Monday, March 10, 2008

Different Cloth

I've written about my stint as a surgical hospitalist. It so happens that I've been contacted about doing it again. Potential obstacles aside, I'm giving it serious consideration; I found it fun and satisfying. Other than the inability to establish in-depth relationships with my patients, it was -- free from much of the para-practice frustration -- surgery at its purest, in some ways at least.

The hospitalist concept is a window into the future, the perfect extrapolation from themes that are regularly discussed in the medblogosphere of late: the implications of the eighty-hour work week restrictions in training; the differing expectations and priorities -- and demands -- of the recently trained; what it says about the prospects for medicine in general, and the practice of surgery in particular. The person who called me was refreshingly candid.

My work in the last few years has been surgical assisting. The guys with whom I've been associated are both much younger men whom I'd (with concurrence of other partners) hired to join my clinic practice. After putting up with the rigors and frustrations and reimbursement cuts and ER calls for exceedingly fewer years than I (in the case of one, it was less than five), they bailed and opened an exclusively bariatric practice, which they run almost entirely in a non-hospital setting, free from the associated agonies and exempted from taking emergency calls from any but their own patients. And the young surgeon who called recently to inquire after my interest had given up his classical-style practice for that of a hospitalist, after completing the usual training plus a fellowship, and then less than four years in practice! In candor, he said, "Those of us coming out of training now are cut of a different cloth than your generation." So they are. And why shouldn't they be?

He joined my clinic a couple of years after I left, and was given an income guarantee, no matter how much production, higher than I'd made in any of my years, though I'd worked harder and harder and produced more and more in each of them. His call burden, while often busy during the nights he worked, occurred only once in seven or ten days. For most of my career, it was every three (when people were gone it was every two). Even with more money and less call, he found it not worth the struggle, the sacrifice of family, the placing of job far above anything else. After only a couple of weeks in his hospitalist job, he told me, "My young son said, 'Daddy, I like you better now.' That's when I knew I'd done the right thing." Who can argue?

In their graves, many of the old guard will turn over, prop on a gamy elbow, and say "Damn right I argue with that!" The current Bulletin of the American College of Surgeons has an article in which a surgeon (well, a former surgeon: she recently gave it up quite young to be a writer!) recalls how an old professor stood in the way of a fellow resident aiming to leave one evening. "Son," the old guy uttered most firmly, "Once you lay your hands on a patient, that patient is yours." That's how I was. Those days -- see it how you will -- are dead: most thoroughly, most Edselly, most sincerely dead. (Lest I be seen as hypocritical, since I gave it up too, let me point out that I hung in there for twenty-five years; I acknowledge that's less than many, but it's literally true that during the last many of my years I was doing at least twice as many operations as the national average, while earning at or below the average and seeing a thousand more patients per year than either of my partners. So, in my mind at least, I'm allowed my spouting.)

For physicians -- medical and surgical alike -- the hospitalist model is a clear WIN-WIN. For patients, it's more like win-win. The win-win for surgeons lies in the freedom from emergency cases and the ease of call whereby, presumably, one would only need to be available on the phone to one's own patients and could, if desired, let the hospitalists take care of middle-of-the-night need to hospitalize them. The ability to plans one's days and nights translates into a considerable lowering of stress. In the case of hospitalists, it means absolutely predictable work hours and the elimination of all calls when not at work. For patients, it's trickier. It's the future, though, without doubt.

First, let's clarify: if you have an elective (meaning non-emergency) operation, you'll see your surgeon in his/her office as usual, be operated by him/her, and he or she will care for you while you're hospitalized. The hospitalist is there for the person who shows up in a doc's office or the ER in need of urgent surgical care, or who is in the hospital under medical care and has need for surgical consult while there. Trading off for the fact that under those circumstances you likely wouldn't be able to see the surgeon who took out your gallbladder last year and whom you just love, is the fact that the surgical consult you get will be approximately immediate, and there'll be a surgeon in house every hour you're there. Not the same one, as it could change every twelve hours, but some one. For patients who present in emergency situations, that's worth something. Isn't it?

At the extremes of every bell-shaped curve there are outliers. I don't doubt there will always be surgeons and primary care docs willing to sacrifice their personal lives in the name of their practices. But the days of the iron men and women are over, and it's happened in the blink of an eye, in a quarter of a generation. I reject that it's because this is the first generation to value life outside of work, or that they're just selfish. The explanation, I think, lies in the changes that have gone before and around them. The profession is under stress in many areas. To maintain income -- at whatever level -- in the face of steadily decreasing reimbursement, docs must work ever harder. They're increasingly bogged down in paperwork and bureaucratic demands, many of which are predicated -- so it feels -- on the notion that a physician is an thoughtless, careless, and incompetent screwup. (Comments on some of my related posts would seem to confirm that apprehension.) Not a week goes by without a notice from the hospital, the insurers, the malpractice carriers announcing the latest requirements for form-filling, order-justification, chart-polishing. Why, the new generation is asking, knock yourself out in such an environment? "Calling" isn't a word you hear much any more. Other than calling for help.

