Why is Med Staff Credentialing Hopeless?

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Being a surgeon is a great career. However, sometimes a surgeon has to deal with medical staff and credentialing. Thankfully for most surgeons this is a rare occurrence and they only have to think about it whenever they start at a new hospital. When working as a locums or per diem surgeon this is a problem that is encountered on a frequent basis. There is no standardized credentialing application. And to make matters worse despite having the same requirements at almost every single hospital, without the same forms, new letters of recommendation and new verifications are required continuously.

As a surgeon that works at different facilities the problem compounds itself because when you work at numerous places you have to get more more and more verifications and the problem expands exponentially causing a great bureaucratic burden.

My dream would be to have a standardized credentialing system and a unified verification platform that would allow hospitals to indicate when a surgeon has worked at a particular location much like the FCVS system works. Another irksome aspect of this is requiring frequent letters of recommendation. These letters of recommendation are oftentimes accompanied with an evaluation form. It would be so much simpler if this could be done annually and logged into a unified database where it could be accessed by all credentialing bodies.

We live in an era where cars drive themselves and our phones have more computing power than ever before. It does not seem like it would be a difficult process for a large accrediting body such as JCHAO to provide a service such as this. In an era where we value and accountability is prized this is one area of Medicine that is lagging far far behind.


The evolution of policing in England: From Bobby police caps to Robocop

Ask anyone outside of the UK (and most people within the UK for that matter) to conjure up an image in their mind of a British police officer and what will you get? A friendly and approachable man in his smart white shirt and black tie wearing a strange chin-strapped rounded helmet adorned with a gleaming silver royal crest and nothing more than a truncheon with which to effectively discharge the duties of his office. For the most part this continues to remain true, and aside from the incremental introduction of stab-vests, CS spray, Tasers and a few other bits of kit, the vast majority of British police do not carry firearms.

Dixon of Dock Green, the quintessential British police officer

Dixon of Dock Green, the quintessential British police officer

 Official UK government figures ([1]) show there to be just over 6000 armed officers in England and Wales, a mere 5% of the total number of police officers in the country. In the year ending 31st March 2017 there were only 10 incidents of police officers discharging their weapons in the whole country.

Firearms officers are normally only dispatched to incidents believed to involve a firearm. Gun crime in the UK continues to pale in comparison to that of the US. Guns were used in over 60% of homicides in the US in 2016 compared to 4.5% of homicides in the UK in the same year ([2]).

Whilst gun ownership is enshrined in the US Constitution, private ownership of handguns was effectively banned in the UK in 1997 following the notorious Dunblane Massacre the previous year when 16 kindergarten-aged children and their teacher were shot dead in their school gymnasium by a lone gunman. Former world number one tennis star Andy Murray was an 8-year-old pupil at the school at the time and narrowly escaped.

The biggest threat with regards to firearms in the UK is not from private owners, but instead is believed to come from pre-planned Marauding Terrorist Firearms Attacks (MTFA). The current threat level for international terrorism in the UK, as determined by the security services remains at ‘severe’, meaning an attack is highly likely. Since the 2008 Mumbai terror attacks which killed over 160 people and the November 2015 Paris attacks in which 137 people died (both incidents involving mass shooting and bombing campaigns), the security services have ramped up preparations for similar such attacks in the UK. Whilst the 20-mile stretch of water that separates the UK from the rest of continental Europe offers a slight degree of protection against the free movement of automatic and semi-automatic weapons witnessed elsewhere on the continent, it is deemed to be a case of ‘when’ not ‘if’ a MTFA occurs on British soil.

This ongoing threat has prompted a paradigm shift in the image of British policing. It is now common place to see armed officers with Heckler & Koch MP5s and G36s patrolling airports, subway stations, shopping malls, tourist hotspots and even Christmas markets. An 11% increase in the numbers of armed officers was seen in 2017, and alongside the recruitment drive and increased police funding, senior officers have begun to develop new tactics to confront the evolving MTFA terror threat.

Counter-Terrorism Specialist Firearms Officers (CTSFO)

 In addition to the regular deployment of firearms officers, there is now a 24-hour immediate response team of highly trained CTSFOs ready to respond to an unfolding MTFA. Established in the run up to the 2012 London Olympic Games, these elite police officers train alongside special forces soldiers to hone skills in close-quarter combat, sniping, fast-roping from helicopters, marine operations and siege tactics.

Rapid deployment

In major cities congestion, pedestrianised zones, abandoned vehicles and street furniture can pose significant obstacles to emergency services responding to a fast-moving MTFA. To counter this, London’s Metropolitan Police Force have access to a fleet of high-speed BMW GS800 motorcycles, each capable of carrying 2 firearms officers to the scene of an attack.

From containment to confrontation

Kevlar-clad CTSFOs stand beside their new fast response motorcycles in this 2016 publicity shoot (London Evening Standard)

Kevlar-clad CTSFOs stand beside their new fast response motorcycles in this 2016 publicity shoot (London Evening Standard)

Previously, armed incidents were dealt with by setting up cordons to contain a threat and attempts made to negotiate with the attacker. This tactic would prove hopeless against ideologically-driven terrorists with suicidal intent and automatic weapons, leaving innocent civilians in their immediate vicinity as sitting ducks. Therefore, the response to such an incident now would involve the first armed officers on scene immediately moving forward to confront and neutralize the threat with lethal force. This would involve them stepping over the bodies of the dead and injured to deal with the attackers in the ‘hot zone’ leaving specialist EMS and fire crews to move in to the ‘warm zone’ behind them to provide battlefield-style triage, immediate emergency treatment and rapid evacuation of injured civilians from the scene.

