The rise of specialisation

The trend towards specialisation in surgery and the establishment of specialist surgical units gathered pace in the 1980s, fuelled by advances in surgical techniques, medical technology and a growing patient population.

In 1986 the surgery division’s general surgery units restructured. A specialist vascular surgery unit was set up and the number of general surgical units was reduced from five to three, with three general surgeons in each unit.

Two years later, under the Cain government’s overhaul of health services in the western suburbs, surgeons gained more opportunities to enhance their skills and specialist interests as the hospital expanded its medical teaching, nursing training, health research facilities and community health education and support programs.

Under Professor Thomas’s leadership of the Department of Surgery, three specialist units were created - breast endocrine, colorectal and upper gastrointestinal.

Benefits for patients

Specialisation enabled surgeons to practice procedures more often, refine their techniques and keep up with the latest research and medical advances in their field of expertise. Their improved skills led to better patient care, according to Joseph Epstein, who was chairman of the senior medical staff in 1994.

“Specialisation and volume counts,” he said. “If you want something done to you, you go to the person who does it often. If you’re a patient, you’re better off. The patient data shows outcomes are better.

One of the inevitable and unavoidable consequences is that you get the ‘grey man’ syndrome – the staff are not as eccentric or colourful as they were in the past but we’re doing better overall.”

The move to specialisation affected every medical service in the hospital. John Mathew was a general physician at Footscray from 1970 for about 30 years. During that era, the medical, surgical, paediatrics and obstetrics division were located together at Footscray hospital.

“There’s an old joke that if you want something done, you get a surgeon and if you want to know what’s going on you get a physician,” Dr Mathew said. “Of course, it’s much more specialised now. I’m a general physician but you don’t find too many general physicians in the city unless they’re old like me. Now people are trained as cardiologists, neurologists or renal physicians.”

The Internal Medical Society of Australia and New Zealand, a peak professional organisation representing physicians, still has general physicians among its membership. But Dr Mathew said general physicians were a dwindling minority who “often come from country towns and the periphery and include old buzzards like me”.

He completed specialist training in diabetes but prefers the diagnostic challenges of general medicine. “If somebody comes in and says, ‘I’ve got diabetes,’ there’s no diagnostic challenge in that. It’s a challenge to get them to start exercising and watching their food . . . So I prefer to be a general physician with an interest in diabetes rather than only seeing diabetic patients.”

Tensions erupt

Specialisation occasionally led to professional tensions between surgeons and other medical staff. Vascular surgery was one of the areas where such tensions erupted.

Vascular surgeon Barry Beiles joined Footscray Hospital in 1995. As head of the vascular unit from 2002-2012, he witnessed dramatic changes in the relationship between vascular surgeons and radiologists, at a national and local level.

Traditionally radiologists were responsible for carrying out non-interventional procedures such as using stents or balloons to dilate an artery. However, by 2002 surgeons throughout Australia started using these procedures instead of performing open surgery on a patient, due to technological advances in aortic stents and other endoluminal diagnostic and therapeutic vascular procedures and devices.

When vascular surgeons decided to do their own angiography, radiologists became annoyed that surgeons were encroaching on their professional territory and poaching their patients. “They (radiologists) were making it very hard for us to get access to their angio suites on a regular basis,” Mr Beiles said. “They had to carefully vet all of our cases and decide how many we would be allocated to do.

“It eventually reached a head for several reasons. There was the issue of what would happen to the patient if a rupture occurred. And aneurysms that required a stent graft were put in as Category 1 patients, which meant you had to treat them within 30 days of them being put on the hospital’s waiting list, otherwise the hospital had to pay $50,000 penalties. The waiting lists started to blow out beyond the 30-day period. That gave the hospital another incentive to iron things out and get us to work together.”

The dispute was resolved in a round table meeting between the hospital’s vascular surgeons, radiologists and management.

“Our relationship became harmonious,” Mr Beiles said. “Everyone realised that we needed each other . . . It’s now accepted that vascular surgeons are independent and have their own laboratories in private practice so they’re not dependent on access to radiology suites. That’s been the case for the past 10 years or more.”

