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Old 05-29-2013, 01:17 AM   #17
acrosome
 
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Default Re: What level Physician skill should an MD have?

Quote:
Originally Posted by Refplace View Post
LOL That was my first thought on reading his post.
I think 12 is ok for GP and most Residents but there usually not spending enough time to get a bonus. A lot of mistakes are made and a lot of trail and error but most of the time its not serious enough to kill anyone.
Yeah- remember, in the U.S. a GP is someone who has finished medical school and done a one-year internship, but they have not done a residency. An FP, on the other hand, has finished a three-year residency, as has an internist. A GP wouldn't have Surgery skill, but an FP would, albeit at a low level, since they do OB and can supposedly do cesarean sections and such. And I guess I'd give the FP higher levels of Physician and Diagnosis, too. From my way of thinking and internist would have Physician and Diagnosis at a higher level than the FP, but would lack Surgery skill. (But I'm pretty sure that in GURPS terms this isn't the case.)

Reminder: First Aid defaults to Physician-0, so someone with Physician skill probably doesn't need to waste points on First Aid.

A note to Peter Knutsen: anything a surgeon is doing in his office is covered by Physician or Diagnosis skill, not Surgery. Surgery seems, in GURPS terms, to almost be a physical skill. It's kind of odd- it covers bonesetting too, for example. (Yes, I would have done medical skills differently.) Well, actually, that's not 100% accurate, since surgeons do minor procedures in their offices- removing lipomas, even some breast biopsies, etc., and that would be Surgery skill. But just examining a patient, reviewing test results, and making a diagnosis is Diagnosis skill. Routine medical care like taking care of an inpatient after surgery is Physician skill.

And, usually there are not two surgeons in a surgical case. It's nice, but usually it's just one surgeon. For some ridiculous monstrosity case like a Whipple or something, yes, any sane surgeon would be sure one of his partners was there to help. Maybe also for a gastric bypass or a re-do Nissen. But for a cholecystectomy? A hernia? Or, heck, any emergency that happens in the middle of the night while you're on call? Not likely. I had to do an exploratory laparotomy in the middle of the night recently for a marginal ulcer at the gastrojejunal anastomosis of a gastric bypass that had been perforated for over a day- no backup, just me and an OR tech. What a mess. (If you're wondering, I just Graham patched it and she did fine.) Having a second surgeon in a routine case is a waste of that second surgeon's time. And, of course, Medicare doesn't reimburse well for a first-assist... ;P
But also, it would be pretty damned unusual for an OR tech or anesthetist or anyone else in the room to spot a surgical mistake made by the surgeon and "help" him by pointing it out. They all have their own jobs to do.

There was a long discussion here: http://forums.sjgames.com/showthread.php?t=100987. (It gets into a general medical discussion, not just PJs, later in the thread.)

And the more I think about it the more annoyed I get at the thought that someone might try to deny me my Surgery-14 after I did that five-year residency! Come and say that to my face, brother! What's a guy gotta do to get a freakin 14 around here? That was five years of 100+ hour work weeks! You're lucky I'm not asking for 16!

Consider- yes, we get +4 for "best" equipment at TL8 for using an OR in a hospital to do most cases. According to the injury rules in the basic set, stabilizing a mortal wound is an average task until -3xHT, when a -2 penalty is incurred, and it gets worse from there. And that's average for something that is very much under a time crunch. So, what is something like removing a gallbladder in GURPS terms? Easy? But let me assure you- I would not want an FP with Surgery-10 removing my gallbladder, and with +4 for using an OR and +4 for an easy task for effective skill Surgery-18 he basically won't fail. Even if you give him a familiarity penalty that's still a ridiculously high effective skill for a non-surgeon to not have some kind of a complication. No freakin way. It gets worse if you want to give the ER doc Surgery-12 (which is defensible, since part of their job is "stabilizing mortal wounds" in GURPS terms, which requires Surgery skill), so his effective skill wounf be Surgery-20. So you have to differentiate a surgeon somehow.

I would propose that removing a gallbladder is not an easy task. Stabilizing a mortal wound seems to be an average task, and would include things like placing a chest tube, ligating bleeding veins, pericardiocentesis, etc. This is all invasive, but not capital-I Invasive. I would propose that removing a gallbladder, or fixing a hernia, be about as hard as doing these things- so, an average surgical task. But it's not under a time constraint the way stabilizing is, so maybe favorable or very favorable if the GM is generous, from the descriptions on B345. (But those descriptions are hard to get a handle on- I won't hesitate at all to remove a gallbladder, but the patient might...) This gives the FP with Surgery-10 an effective skill of Surgery-15 or so to remove the gallbladder without complication in an equipped OR, or better if he takes longer than average (which for a laparoscopic cholecystectomy is probably about an hour- I've done them in half that when I was really on my game and the case was uncomplicated). That sounds a little more reasonable, but frankly still seems kind of high, and is where an actual surgeon with Surgery-14 would get differentiated, with an effective Surgery-19, so he's even good if the case is more difficult than most. As he should be. I've removed hundreds of incredibly sick not-your-average gallbladders, and had a few minor complications, but never a major one such as a duct injury (knock wood).

I mean, we're talking about people with doctorates, here- the equivalent of a PHD. And then 3 to 5 years of OJT in residency. And then maybe 1 to 3 years of specialty OJT in fellowship to become a subspecialist. I really don't think that having a skill-14 in their specialty field is out of line. A generalist like an FP? Sure, Physician-12, Diagnosis-12-14, Surgery-10 seems reasonable. ER doc: Physician-12, Diagnosis-12, Surgery-12. (Heck, half the time they don't make a diagnosis.) Internist: Physician-14, Diagnosis-14. Surgeon: Physician-14, Diagnosis-12-14, Surgeon-14 (five year residency, not three, remember?) Then, how about cardiac surgeon: Physician-14, Diagnosis-12-14, Surgeon-16! Chest surgery is at -3, remember? And they did a five or six year general surgery residency plus a two or three year fellowship to specialize in cardiac surgery. They deserve Surgery-16. Similarly, neurosurgery is a seven year residency, so it sort of has a fellowship built-in, doesn't it? And head surgery is also at -3, so the neurosurgeon gets Surgery-16.

Maybe an internist deserves a point in Surgery in GURPS terms, but I've known too many of them who fear putting in a central line or removing a dressing, let alone placing a chest tube or setting a bone. I'd be more likely to force them to default from Surgeon at -5. With Physician-14 this is a default Surgery-9, which jives with my experience of internists and would let them make reasonable attempts to stabilize a mortal wound if given a crash cart, for example. This is where GURPS skills loose granularity- what skill covers intravascular interventions such as placing a cardiac stent? I assure you, a cardiologist doesn't deserve Surgery skill any more than a pulmonologist does, but Surgery skill in GURPS terms covers anything invasive.

Last edited by acrosome; 05-29-2013 at 02:40 AM.
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