Thursday, September 13, 2007
My first encounter with the concept of the "hospitalist" was a sour one. As with many of my long-held medical beliefs, I eventually came to another way of thinking. (You may have read about my own gig as a surgical hospitalist, and about the fact that it was a period of unmitigated pleasure for me.) But that first time -- which involved the medical iteration of the concept -- was a bummer; not for what it was, but for what it wasn't.
When the internal medicine department of my clinic announced they were moving to the hospitalist model, I considered it a terrible idea. Patients expect many things of their doctors; among them, that they'll be there in their hours of need. I understood the practicality: having docs at the hospital meant more immediate care for those housed therein, and it meant the rest of the internists could remain in their offices. Among other things, there's more money to be made by keeping up a schedule there than by running back and forth. Considering the time required, hospital medicine isn't all that well reimbursed. But I'm a three-rounds-a-day guy. My reservations had to do with assuming patients would feel abandoned. And I was right.
In the very first week of the trial period, I was called in to see a young man in extremis. Suffering from long-standing AIDS, and cared for by one of the really excellent internists (my doc, as a matter of fact) in the clinic for years, he'd been brewing, unbeknownst, a rare tumor of the small intestine. Probably a day before being brought to the ER, it had perforated, and when I met him he was a very sick puppy. The diagnosis was as yet unclear, but the need for surgery was obvious.
Regular readers know how much I enjoy intestinal surgery. Other than for releasing obstructions, operating on the small bowel is less common than on the colon: despite there being four times as much of it, conditions requiring removing a chunk are fewer. A couple of things make it more fun than colon resection. First, it's looser. You can grab a handful and deliver it through the wound, where working is easy; most parts of the colon require cutting it loose before you can address it. Second, small bowel heals like crazy. With its rich blood supply, generously provided in all directions in all locations, it takes real effort to screw up putting it back together after removing a part. Much more so than with a colon anastomosis, in other words, leakage is highly uncommon. Don't get me wrong: there are some situations where small bowel surgery is a nightmare. It can stick to itself so densely that you can't tell where one edge ends and another begins. Dilated from chronic obstruction, it can become as thin and friable as wet tissue paper, turning every touch into a potential perforation. In those cases, you more than earn you pay. Other times, it's purely recreational.
With this patient, it was somewhere in between. It's hard to luxuriate in the pleasure of operating when a person is as sick as this man was; still, the need was clear, the pathology easy to recognize, the conduct of the operation self-evident. (I should also say operating on AIDS patients is never without at least a little concern for oneself: the errant poke with a needle, the splash in the eye. In this case, the soaking through of the supposedly impermeable gown. I'd add that, in my practice, AIDS patients were among the most likable people I met.) After removing the part containing the tumor and sewing the ends back together, I washed out the belly with liters of fluid -- the last dose containing antiseptic solution -- closed the mid line and left the skin open.
On the first post-operative day, he looked a million times better than when we were introduced. "When will I see Dr. Jones," were among the first words out of his mouth. Not that he was unhappy with me. He just really wanted a familiar face; particularly one that had cared so closely for him for so long through so many previous mini-crises, with whom he had a deep level of trust. I had to explain the new world to him. The disappointment -- and concern -- was obvious on my patient's face. Sure he'd want to know, and that he'd come by, I called Jonesie and told him of his patient, and of his desire to see him. "OK, I'll get there during lunch," he said. "But only to tell him why I won't be there any more." (To be fair, in this case it wasn't that I needed help in managing the patient. Still, then-to-fore, Dr. Jones would absolutely have been making hospital rounds and would have at least dropped by to say hello.)
Times have changed. As hospitalists have become nearly ubiquitous, I think patients' expectations have changed, too. Moreover, it's become clear to me that the care provided exceeds that of good ol' Doc Jones, for lots of reasons. People are managed as outpatients who'd have been in-house in the past. Many operations are done in surgicenters -- ones that no one could have imagined a while back. The average person in the hospital, therefore, is sicker than a decade or two ago. There are pressures to get people home; management is more difficult; both diagnostic and therapeutic interventions are more complex. Clearly (in my opinion, anyway) docs who do nothing but manage today's in-patients are better at it, and more efficient. What's lost by the absence of the personal doc is more than made up by the fact that the people rendering the care in the hospital do it really well.
Surgery, by the way, is a little different: our stock-in-trade is the hospitalized patient. There's really no such thing as a purely office-based surgeon; nor would any self-respecting surgeon operate and turn the post-op care to someone else. So the surgical hospitalist -- such as I was for a while -- is a different concept. Surgeons manage their own hospitalized patients -- with, for some, the help of intensivists.* Taking acute consults and doing emergency operations, the surgical hospitalist makes the life of the rest of the surgeons far more pleasant, allowing them to see their patients, carry out their scheduled surgery without interruption. ORs run more efficiently because of the more ready availability of someone to fit in the unscheduled cases (surgeons with an office full of patients tend to want to do urgent -- not emergent -- cases at the end of their day, making for an ever-increasing backlog at that time. Present company excluded: I always did 'em at the first available opening, even before I was the on-the-spot guy.)
I think the hospitalist concept turns out to be a good deal for everyone.
* To this day, some of my mentors eschew the idea of surgeons ceding any care to the intensivist. I think that attitude is an example of the disconnect between academe and what I'd call, oh, I don't know, real life. When I was in training, I had multiple patients at all times in intensive care, and was comfortable with -- not to mention good at -- their management: ventilators, cardiotonics, renal failure (up to but not including dialysis), the whole nine yards. In private practice, I'm happy to say, critically ill patients were fewer by far. And, for the same reasons I listed above regarding the better care given by hospitalists, docs who are constantly managing the critically ill are better at it than I became over time, after leaving the shadow of the ivory tower. I didn't -- nor, I'd guess, would any surgeon (general surgeon! -- you can't drag an orthopod into the ICU with a cable. A neurosurgeon will go, but will not look below the forehead) -- give over the entire job of critical care. But collaborating with intensivists is mutually satisfying and edifying, and beneficial to the patient. My mentor's castigations to the contrary.