Face to Face

Do we continue to do “good” when we know there is something “better” available? Is something wonderful in the trial stage or maybe still in the lab? Is a new treatment too expensive, does insurance cover it, is one patient more worthy than another patient? Do we make a stand for our patients or go with an overused procedure with mediocre results because the reimbursement is there? Are we all becoming employees of insurance companies? In other words, is “good” good enough? My mentors who were pillars in our field would say, “no.” At Houston Methodist, famed heart surgeon Michael DeBakey left his mark on many of us who shadowed him and were his students. As his surgical resident, he would say to me, as he did in his writings, that our job is to “relight the lamp of excellence.” DeBakey, however, was known as a perfectionist and a tough task master. Could perfection like DeBakey’s be the enemy of good or was his difficult nature aimed only at those other medical professionals who were making it harder to achieve his patients’ best health. At Houston Methodist, we have invested in the finest technology possible for our Otolaryngology – Head and Neck Surgery patients and learners. We have the state of the art in single port robotic surgery, a virtual surgical suite and research areas like few others and equipment in all of our clinics that is top of the line. How do we mesh this investment in the future with the mediocrity of a procedure or strategy simply because it has been approved by the insurance company for reimbursement? We must do what is right for the sake of our patients and move forward the discovery of new frontiers in medicine. Perhaps most influential in my education was Bobby Alford, 43-year chair of the Department of Otolaryngology — Head and Neck Surgery at Houston Methodist Hospital and at Baylor College of Medicine. He trained me to be a lifelong learner. Like others before him, including William Osler, the father of modern medicine, he taught the importance of doing three operations on each patient. Before the operation, practice in your mind’s eye the operation that you believe is needed for the problem or pathology. Then, do the best operation you can as circumstances arise. After, when the operation is over and it is still that same day, once again in your mind, do the operation a third time. This time, perform the operation you might have done could it have been even better. For surgeons today, this mental practice gives more encounters with patients’ problems and pathology. A surgeon must have as many clinical encounters as possible, especially with today’s limits on hours spent in a work week or time spent in a shift. With every patient there is something different and something new to learn to build on your personal clinical database. Dr. Alford, like Dr. DeBakey, said physicians must preserve high standards and protect rights and best interests of their patients at all costs. He added that specialists in Otolaryngology — Head and Neck Surgery “must differentiate themselves for the excellence they offer to patients, lest they become generic.” He was influential in every stage of my development as a physician and as an educator as he was in the otolaryngology field — a field that has drawn the top graduates of most medical schools for decades. “Today’s health care scene often pits payers and patients against physicians,” Dr. Alford said in 1996 as the guest of honor at the prestigious American Laryngological, Rhinocological and Otological Society Society, and his words are still true today. “Consequently,” he added, “quality of care has suffered and innovation in diagnosis or treatment is threatened, hampered or in decline.” High quality health care has become associated with high cost and is often said to be not cost-effective. This overreaching statement delves into the ethics of surgical innovation. In my regular conversations with my contemporary, Ronald Kuppersmith, past president of the AAO-HNS, we frequently discuss new technology entering our field. Dr. Kuppersmith was my upper level resident, teaching me how to do my first tracheostomy as a PGY-1. He has gone on as an innovator, helping bring new technologies into our field, resulting in better patient care. Ron continues to influence my beliefs that new technologies can be cost effective and improve quality of care and that we must continue to improve by being ethically innovative. I also believe it can be lifesaving and also life improving for the longer life expectancies of future generations. If physicians focus their attentions, intellects and innovative energies on process re-engineering and disease management, the pursuit of excellence is possible. As physicians beginning a residency, we had ideals in front of us. I challenge myself and our new residents to envision those ideals and hold fast to our dreams for the future of our profession and our patients. Mas Takashima, MD, FACS Professor and Chair Department of Otolaryngology — Head and Neck Surgery Houston Methodist Academic Institute