrounds, read their patient ratings and self-proclaimed expertise, and bargain shop. The Internet's promotional hysteria has thus increased the heat for patients without increasing the light. And 30 years ago, we thought that physician ads in our local newspapers were scandalous.
This means that many surgeons now treat patients who travel some distances to see them, a phenomenon that used to be limited to the few surgeons who had national recognition among their peers for particular expertise and therefore were seen as “resources” for the rest of us.
How does this marketing and buying revolution impact the way we treat and follow our patients? I have participated in panels where audience members asked this question, and the panelists' responses were surprisingly diffuse, at least to me. Some surgeons discharge their patients immediately after surgery to the care of local physicians in their home states, even for dressing removal. Some surgeons require postoperative visits and some do not, and some even follow their patients' early postoperative courses through the patients' own emailed cell phone photographs.
Thus the adaptation of patients and surgeons to the Internet has inadvertently created a new variation on itinerant surgery—only now it is the patient who is traveling, not the surgeon. This common practice is a prescription for serious future problems and strikes at the integrity of the surgeon-patient relationship. At the very least, it taunts the Law of Unintended Consequences.
In the nineteenth and early twentieth centuries, itinerant surgery was the only way that many rural communities could support surgeons. The itinerant moved from town to town operating and leaving the care of outcomes—good and bad—to the local physicians, who may not even have seen these procedures before. The surgeon typically was not available for follow-up care, having traveled to another rural hospital or returned to his or her home city all in the same day. The American College of Surgeons specifically prohibits itinerant surgery. However, medical opinions have varied greatly about the necessity and ethics of itinerant surgery and its effect on the quality of patient care.
In 1987, the Office of the Inspector General performed an analysis of 242 general surgical, orthopedic, neurosurgical, and urologic operations performed by itinerant surgeons during the previous year in a random sample of 72 rural hospitals with 50 or fewer beds. The Office of the Inspector General's interest was not medical ethics: at the time of the 1987 study, Medicare paid surgeons for a 45-day postoperative global period, and they wanted to know if they had received the expected services.
These were the findings: Twenty-eight percent of the sampled rural hospitals employed itinerant surgeons, who performed 73 percent of the cases. The inspectors also found a higher risk of poor quality care with itinerant surgery, which was a startling (but predictable) eight times the average Office of the Inspector General study prevalence in similar hospitals. Seventy percent of the cases reviewed were elective, and therefore could have been performed elsewhere. Further, 8 percent of those elective surgeries were found to be contraindicated. In 63 percent of the records reviewed, the itinerant surgeons did not provide postoperative care but billed Medicare anyway for global fees that included this care.
Though not every finding applies to plastic, particularly aesthetic, surgery, many do.
Forgetting the Internet, what is it that people have expected from their physicians? What were the patients of fourteenth century physicians or of shamans hoping for when they called for the doctor? In the years of the great plagues, when carts came through town each night to pick up the dead and carry them off for burial, what on earth was our function? What did the man do, when called out at night to visit the sick for whom he had nothing to offer even for palliation, much less cure? One thing he did, that we surgeons still do, is plainly magic. After the shaman went through his convulsions and shakes, saw visions, heard voices, and fell into long stretches of unresponsiveness, he came back to life, dancing around the bedside, making smoke, chatting incomprehensibilities, and touching the patient everywhere. The touching was the real professional secret, always obscured by the dancing and the chanting but always there, the laying on of hands. The doctor's oldest skill was to place his hands on the patient—the personal, private physician-patient relationship derived from these intimate interactions.
The Internet has changed the way we live, the way we research, and the way we find our physicians. Yet, none of our representing plastic surgical societies has stated its opposition to itinerant surgery—no matter which party is moving around—or established guidelines for surgeons treating patients who travel from a distance. The Code of Ethics of the American Society of Plastic Surgeons contains the following sentence, which is important but incomplete:
“Section 2, XI. Each member may be subject to disciplinary action, including expulsion, if … (J) The member performs a surgical operation or operations … under circumstances in which the responsibility for diagnosis or care of the patient is delegated to another who is not qualified to undertake it.”
That includes the patient who has gone home.
I suggest the following addition, created from the Statement of Principles of the American College of Surgeons (section II, F; revised March of 2004):
Time and distance are not relevant in determining whether an individual surgeon has performed “itinerant surgery,” regardless of whether the surgeon or patient is responsible for the separating distance. It is the charge of the operating surgeon to establish methods for maintaining continuity of care regardless of how far the patient has traveled.
Discharge of a patient to any location that prohibits in-person postoperative care while early complications can still occur may constitute itinerant surgery. Postoperative care must be rendered by the operating surgeon unless it is delegated to another surgeon equally well qualified to complete that care.
Let us not allow Internet “magic” to succeed in making any part of the plastic surgeon-patient relationship disappear—even from a distance.
Mark B. Constantian, M.D.
19 Tyler Street
Nashua, N.H. 03060