I've said it before -- and I'll point out that it no longer affects me, as a provider at least, so the axe I'm grinding is not my own: the inevitable result of the trend to control healthcare costs only by cutting reimbursement, along with adding more and more onerous bureaucratic demands is to select for an entirely different sort of practitioner than we've had. People willing to work hard and to strive for excellence but who expect some sort of recognition of it will look elsewhere than in the field of medicine. Will look? Already are! And the ones that haven't heard, bolt like my compadres when they get the full taste of it.

Since it's less and less likely I'll have a surgeon like me if I need one (I don't live in Cleveland or South Africa), my plan is to remain healthy, and then drop dead.


Anonymous said...

Thanks for this article. As a trauma surgeon (or as I sometimes feel, a trauma hospitalist) who has at times considered jumping over to the surgical hospitalist group starting to form at the hospital, I think you're dead on. I was raised without the 80 hour work week and I see the difference in residents today. It's not necessarily worse, it's just different. The expectations are different, but then again, the culture they're entering is different. Of the recent residents to have graduated, only one has gone into a "pure" private practice, and as a plastic surgeon. Everybody else has found themselves in some sort of salary guarantee. Since coming out myself, I've been astounded by the level of paperwork and insurance issues I've had to deal with. I almost think we should dedicate a year of extra training to that alone.

I'd like to do a study on what percentage of graduating medical students change to other careers after spending some time doing medicine. I think it's a lot higher than we'd suspect, and probably growing. There's a lot of disillusionment out there and it will affect the availability of physicians into the future.

DDx:dx said...

I believe there is a value in continuity that has to be lost somewhere here. I just can't prove it. All that signing out has to be inefficient. And the patient's perception of "CARE" has to be diminshed. And, perceptions(placebo) are real...
But I agree things are changing. In my practice we did the new guy guarentee fiasco twice. They earn more than anybody else for two years, then when they see the production issues coming bail. After the second time i decided this was not a good business model.

I have a suggestion for surgeons at your stage. Move to a small town with 4-5 Full Srevice Family docs. They do endoscopes, OB, sections. You teach them surgical skills( laparoscopy, appy, chole, hyster) and they cover. They appreciate the increased service for their patients and they develop skills and you are free to go fishing since they'll cover pt. F/u, hospital stuff.
I can tell you of a place this has worked.

Bard-Parker said...

Excellent post, Dr. Schwab. The postition of the "surgical hospitalist" or "acute care surgeon" provides what residents coming out of practice want these days, a predictable schedule and predictable income. And given the number of graduating chief residents who move on to fellowship this is probably the only way some hospitals are going to be able to provide general surgical coverage for their emergency departments.

Anonymous said...

The full-bore, dedicated for life physician from the days of giants was actually two people, almost all of the time. the physician, and his (occasionally her) devoted spouse. The spouse raised children, ran the household, interfaced with the community and made sure the physician was fed, clothed and emotionally supported. Some might have survived without this support but perhaps there was an office manager or a mother who largely fulfilled the support role. The doc who tried to do it alone, or whose spouse bailed, was a sad and often angry soul who ran up large tabs at the hospital cafeteria. He had his gas and phone cut off but didn't notice until 6 weeks later. He spent several hours a week talking on the phone to his children (if any) but rarely saw them.

Today's spouses are less willing to play the role. And who can blame them. It's another side of the sea change I wanted to point out.

And I won't get started on the soul-destroying nature of the paperwork these days. It seems to get worse each year. I feel my desire to care for my patients bleeding from a thousand paper cuts.

Anonymous said...

Prescient timing, Dr. Schwab! I have been thinking about the topic of the surgical hospitalist a lot recently. i'm finishing up my 3rd year of med school- I loved my general surgery clerkship, and I really like the idea of a 50 hour workweek post-residency (as opposed to a 80 hour one). I was raised in the kind of support network Dr. Bean points out is necessary to support a "full-bore" physician; I never knew my dad until he took a more administrative job. I don't want that for my kids.

Dr. Bard-Parker remarked last year: "Back before the limits, you had to be very dedicated or very crazy to go into surgery. You knew that you would give up a large part of your life, possibly sacrificing your marriage and sanity. You knew that and still chose to do it. Now it becomes just another specialty, made attractive by the hour limits. The true story will be told in 5-10 years when the 'baby boomer' surgeons begin to retire."

