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.