Sunday, January 14, 2007

House Doc (Not "House, Doc")


I received a request recently to share my thoughts about the future of surgery; specifically, I was asked about the concept of the "acute care specialist." About the future, as I've implied in some earlier posts, I have concerns. Despite my occasional wistful posts about the good old days, my worries are less about the people choosing to enter the field (I've indeed expressed concerns about how various factors are converging to select people with different expectations and perhaps a lower commitment level -- not entirely negative, in terms of a surgeon's self-preservation) than about the milieu in which they'll be practicing. I've also said here and elsewhere that whereas surgeons may have brass balls, they don't have crystal ones. So my predictive powers are diminutive at best. Nevertheless, because I see a continuing trend toward needing to work more to receive less, and an undeniable trend toward making the choice of surgery less appealing which is already manifesting itself in the numbers and kinds of people choosing it, I think the concept of the "acute care specialist" has a definite future. (Whew; long sentences!) And as it happens, I have personal experience on which to base that conclusion.

For a while after I bugged out of my full-time practice, the clinic at which I worked used me as a mentor of sorts for the surgeons they hired to replace me. (It took three.) Later, when one of the surgeons (the female, as I recall) got pregnant, they approached me to assume her practice during her maternity leave. I demurred, but proposed an alternative: becoming a surgical hospitalist (i.e. an acute-care specialist), working daytime only but taking care of all the acute consults, and urgent operations that came up during my shift. They agreed; and it turns out that it helped the (comparatively) over-worked surgeons far more than if I'd re-joined the practice. And it was a hell of a lot of fun.

Any group of surgeons (it's true of all genera of doctors) rotate on-call responsibilities. Details may differ, but in general when one is on call, one is responsible for all the emergent issues that arise; and since it's rarely practical to empty one's schedule on call days, being on call means frequently disrupting the office or operative schedule. Which has a domino effect on many people, including the surgeon; especially if, like me, that surgeon hates -- REALLY HATES -- to be late or make others late. For me, call days were corrosive. On my gastric lining. And, vis a vis the milieu referenced above, since surgeons (and all docs) are of necessity trying to shoehorn more and more patients into a fixed number of hours in a day, disruptions are, well, disruptive.

Enter the hospitalist. During the hours I worked (7 am to 5+ pm), the on-call doc knew he'd not have to interrupt his schedule. Huge relief, reflected in oh so many ways. As for me, I was having the time of my life: 100% of my time was dedicated being an actual surgeon. No distractions, no business crap, no politics, no paperwork beyond the usual charting requirements. Expecting a fairly mundane practice consisting mainly of appendectomies, I was surprised to find myself doing colon resections (for bleeding, for perforations, for toxic megacolon), acute gallbladders, gastric cases. And, of course, bowel obstructions, incarcerated hernias and appys. Couple of wound dehiscences (not mine!) Tracheostomies for the ICU patients. Trauma, too, but not a whole lot: around here, most bad things happen at night. Being readily available for consults, I was able to provide better surgical care than some patients might otherwise have gotten: instant response to requests for a visit. The medical hospitalists were delighted: rather than having to receive excuses and invective from a frazzled surgeon trying to juggle several things at once, they had quick access. The upshot was more timely requests for surgical input: pancreatitis, bowel obstruction, undiagnosed abdominal pain -- often previously suffering from late call to a surgeon -- were attended to in a timely manner. ER docs were happy, too, for the same reasons.

Nothing is perfect. By definition, each patient I encountered was someone with whom I'd had no chance to establish a prior relationship; and they were all pretty sick. Every operation I did had to be insinuated into an already full schedule. (Actually, the OR folk were delighted: lots of surgeons try to schedule urgent but not emergent cases at the end of their office hours. I was happy to squeeze in anywhere, meaning the pile-up of cases in the evening was reduced.) I didn't have the long-term relationships that I'd treasured in my office-based practice. (I did have office hours a half-day a week for followups, but it wasn't the same.) But it was, in a new way, highly satisfying: rather than being a threat, an imposition, urgent cases and consults were welcome. Clearly, I was providing a very useful service to patients and the nurses caring for them, to my fellow surgeons, to the medical and ER docs. Nor was it anything less than wonderful that I was never working at night -- other than hanging around to do a case I'd had to schedule after my "shift" was over. (In fact, I'd negotiated the option to punt such cases to the on-call surgeon, who took over at the end of the day. Rarely did I take advantage of the possibility.) (Also: hospitalists in many situations work at night as well. It's just that I didn't, because that's the deal I arranged.)

I gather, from reading other opinions, that the concept is not universally embraced by all surgeons. Some, I infer, think it cuts into their gig. In situations where the acute-care specialist might be hired by the hospital, it threatens those in private practice on many levels. In my case, I was hired by the clinic, and served only my own former group. My presence allowed a busy group to ply their wares uninterrupted -- if trends continue, that will be increasingly valued.

12 comments:

Anonymous said...

From a patient point of view my first instinct is to endorse the concept of a surgical hospitalist as a way to increase quality of care.

My first encounter with a general surgeon was such that I could tell he was extremely unhappy with the situation that arose from 1) not having an appropriate specialist available in a timely manner; and 2) not having OR access until 9:00 at night (I presented with an acute abdomen at 8:00 that morning).

After reading your recollections here I cannot help but wonder why this concept hasn't been implemented more commonly? - it sounds both efficient to the provider and beneficial to the patient. At the least, the patient will feel that s/he is getting undivided attention rather than the impression that she is a bothersome disruption who didn't have the common courtesy to schedule her surgical emergency.

