The Surgeon in the Present Socio-economic Context

In recent years, the economic situation in Spain has had an effect on all parts of our society. The national healthcare system has been greatly affected, as economic and political decisions have had negative consequences for both patients as well as medical professionals. Cutbacks in service portfolios, copayments for medications, salary reductions, lack of professional incentives, and practically nonexistent funding for training and research have all resulted in a loss in healthcare quality. The main problem of these measures is that they follow guidelines that are exclusively political, without the necessary participation of healthcare professionals. Surgeons cannot and should not overlook these changes that are encroaching on their future professional careers.

Of late, some Spanish autonomous communities have been trying to implement a private administration model in public hospitals, although we really do not know what the benefits for patients are or if healthcare costs are able to be reduced, for that matter. There have been no economic studies that answer the question of which model is the most efficient. In regions that have opted for the private management model, there is a general lack of transparency.

Justification of expenses should be an objective of any healthcare organization, whether public or private. But this is not necessarily synonymous with reducing the range of services provided. The public administration of hospitals in our country is currently undergoing a process of transformation toward a more efficient model, which in many places is being spearheaded by the healthcare professionals themselves. Current neoliberal guidelines defend private administration models, arguing the need for efficiency. Nevertheless, in said models and due to economic reasons, there is a risk for adopting objectives or priorities that have little to do with patient needs. This situation can pose doubts or ethical conflicts for medical professionals, while their work conditions become less favorable. Recently, in the Community of Madrid, healthcare workers have rejected the imposition of this model in several hospitals with a committed and exemplary attitude, and regional administrators have had to change their decisions after a court sentence.

Optimizing the administration of available resources should be a priority objective in all medical centers, particularly in surgical units. However, providing quality care should be equally important. Measures such as extending the ordinary work day, overloading surgery schedules or reducing personnel on duty should be carefully considered as they can result in a loss of quality of care or patient safety, whose consequences could potentially be worse, even from a financial standpoint.

The current context of the healthcare system has made evident the need for surgeons to be familiarized with basic hospital administration tools. This can be defined by making doctors responsible for decision-making in order to improve the correlation between care quality and cost. This would entail assuming responsibilities beyond clinical practice. Surgeons should therefore be aware of the costs incurred by their actions and decisions in order to determine the most cost-efficient treatment for each patient. The excessive variability in clinical practice, especially in those processes where there is scientific evidence available about diagnosis and treatment, may be a threat for patient safety and also for the sustainability of the healthcare system. In surgery as well as in other branches of medicine, the origin of this variability lies in the different styles of practice, lack of scientific evidence or its miscommunication.¹ Thus, in published studies about variability in surgery, unjustified variations have been observed in the use of antibiotics and thromboembolic prophylaxis, hospitalization protocols (admittance/MOS), surgical techniques and anesthesia, many of which are evident areas for improvement.^2,3

We surgeons should develop new work methods to systematically study the effectiveness and efficiency of our interventions. Both clinical practice guidelines as well as clinical approaches have been shown to be effective tools for reducing variability. Their objective is to establish explicit evidence-based recommendations aimed at influencing clinical practice. A perfect example would be the increase in the number of major outpatient surgeries that, while maintaining the same level of quality, have reduced the number of avoidable hospitalizations, increased multimodal rehabilitation in digestive surgery, and reduced unnecessary hospital stays in processes such as cholecystectomy or thyroidectomy. Another tool that has been adopted from the business world and that has been shown to be useful to achieve better results is benchmarking, which is a group of activities that tend to achieve better results.

Along these lines of work, the Spanish Association of Surgeons has developed on-line training courses, both for surgeons as well as for residents, aimed at teaching basic hospital administration principles that until now had not been taught in medical colleges. Likewise, a new edition of updated administration guidelines is being prepared with a more practical orientation.

Technological advances have significantly aided the development of our specialty in recent decades; they have facilitated surgical techniques, minimally-invasive surgery and organ transplantation. While the industry has collaborated especially in this progress, it has occasionally supported very expensive practices and techniques, whose cost–benefit ratio has not been scientifically demonstrated. The lack of funding for the continuing education of surgeons in our country's hospitals has led to an undesirable dependence on the industry, which creates conflicts of interest on many occasions.⁴ In the current situation of the public healthcare system, surgeons should maintain their commitment with the healthcare organization, but remain independent and critical of both the administration as well as commercial pressures, with the aim to maintain quality, science-based, updated and efficient healthcare.

Conflict of Interests

The authors have no conflict of interests to declare regarding this article.