Thursday, September 13, 2007

Hospitality


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.

14 comments:

Anonymous said...

You could view this as a specialization trend, in which case we are only in the middle now.

Do you think we may get towards the day when hospitalists manage postop surgical care themselves?

It would hit general surgery last because they pride themselves on that stuff. The biggest obstacle is clearly that once you operate on someone they are yours and passing them on to a hospitalist to manage things you did seems like abandonment.

But I could certainly see it happening. Private practice ENT guys don't want to touch head and neck cancer because they're outpatient surgery and one H&N case means rounding for a week when you don't have enough inpatients to make it worth your while. But if you had a hospitalist to round on that one patient...

I think it's going to happen in the subspecialties. God knows it will only require a tiny nudge for ortho to dump anything medicine-related. Care would probably be better with one hospitalist who manages all postop care for an entire group. The only downside is the loss of personal contact with your patients. Videoconferencing?

Sid Schwab said...

Given the uncertainties of the economic future of medicine, I suppose anything is possible. But I really doubt it would come to pass that surgeons would devolve to the point of only operating, and turning the post-op care over to others (a guy I trained with went into practice in a public hosptial in Hong Kong, and that's pretty much what he did. In fact, it was even more: he'd meet the patient as they arrived in the OR, and didn't see them after they left.) The ACS proscribes "itinerant surgery," meaning going somewhere to operate and leaving the care to others. But in the name of efficiency and economics, I suppose it could happen.

rlbates said...

Nice post! I can't image turning the postop care over to someone else, but I have given thought to being the one to give that postop care should I ever have an injury that kept me from operating (know a plastic surgeon who had both median nerves injuried in a bilat carpal tunnel surgery by his old mentor).

SeaSpray said...

Good post Dr Schwab!

Speaking as a patient it has always meant a lot to me to see my docs on their hospital rounds.

I have a good support system- loving family and friends but still.. it means a great deal to me to have the surgeon come to me either after procedure, in post-op and the next day to my room if I stay over. I think the continuity is important. It just shows that the pt is worth the follow-up and it is reassuring.

In previous posts you have discussed the awesome responsibility, the sacredness of performing surgery on someone who has given you their implicit trust that you will do everything you can to help facilitate their healing with all the knowledge and skill you have acquired through years of medical/surgical training.

I think when a pt has come to this point of total release of themselves, knowing there are risks and yet gives that doctor their implicit trust...that it is so very important and whenever possible (it's not always) for THAT doctor to follow up with their pt. THEY are the ones that KNOW what the facts are and Know the pt, unless of course it is an emergency surgery. But even then I still think it is important to have a good follow through and as a pt I don't want to hear it 2nd hand, I want the one who did the work.

I am fortunate that I have always had good follow-up care. I am thinking of your "Good Vibrations" post that you did in February or sometime in the winter where you talked about how important it was for the pt to go into the OR with a good attitude and they were the ones that usually came through surgery better and healed more quickly. You went out of your way to visit with them before and after surgery. I am sure that meant a lot to your patients and they were blessed to have you for their surgeon.

It just seems like everything is getting so impersonal today not just in medicine but overall.
Maybe I am missing the point.

And of course as doctors you are in business for yourselves and with reduced reimbursements, etc. you need to do what is best for your practice, i.e. yourself, partners, the corporation which also affects your patients.

It is great that you understood that the aids pt wanted to see "his" doc because indeed he was the doc that was in the trenches with him. I am sure he appreciated you too.

Also, from what I have read in the med blogs, it seems that doctors appreciate the good relationships they have with there pts. Dr Keagirl touches on this in her recent post in which she talks about how a pt dying rocks her and the staff and she remembers the last time she was with that pt.

I know surgeons love to operate but wouldn't they miss the whole package?

"surgeons with an office full of patients tend to want to do urgent -- not emergent -- cases at the end of their day"

How do they do it? How do surgeons work all day and then have the stamina to do surgery at the end of that busy day or go in on call to do surgery? Is it the tough surgical residencies that prepared you to work like this? Or just that you do what you have to do?