To which I would reply: "maybe." Isn't it okay to want both, though? I don't mind assuming more responsibility; I don't mind the thought of staying to finish a case; that's how medicine works. But that's also not the same as being told I'm going to have to work 80 hours a week, just to keep up with a group practice's requirements for pulling one's weight. The outlook by current surgeons seems so grim, except those who either live for the 80 hour weeks (as one of my clinical preceptors did, and more power to him) or those who have escaped to a position that allows them to both be present at work and in their personal lives. Finding a position like that often comes at a cost, however: restricting one's practice to only doing breast cancer cases, for example.

So, can I have my cake and eat it too? (i.e., do you really think the future practice model is that of the surgical hospitalist?) Will the gatekeepers of surgery permit surgical hospitalists to expand, or will we of the "future" have to wait until all the current academic chairs of surgery are dead? After all, it's one thing to have an already-established surgeon become your hospitalist, quite another for someone fresh out of training to seek the same arrangement.

How would hospital billing cope? Would I be able to pay off my loans before I retire? (Your alma mater isn't cheap, by the bye...)

As a blogger who's seen both sides of the coin, any future opinionating you have is eagerly anticipated...

Anonymous said...

I agree completely.

In addition, in the old days surgeons were compensated not just with money, but with respect. Now, the surgeon is a health care provider, as is the PA, the chiropractor, the pharmacist, and the xray tech, and all are as important in their spheres as we are in ours. I can’t tell you how many times I have had a conversation along these lines:
“What do you do?’
“I’m a surgeon.”
“What kind of surgeon are you?”
“I’m a general surgeon.”
“Oh, just a general surgeon?”

They have no clue what it means to be “just a general surgeon” of the Sid Schwab school. They do not agree that what happens in the consult room, the OR, at the bedside, is the most important interaction that occurs in the “health care industry,” and that everything else, and everybody else, is and must be subordinate to that. They don’t understand how damaging it is when a medical records clerk sees it as her duty to interrupt clinical activity of physicians and surgeons to get a chart closed out, a form signed. Every time that happens, and it is an everyday occurrence in any hospital, the surgeon realizes that he’s just another hired hand, and there is no reason to keep giving of his and his family’s soul just to be treated like a paid-by-the–hour technician.

Recent statistics indicate that of the 1000 surgery residents who complete training every year, only 300 go into general surgical practice. 300 each year to take care of 300 million Americans. Who’s going to take care of us, Sid?

rlbates said...

I enjoyed your post, Dr Sid, and am enjoying the comments. I limited my hours (so I could be an "average" wife), but that severely limits the income. Balance is hard to achieve.

Good luck to you Annoyn 2:51 pm.

Bongi said...

this is the ideal world where there are enough hands to put to the plough. but what if 80 hours a week just doesn't get through the work??

i love the concept of 80 hours and the concept of a hospitalist to hold the fort so you can go home and lay your head down to rest, but that is assuming there are enough hands. where i come from, these points are mute.

Sid Schwab said...

anon 2:51 I do think it's increasingly going to be the model, for reasons I mentioned. But there'll be two parts: the hospitalist and the office-based surgeon who does elective work. Each will have it better than the current single-practice covering it all. How will it all shake out? I don't know. As has been suggested, the number of people going into surgery is declining, and as the hours worked are becoming less (or at least that's the aim of the new generation) the needs of the community may not be met. The group to which I'm talking is planning on "physican-extenders" to do followups. Also, they have an arrangement with the hospital and the local clinic, financially: they are paid by the shift, reasonably generously, regardless of production. The clinic and hospital take the billed income, with the clinic reimbursing the hospital for the money they've guaranteed, based on revenue. So the surgeons make no more or less whether they operated like fools or sit around. So far, they don't do a lot of sitting around, however. Of course there are many other possible financial arrangements. When I did it before, there was a guarantee, plus a percent of the production over that. I made more than the guarantee; at that time, the guarantee was lower than the current situation. Could you pay of your debts? Yes. And have a second house and a Lexus? Maybe not.

jb: my plan is to die with a virgin belly. I do worry if my wife needs surgery, however.

ER's Mom said...

Interesting post. I'm considering a spot as an OB-Gyn hospitalist myself. It's not the hours that hurt, so much as the razor-thin line we tread to make production.

As a mother with young children, it is intriguing to have set hours. Yes, my salary would go down, but my free time would increase.

rlbates said...

I meant -- good luck Anon 2:51

Jeffrey Parks MD FACS said...