Erica said...

Your scenario is brilliant in its simplicity. I wonder how much difference a surgical hospitalist would make in my facility: our ER averages 300 patients per day, and oftentimes the Gen Surg on call is also the Trauma Surg on call, and depending on the guy in question, may also be Vascular on call. There are times all goes smoothly under this (scary, to me) system. I think when each has multiple call responsibilities, they do bow out of office hours for that day - but still there are times I can recall when hot appy's et al. have sat for a few hours for the surgeon, whatever the reason. We'd have a lot higher patient satisfaction score if there'd been somebody slightly more available or more geographically advantageous - or an official backup/bailer when the main On Call was tied up in a long case, etc.
And given the grumpy factor of a lot of our surgeons whenever they're swamped like that, I've gotta think they'd be in favor of having a wingman too... Something to think about, anyway, though I doubt I'll change the world this week...

#1 Dinosaur said...

I agree with you Sid, and I think the process will occur much like the growth of medical hospitalists. The major resistance will be the inertia of the current practitioners, and I think you might agree that surgeons as a rule tend to be more resistant to change than non-surgeons. All that means is that it will take longer. But I do think it's inevitable.

Anonymous said...

The trauma guys at my place are trying to move our institutions towards the ACS model. The vast majority of both community and academic surgeons here are very enthusiastic about it -- it makes their lives soooooo much easier. Sure, you lose a few cases, but the positive impact upon both schedule and psyche is spectacular.

Anonymous said...

I agree that such a change will occur; however I think it will be like our conversion to the metric system---inch by inch!!

The Independent Urologist said...

Makes complete sense, economically and ergonomically. That's why it'll never happen.

Dr. Dagny T. said...

The problem with having a hospital hire a "on call" surgeon is that it WILL cut into the salaries of the other community surgeons. On top of that, who does the follow up (that is usually not reimbursed due to global charges)? It would make sense for the surgery group to hire an "on call" surgeon and all charge/reimbursements go back into the group, but in some cases, like my group, we just don't have enough revenue/patient population to justify the cost of a "part time" surgeon (we can't get another partner, as it is). For our medical colleagues, they do not lose much to the hospitalists, because reimbursement from hospital care (the 9922Xs and 9923Xs) are pitiful anyway and it is more cost effective to have a hospitalist care for your patient, after all, the patient will still need to come back to you as an outpatient (and that is the majority of your revenue). In the case of surgery, you only get reimbursed for your procedure (that will be done by the surgilist hired by the hospital). Thus there is a true economic difference to surgilists and hospitalists and their effect on the other community physicians. Don't be surprised that if the hospital starts to hire one surgeon, it may end up having all the remaining surgeons (if there are any) on their payroll, too.

Richard said...

I'm curious how it worked for you, Sid, when the consult involved a patient that did not require emergent surgery. I'm thinking of the most recent consult I received for a patient with decubitus ulcers. The patient needs debridement and a diverting colostomy, but it can be done in a day or two. Under your scenerio, who would have done that case?

Sid Schwab said...

richard: I'd guess it would vary from community to community, depending on the usual issues of turf, desire for work, etc. I never much liked dealing with decubiti, especially if a flap was going to be needed, and there was a plastic guy who loved that stuff. So I'd guess I'd have asked if the "office" guys wanted the case, and if not, I'd have done the colostomy and consulted with the plastic guy. The way the current group is constituted, I'd guess they (the hospitalists) would be the ones to handle it.

Kristin said...

I was wondering how many surgeries a surgical hospitalist could support in a day. Could you potentially round on patients belonging to private practice physicians? How many patients could you handle monitoring and how many emergent consults could one person handle?

Thanks! This model is intriguing!

Sid Schwab said...

Kristen: good questions. In general the hospitalists only round on and care for their own patients, not those of other surgeons, except in unusual situations such as urgent issue with primary surgeon or his/her backup unavailable. Which, of course, ought not really happen. Surgeons who operate on a person are responsible for that person's care.

As to how many at a time: the question applies to anyone. Presumably if a hospital is so large as to have more patients than one hospitalist can handle, then it could support a larger group. The surgical hospitalist model differs from the medical in some ways: the latter tend to assume care of all hospitalized medical patients: office docs admit their patients to the team and don't do the care. With surgery, there are two simultaneous tracks: surgeons doing elective (ie, scheduled) operations admit, operate, and manage. The hospitalist is responsible for urgent cases: trauma, emergently needed operations like obstructions, perforations, bleeding, appendicits, etc. And for consults on already hospitalized medical patients.

Anonymous said...

Dr. Chris Kosakowski, MD, started the first Surgical Hospitalist program in 2001 at Sutter Medical Center of Santa Rosa. Private practice surgeons in the area often boycotted hospitals, services, and payors at their whim, often leaving 10's of thousands of patients without surgical specialists.

Dr. Kosakowski, by integrating computer systems and billing systems, was able to cover 2 of the 3 hospitals in Santa Rosa (almost 200 beds), 2 ICUs, 2 emergency departments, general, vascular, sometimes specialty surgery (such as urology), and a wound care center. He did this with between 3 and 5 rotating surgeons, drawing on surgeons sometimes from regional hospitals, thereby integrating regional care.

Dr. Kosakowski's surgical hospitalist program provided care for much of Sonoma County that otherwise would not have had access to surgical care. He was very forward thinking and, like the model for Sutter Santa Rosa, Dr. Albert Schweitzer, a truly caring individual.