Sid Schwab said...

seaspray: I think it's both the training and the need to do what you have to do. The training may not "train" to do that, but it separates out those who can't or won't.

ER's Mom said...

How do they do it? How do surgeons work all day and then have the stamina to do surgery at the end of that busy day or go in on call to do surgery?
**************************
I'm not Sid, but here's the answer : you just do it. For us, the buck stops with us and we take the responsibility.

And you can't teach that in training, it's already ingrained into you from a young age.

Greg P said...

There are good things and not so good things about hospitalists.
Ideally, one of the things that one would hope happens is lots of communication with primary care docs -- in both directions -- since sometimes primary care docs may have important information to share. I don't see this happening. There is the discharge summary of course, but many times I see them dictated without the mention of a copy to be sent to the primary care doc -- probably an oversight, but it means the doc must request a report. I also see many of these reports being quite unhelpful as to explaining the rationale for various changes in the patient's medications.
There is also the problem of doctors having lots of experience with in-hospital care, but no outpatient care, and therefore not having an understanding of all the social, financial, and other issues that impinge on compliance. There is a different mindset when you're responsibility to a patient ends at discharge.
There may or may not be such great efficiency of care. In our hospital, the hospitalists have extensive lists of patients to see, so time and again, you see patients who could have been discharged, transferred to a lower level of care, but it doesn't happen until the hospitalist slowly works his way down the list. You also see a lot of handing off -- Dr. A sees today, Dr. B tomorrow, Dr. C the next -- and this can at best be Ok, but can lead to procrastination in decision-making, sometimes flip-flopping of treatment plans.

The Independent Urologist said...

as usual, nice post.

Sid Schwab said...

Greg: Your points are good ones, and I've seen such things. My experience is partly skewed, I suppose, by having worked with a pretty excellent team who communicated quite well. Even then, miscommunications such as you describe were not unheard of. One thing that facilitates is the fact that all clinic records have become digitized, and there are modules at the hospital from which all clinic data is available at any time with a few clicks. A problem is that the hospital has lagged behind, so the automatic entry that occurs with clinic records doesn't happen with hospital summaries, etc. But I think that's in the future.

It does seem to me that, for better or worse, the hospitalist is the model for the future, if for no other reasons than finanical and "lifestyle" as they apply to "office" docs. There's also the issue of privileges, which are under pressure to be restricted and narrowed -- not just turf issues, but quality. Or perceived quality. It seems to me that, given the choice of admitting their own patients or turning them over to hospitalists, very few of the current docs are choosing or would choose to do the former. Problems notwithstanding.

SeaSpray said...

Well...it's obvious surgeons work hard. I sure hope y'all play hard too, that when you do have your down time your able to disconnect, relax and renew with whatever brings you great pleasure.

Last spring I was talking with one of my mom's docs and he was telling me that he loves doing surgery but when he is off he loves doing carpentry and he is always fooling around with a tool somewhere, if not the OR then at home. Interesting. And he was proud of his home projects. :)

It has to be a calling. Thanks for answering. :)

Greg P said...

I think you're right. For now it's the model that works. The biggest thing that happened was that financially going to the hospital stopped working for the primary care docs.
This isn't to say that the hospitalist model cannot be improved upon, or that it cannot be replaced by something better.

dr.p said...

How does it work economically?
How much of a stipend can you get since most of the unassigned patients are bad debt.If I was a hospitalist at my 100 bed hospital without residents I would get all uninsured appy and couldn't make ends meet. Who is paying ?

Sid Schwab said...

dr.p: in my case, I was working for my former (fairly large) clinic, and I was given a guaranteed daily amount. They billed my billable services, took out some overhead, and gave me any amount above that guarantee. Since it provides an obvious service for hospitals, and for the other surgeons in town (although it takes some a while to realize it -- assuming they have enough of a practice not to depend on emergency cases), in many cases hospitalists have a similar arrangement with their hospitals. I don't know if the numbers work out for a 100 bed hospital or not...

dr.p said...

Thanks

I appreciate the input.

Dr.P