Sadly, I feel that this move toward "emergency surgery specialists" and "surgical hospitalists" may be inevitable. There's an interesting article in the latest ACS newsletter about the generational differences in surgeons and the effect of this on perceptions and expectations of what it means to be a surgeon. Check it out if you have time. Essentially, the sense of a "calling", common to surgeons from your generation, have fallen by the wayside as Generation X and Generation Y have assumed major roles in the medical workforce. Lifestyle issues dominate one's sense of self-satisfaction for the younger generations. Is this bad? Not necessarily. I suppose as long as adequate and SAFE surgical care can be delivered in such a system, I won't have too much of a problem with it. I guess I'm a bit of a dinosaur; working just with another guy, call every other night and weekend, but hell, I like it. We'll see if the burnout factor comes into play....I still like to idealize the practice of general surgery; warriors who can take care of anything, no matter the time of day, and I try to conduct my own practice with such an outlook but I'm not like everyone else. Reality is what it is. It's almost sad to foresee the demise of "classical" general surgery...

Anonymous said...

i'm in medical school, and I could not imagine or design a class more full of energy or brilliance. If you want to make a point about who is being attracted to medical school right now, you might want to consider the demographic changes. Many of my classmates actually tried other career fields before deciding on medicine (the opposite of the pattern the first poster described). These "non traditional" medical students diversify a class of people like me who came straight from college.

So who is attracted to medicine now? In my medical school we have students that published novels, played years of professional basketball and one who swam in several Olympics.

Is it easier to get into medical school now? Maybe the sheer number of applicants are a bit down from the era of draft-dodge by medical school (worked better for my father than for you). But, students typically study almost an entire year for the MCAT now, and GPA averages are still extremly high. My father just rolled out of bed and took his MCAT.

I understand the point you are trying to make about challenges in medicine discouraging and repelling the next generation. But I think you are selling us short....

Sid Schwab said...

anonymous: thanks for your comment, and your hopeful outlook. I hope you're more right than I am. Time will tell. In a way, though, you are making my point: people are selecting medicine to be a part of a rich and varied life, as opposed to be their whole life. It's a difference. Better or worse? Remains to be seen. Longevity in their chosen field? Also remains to be seen. Everyone -- or nearly so -- who chooses medicine sees it as a calling, at the outset. My classmates and I and my contemporaries certainly no less so than you and yours. It may well be -- and I hope it is -- that those entering the profession now have their eyes wide open to the changes that have occurred. Maybe, in fact, that's why they plan to have lives of more balance than I did; namely, a recognition that satisfaction can't come from their work alone. Which is good for them. Given the anticipated shortages, there's reason to wonder how it will work for those on the receiving end.

Dan Walter said...

Mitral valve woes:

Anonymous said...

"So who is attracted to medicine now? In my medical school we have students that published novels, played years of professional basketball and one who swam in several Olympics."

You'll find those types of people in jail also.

Surely the "doctor shortage" will be exacerbated with these decreased hours. I have a horrible feeling some doctors are going to act like the firemen in Gangs of New York. Sit on barrels on the hydrants and not allow less qualified workers to do the job; then wait before someone stumps up some exorbitant amount before going to work.

When someone like Dr Schwab says he doesn't want the new generation to do any work on him it SCARES me!

Obviously we need to train many more doctors to alleviate this threat. I'm not sure that the AMA would be thrilled with that.

Sid Schwab said...

anonymous: don't let me scare you. There are plenty of good (enough) doctors around. And the AMA, along with the ACS and pretty much all physician organizations are aware of the downstream shortages and are politicking to do something about it. But it's not up to them, really: it's up to those who provide funds; ie, Congress. Who, mainly, remain intent on diminishing funds for teaching institutions. That could change, depending on which party is in the White House.

Anonymous said...

...the inevitable result of the trend to control healthcare costs only by cutting reimbursement, along with adding more and more onerous bureaucratic demands is to select for an entirely different sort of practitioner than we've had. People willing to work hard and to strive for excellence but who expect some sort of recognition of it will look elsewhere than in the field of medicine. Will look? Already are! And the ones that haven't heard, bolt like my compadres when they get the full taste of it.

There is so damn much wisdom in that quote above it virtually nauseates me that society just either can not or will not see it.

It sounds like it came straight from the mouth of Dr. Hendricks in Atlas Shrugged.

Damn! I mean, just damn!

Anonymous said...

There are still plenty of willing applicants drsam. Hard work rather than striving for excellence is the usual way through medical school.

Medical students are like Decathaletes- they chug along with good results in a range of fields but about 10-15% behind the stars in each discipline.