Bringing surgeons into the tent of preventative medicine

Specialisation in other areas forged closer ties between the hospital’s surgical units and its medical units, according to Mr Beiles. The introduction of specialist services, such as the hospital’s diabetic foot service, the endocrine unit and the renal unit have brought surgeons into the process of patient care at an earlier stage, involving them in a more proactive, multi-disciplinary approach to preventative health care.

The vascular surgeons have a ward round meeting each week with the renal unit staff to discuss patient treatment options. They are also in constant communication with the endocrine unit, with surgeons seeing the unit’s patients on request.

“Patient outcomes are better with a collaborative approach,” Mr Beiles said. “Many years ago people with infected diabetic feet might be missed and could lie around and lose precious time and lose limbs because diagnosis was delayed while their other conditions were dealt with.

“Close collaboration between our units is now a regular occurrence. It means that we are very focused on time critical patient conditions. So the diabetic infected foot, to us, is an emergency. We’re not missing those and getting patients with advanced disease that makes the leg unsalvageable. We’re able to save more legs this way.

“We’re not getting delayed referrals. As soon as a diabetic patient hits the ward, we’re notified that there is a diabetic patient in the endocrine unit with a foot problem.”

General surgeon Trevor Jones replaced Professor Thomas as head of the Department of Surgery when Professor Thomas left in 2000 to take up an appointment at Peter MacCallum Hospital.

Mr Jones was one of the hospital’s most influential and legendary surgeons. He held senior leadership roles as a clinician and surgical teacher for 37 years at Footscray, until his retirement in 2014 at the age of 70.

During his career Mr Jones mentored and trained more than 600 surgical registrars and interns.

Mr Sayed-Hassen was a registrar at Footscray under Mr Jones’ tutelage. He is now the Director of General Surgery, at Eastern Health. “Trevor Jones is one of the greatest teachers of surgery I have ever worked with,” Mr Sayed-Hassen said. “As a surgical teacher, I have modelled myself on him.

“A big population of currently serving Melbourne and indeed, Victorian, surgeons would have been influenced by Trevor in one way or another,” he said.

The successive generations of surgeons trained by Mr Jones now work in many different specialty fields of surgery: orthopaedic, paediatric, upper GI, general surgery, breast, endocrine, hepatobiliary, ENT, colorectal, and trauma.

Mr Jones said the rise of specialisation over his long career had obvious advantages for patients and surgeons. But it also posed problems for the profession and hospitals: as surgeons are narrowing their focus, many are losing their broader skill set as general surgeons.

Some surgeons had become so specialised in a particular area that hospitals were having difficulty managing their emergency caseloads, according to Mr Jones.

“If you’re rostered to work in the emergency surgery department, you are supposed to look after every patient that comes in,” he said.

“There are some surgeons who feel unhappy about having to do some of the general surgical problems, including simple procedures such as taking a gall bladder out. My attitude to these fellas is that if they’re unhappy about doing these things, they should go and get trained, because surgeons employed at this hospital and all other hospitals are employed as general surgeons.”

Mr Jones said some younger surgeons at some hospitals had refused to go on the emergency surgery roster, which created a bigger workload for their colleagues. It was a problem that hospitals and Colleges of Surgeons were grappling with worldwide.

Mr Jones said if the problem remained unchecked, costs would spiral as hospitals increased the number of surgeons on call.

“To reduce this to absurdity, rather than having to pay one surgeon on call, we are eventually going to have to employ a colorectal surgeon, an upper GI surgeon and endocrine surgeon, which is just ridiculous,” he said. “We haven’t reached that point yet but it’s heading in that direction.

“This is a generational issue and an industry-wide problem. Younger surgeons will say, ‘I trained to become a specialist’. My attitude was to tell them, ‘You’re general surgeons, get on with it’. But that isn’t the prevailing attitude among hospital administrations, it’s a reflection of my age.

“The best surgeons I’ve ever worked with are general surgeons – one in Wangaratta and one in Port Moresby. They could do everything: hip replacements, removing cerebral tumours, opening chests, repairing hearts as well as doing all the orthopaedics and the general surgery.”