Who Wants an Open Appendectomy?

The first laparoscopic cholecystectomy was performed, believe it or not, in 1987 (J Laparoendosc Adv Surg Tech A. 1997 Dec;7(6):369-73.). Though there is a long history of similar procedures, this was the first demonstration of the discipline, which required the invention of small cameras to allow for the technique. There was a traditional practice of surgery, but the introduction of technology, technique, and a recognition of reduced morbidity and mortality has revolutionized the surgical disciplines, making open cholecystectomies and appendectomies nearly completely unnecessary except for extreme cases of infection, rupture, or just poor technique or training.

        Imagine if surgeons were to eschew the move to these techniques. We would still be performing open procedures on even the simplest of pathologies (for example, hernia repairs and such). The cost of healthcare would be higher due to the associated need for prolonged hospitalizations, the increased risks of morbidity and mortality, and the staffing and facilities required. Also consider the increased scar formation, body self-image issues, and risks of abdominal adhesions, etc.

        Now surgeons are even starting to move to robotic surgeries (DaVinci, etc). This has demonstrated improved outcomes with certain surgeries (prostatectomy), and requires less assistants, with a steadier hand for our more experienced surgeons.

        I do not understand the resistance of primary care physicians and other medical physicians (as opposed to surgery physicians) to advance their own practices. Just because we have done it the same way for centuries does not necessarily mean that we are doing it right. And the availability of technology tools now readily at our disposal should encourage us to move into these advanced care models. Those who insist that they cannot, should not, or will not improve their practices risk their own obsolescence, much like surgeons who might insist that open surgeries were still the best way to remove a simple non-obstructive gallstone.

        For us in medicine, the open surgery equates to the delivery of episodic medical care. I still can’t fathom the need for a primary care physician to walk into their office, comfortable with a full schedule of 28-36 patients before they walk through the door. To me, that is tantamount to early burnout, reduced patient satisfaction, reduced quality of care, and increased healthcare delivery costs due to patients being diverted to urgent cares and emergency rooms. The creation of healthcare teams, which include the use of physician extenders (Physician Assistants and Nurse Practitioners) whom enhance and maintain the physician health plans for patients, open access scheduling to allow for those patients who really need to be seen same day, and population health tools to effect patient recall, close gaps in preventive care, and assure adherence to care plans are all the modern means to providing good primary care in our era.

        The payment model follows that evolution in the delivery. We can no longer depend on the episodic fee-for-service model which has supported our healthcare system to date. It is unsustainable, not cost-effective, and rewards those who underperform and punishes those who over-perform by equilibrating payment for all. Those primary care physicians whom already deliver an enhanced practice model are absorbing the costs, recognizing that in the end it improves patient health. But we cannot depend on one model of payment, as delivery throughout the United States differs based on state regulation, socioeconomic status of the population, and availability or lack of healthcare provider teams. I applaud the creation of new healthcare payment paradigms—capitated healthcare, Direct Primary Care, subscription models with traditional insurance, value-based models, Medicare Advantage models, and government models. Each has its own merits, and should stand to benefit the needs of those whom choose those models. Innovation in payment models should lead to a diversity of primary care experiences, though there should be an underlying focus. This has become known as the population health model, incorporating the Triple Aim focus. I believe that rewarding physicians for practicing good medicine, providing excellent availability, and reducing healthcare costs should be provided a shared savings payment, as well as a Per-Member-Per-Month payment to maintain that longitudinal model of care for Chronic Care. This must become the dominant payment model. As surgeons have been incentivized to practice new techniques of surgery, the healthcare payment industry must follow suit in rewarding medical practitioners in primary care as well as in specialty medical care.

        It is the equivalent of the revolution in laparoscopic and endoluminal surgeries. If we can embrace this migration in medicine, then we will improve the care of patients, reduce costs, morbidity and mortality, and improve the patient satisfaction enigma which is easily solvable in the face-to-face encounter. For what patients really want is to see their physician when it’s easy, convenient, and/or necessary. Those practitioners whom stay behind are left behind, and to be left behind risks our own obsolescence by those who do advance.