Operating in a Contemporary Safety Net

It is summer, and I have just started my fourth year of general surgery residency, having just returned from two years in the lab. My “lab years” were spent as a Scholar–in–Residence of the American College of Surgeons. The scholarship that I engaged in included obtaining an MBA and a Graduate Certificate in Professional Ethics. The ethics component was self–designed with help from an advisor, and was made up of graduate courses in political theory, healthcare financing law and bioethics. To say that I was reflective as I returned to the clinical rotations of the fourth year of residency would be understated.

During this two–year period, I did not operate. I did do some clinical work during this time, but there wasn’t anyone in town willing to hire a partially–trained surgeon to do anything operative. I ended my third year of residency very happy with my technical skills, and was not sure just how these skills would survive a two–year hiatus. The challenge, as I thought of it then, would be to return to clinical rotations with this insecurity in mind and try to gain insight into just how rusty my skills were in a short period of time, and rectify them. I was in for a surprise.

I felt a chill of trepidation when I discovered that the rotation that had been selected for me to return to was one in which I would be assigned to operate on and care for a low–income population of uninsured or underinsured patients with surgical problems—with minimal attending supervision. The patients were referred from the Federally Qualified Health Centers in town. The rotation had arisen from altruistic roots. The surgical service, provided at a large, academic urban hospital, was established when the city’s last remaining public hospital closed its doors for surgical patients. The service was an upright attempt to provide surgical continuity for this population. As I started the rotation and performed my first surgeries in two years with very minimal supervision, I realized that I would be participatory in what sums to a thoroughly unjust healthcare system. I would be caught in a swirl of humanitarian justice celebrated and a focus on a justice that seemed to fall short of a mark.

The indigent hospital itself managed the clinic with a full complement of staff befitting a contemporary surgical clinic, albeit with a rather rudimentary computer system. The recordkeeping mechanism in our surgical office, however, was done without administrative assistance. We occupied a small room amongst the academic surgical offices at our home institution. The chief resident sat at a large desk, the intern at a smaller desk, and the medical student had a chair and a laptop. The recordkeeping mechanism tracking who needed surgery, who had had surgery, and who needed follow–up on pathology was maintained by all members of the team. It involved one labyrinthine Excel spreadsheet, with multiple tabs, and a complex color–coordinated scheme of organization. The team would scan the entire thing on a daily basis to make sure nothing would be missed.

When it came time to schedule a patient for the operating room, it was my responsibility as a chief resident to get an attending to “cover the case”, which amounted to finding an attending who agreed, at the bare minimum, to be present for the “critical portion” of the case. If the case was complex or very difficult, an attending surgeon would have to be sought who would scrub in and help perform the procedure. Not every attending would cover a charity case—the reasons why were not forthcoming. One surgeon would scrub every case he was asked to cover, stating that he felt every patient should have the same chance at the best treatment. Another would come to the room, but sit along the wall and review manuscripts as we operated, there to grant reassurance, and answer questions, but not, presumably, to direct the overall decision–making. All patients with breast cancer were seen, and operated on by one very dedicated breast surgeon with a humanitarian bent.

I...