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.

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.