Murray Pfiefer: Dangerous plan makes little sense

Considering Dr Salmond's proposal for "technicians" rather than highly trained surgeons to perform minor operations, I'm reminded of the old story about the professor of medicine telling a class of young and eager first-year students: "I could teach all of you the techniques of removing an appendix in 20 minutes. But it's going to take me five years to teach you what to do when something goes wrong."

Labour shortages are a major issue for almost all branches of the health sector including medical technicians, nurses, doctors and surgeons. In this climate it makes no sense to suggest technicians can fill the shoes of surgeons.

New Zealand is becoming increasingly intolerant of risk and medical error. While the medical community worldwide is focused on finding ways to reduce error and improve standards, we see regular examples of "botched surgery" paraded in the media. It seems unlikely the public will tolerate any reduction in the standards of medical care.

Yes, technicians do perform cataract surgery in the Third World but it doesn't necessarily make it a good idea here. While these operations are a blessing for people who have their vision improved they are often a "one size fits all" solution and don't produce the quality of vision the public expects in New Zealand. If our surgeons were to accept and support this idea, I confidently predict a huge public outcry from hundreds of people disappointed with the end results.

The difference in cost between employing a surgeon and employing a technician are not that great. The overall cost of surgery is derived from the cost of employing all staff in the operating team including nurses, anaesthetists and technical assistants. It also takes into account the cost of operating theatres, equipment and other consumables. Replacing a surgeon with a technician will make the operation only marginally cheaper but won't make it any safer or more successful.

This reminds me of the motor technician who complained about the cost of a heart transplant. "I remove and replace car engines all the time which is basically the same thing," the technician said. "The cost is nowhere near as much."

"Try doing it while the engine is running," the surgeon suggested.

The human body can behave in unpredictable ways so people need experienced, capable surgeons. The art and skill of surgery is not only about executing routine operations with excellence but also about exercising judgment and expertise when things don't go according to plan. This comes only with high quality training, good supervision and practice. Being called in to "trouble-shoot" someone else's operation is like peering into the proverbial black hole.

Another skill expected of surgeons is to know when not to operate. This is often considerably more difficult than simply doing the operation regardless. An inappropriate operation may cost the patient his/her life. The idea that large volumes of non-urgent elective surgery can be done by technicians assumes that surgery is largely technical and fails to take account of the importance of the surgeon-patient relationship.

Most New Zealanders will have one or two operations in their lifetime. Patients need to have a personal sense of confidence in the surgeon with whom they are so intimately involved. They need to trust that they will turn out for them, even after hours, if something goes wrong. In an ideal world the surgeon, the patient and theatre staff will work as a team.

New Zealand surgeons, particularly in smaller centres, don't do enough operations in certain areas to give them the expertise and confidence to practise safely. People are coming into tertiary hospitals to avail themselves of surgical expertise, so waiting lists grow and rural surgeons become more professionally isolated.

If we allow ourselves to adopt a factory approach to surgery we will see technicians undertake the bulk of routine surgery in procedures such as hernia, varicose veins and cataract operations - then presumably better-qualified but less experienced surgeons will supervise them and advise when things go wrong. This highly dangerous proposal makes little sense.

As Chairman of the Government's Health Workforce Advisory Committee, Dr Salmond and his team are charged with providing useful and intelligent solutions to address current workforce shortages in the health sector. I hope he can find a more comprehensive and realistic answer.

* Murray Pfiefer is a general surgeon based in Invercargill.