It is the work ethic that has always distinguished the medical profession; when this is lost the loss of prestige will follow.

Assrot said...

Hmmm... Beings I am not a doctor, I'm not sure I completely understood this post but I will tell you this.

I absolutely refuse to see any of the "new school" doctors. They have no bedside manner. They care very little for their patient. Medicine is a business to them not a way of life.

I prefer the "old school" doctors. By that I mean a doctor that will listen to what a patient says and actually hear and respond to what is said. A doctor that is not in a rush to get you in and out of his treatment room in less than 5 minutes. A doctor with a good bedside manner. A doctor that still cares about helping and healing people not about his medical business as opposed to his medical practice.

If a doctor is less than 50 years old, I won't even talk to them much less let them treat me for anything. They are a waste of time and money and they seem to have the God Complex more than average.

Y'all can have your young, smartass, whipper-snapper doctors. I'll take the old codger that takes his time and talks to me like a person rather than a piece of meat and an insurance card.

SeaSpray said...

I enjoyed the post and comments.

walt dandy said...

I know I'm joining the discussion late, but I just recently discovered your blog (mostly, I'm proud to say, because I've been getting killed for the last three years and am now on research). I feel as though I need to defend my generation. I can say with confidence that the few of us who entered training in surgery or one of the subspecialties from my medical school class did so for the same reasons that you older fogies did. Are we afraid of hard work and q2 call? Not one bit. What is alarming is the fact that very few of us did not opt for one of the "lifestyle" specialties. My goal here, however, is to shed light on the fact that the 80 hour work week does not mean you clock out as soon as you hit 80 hours. The work must get done, and it does. Sure, we've done away with some of the old-school ways to trim hours. For example, before the 80 hour work week rules came into effect the philosophy was that no one leaves until the day is done. If that means that the chief resident is clipping an aneurysm with the boss until 1 or 2 am, the junior residents waited for that case to be done. That is pointless, so now they go home when everyone is tucked in and taken care of and the case goes on. Also, in the old days the junior resident on the service would take the vast majority of the call (often up to 4 nights in a row), but now the older residents and off-service residents (like myself) have had to pony up and join the call pool. We became compliant with the 80 hour rules simply by distributing the workload and by cutting worthless endeavors from our training program (eg. our department has hired nurses and other ancillary staff to lighten the load of some of the menial tasks like filling out the stacks of paperwork necessary to discharge a patient from the hospital or transfer a patient out of the icu)
One thing I have noticed from my observations of our faculty is that while it is important to be willing to dedicate your life to this profession and make many sacrifices in terms of family life, you have to be very aware of the fact that other people in the hospital are very quick to recognize those individuals and take advantage of them. You also have to be willing to draw the line sometimes. As an example (and I don't mean for this to be inflammatory), ER physicians are very fond of getting a blessing from a specialist before sending a patient home, thus effectively transferring liability for decision making to the specialist. As such, they can be very insistent that a patient who shows up in their department at 10pm on Sunday with chronic back pain be seen immediately, lest they send them home and get sued for missing something more ominous. I'm not exaggerating when I say that the majority of the after hours consults we see are non-emergent.
The point I'm making is that it is not difficult to get the important work done (i.e. the work that has direct bearing on the care of the patient, who is at the center of this equation) in 80 hours if residents are not wasting their time doing menial paperwork, acting as social worker, patient transporter, etc. The other point is that there are still those of us who avail ourselves to this profession, but our ranks are shrinking. I'd also like to point out that we live under the very real threat of having our program placed on probation (as happened to the Yale general surgery program, the Johns Hopkins medicine program) if we do not comply with the 80 hour rules. That is not helpful to anyone, including patients. So yes, there are times when we begrudgingly have to give up a good case or turn a sick patient over to one of our colleagues in the interest of not destroying our training program. The ACGME (the accrediting council for residency programs) has wisely realized that if they do not enforce these rules the government will, and then we'll all be in a shitstorm with our mouths open.

Sid Schwab said...

walt: I acknowledge there are no absolute truths here. There have always been and, one would think, there will always be people at each end of the spectrum and at all points in between. I see a trend that worries me. It may be true that it applies more to general surgery than to all surgical specialties, but I think it's not limited to there, nor to surgery and not "medical" fields. The work hours are only part of it. In the end, you get what you pay for: ie, as reimbursement for physicians of all kinds continues to drop, it's natural that the number of people to enter into the field and to make the kind of sacrifices that it requires will drop; the nature of people going into it will change; and those that remain and continue to enter will choose to practice in a less fully-committed way. Because many doctors (perhaps not all), it turns out, are human.


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