 Inter-agency cooperation

During a sustained MTFA, plans are in place under the banner of ‘Operation Temperer’ to draw on the armed resources of the regular army, the Ministry of Defence Police and the Civil Nuclear Constabulary (who guard the UKs nuclear sites) to backfill regular armed police roles and provide additional operational capability. If required, special forces personnel can be directly deployed to confront and neutralise a terrorist threat. On 22nd March 2017 a lone attacker drove his van at pedestrians walking along London’s Westminster Bridge, killing 4 people and injuring 50 others before fatally stabbing an unarmed police officer outside the gates of the Houses of Parliament. At the time a friend and colleague of mine who is a British Army doctor was refereeing a military rugby game just outside of the city. One of the players on the field happened to be a special forces soldier. As the attack unfolded many miles away a helicopter landed unannounced in the middle of the field of play. That particular special forces soldier was promptly summoned into the helicopter and flown away before anyone on the field had any idea that a terrorist incident was in progress. Clearly this particular soldier was on standby for just such an incident.

 The UK has seen an uplift in armed police resources and operational capability in response to world events in recent years and the ongoing terrorist threat closer to home. This alongside the establishment of the London Major Trauma system in 2010 followed by similar regionalised trauma systems across the country has enhanced the UK’s ability to respond to mass casualty events. Lessons continue to be learnt from recent incidents such as the 2017 Manchester Arena bombing, London Bridge attack and Grenfell Tower tragedy. Through multi-agency training and proactive preparation more lives will continue to be saved in future.


References

[1] https://www.gov.uk/government/publications/police-use-of-firearms-statistics-england-and-wales-april-2016-to-march-2017/police-use-of-firearms-statistics-england-and-wales-april-2016-to-march-2017#fn:3

[2] https://www.bbc.co.uk/news/world-us-canada-41488081

What Makes an Awesome Trauma Surgeon?

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Clearly, the ideal physician candidate is a high-quality surgeon who can demonstrate both good patient outcomes and a safe decision-making approach. However, strong clinical abilities are not the only requirement for a successful trauma surgeon.

By nature, trauma surgery calls for strong leadership skills. Successful trauma surgeons have the ability to both inspire and orchestrate a trauma team. They are level-headed and have a treatment vision that drives patient care. Above all, they are respected by everyone they come in contact with, and they understand that a raised voice is only effective when used sparingly.

Good trauma surgeons are also team players. Look for candidates who are willing to take part in referral recruiting activities, such as giving clinical presentations to paramedics. Certification as an ATLS instructor is also a good sign, since it shows a candidate’s commitment to the overall trauma system.

What to do with a recent graduate.....

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Being both a clinically active surgeon involved in resident education and also being the principal at a locums-type company, this time of year always causes me to reflect. Beginning around May, Chief residents begin to approach me because they have finally begun to explore the employment landscape and become rather disenchanted. Chief among the complaints are a lack of understanding of the contract which leads to a feeling that they're being taken advantage of, an impossibly restrictive call commitment which paints a bleak landscape for the next year or two, and only a vague promise of a bonus. The dilemma is that these very surgeons are oftentimes not prepared for the demands of independent practice let alone the premium locums practice where they will be called upon to perform difficult cases, oftentimes with limited ability to consult a senior surgeon.

It is rare in these times that residents completing their training are ready for full independent practice the way the previous-generation was. This is because of decreasing autonomy on call and in the operating theatre. Almost every facility has an in-house attending now. This is good for patient care in the short term, however it poses a great challenge to the trainee who is forced to be on call by themselves for the very first time when there is no one available to assist them. It is a shame that there cannot be a balance between the need to prepare residents for independent practice and optimal patient care.

This always poses a great dilemma for myself because I would like to provide an optimal alternative to a traditional practice setting where Physicians are empowered. I have to recognize the limitations of individual providers as a result of the modern training paradigm. The way that I deal with this is by addressing is on a case-by-case basis. The best way for me to handle this is to consider each case and try to pair them with the optimal practice setting. For example a resident that does not feel particularly comfortable with emergency situations would be best suited in a busy elective practice where most of the action takes place during the day where there are other surgeons around. Alternatively some facilities require formal proctoring of the first 10 procedures. These are oftentimes good settings for these young surgeons. Sometimes we have to refuse a recent graduate because they do not have the skill required to take on independent trauma surgery. This is where being on both sides of the equation is a great benefit to InterTrauma Consulting. Unlike traditional a traditional locums company which is very interested in business we are also concerned with patient safety, the reputation of the clinicians, and ensuring that there is a good fit between the provider and the center. It seems obvious to me that companies that are tasked with providing coverage should have clinical insight and I am disappointed that more are not. All this is however our greatest advantage.