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.

Thinking Out Loud....

(I'm hurriedly trying to change the subject from my sorry post below, so I'm rushing to print before fully fleshing out something I'd been working on. In retrospect, I wish I'd not posted my little fiction piece; but I've decided to leave it and move on. Quickly.)






This may sound self-indulgent and egotistical (what? from a surgeon??) but bear with me: I have a point.

I think I can honestly say my patients did well to have me as their surgeon, even as my wife may have gotten the short end, husbandly, and my son likewise, fatherly. By which I mean I spent my career, for whatever reasons, highly devoted to my patients and my practice, at the expense of my family and personal life. I simply had no choice in the matter: it's how I was trained, and what I believed. I was never entirely comfortable ceding surgical care to anyone else, even my closest partners. And for the first few years in practice, until I realized the folly, I even abhorred medical help: I felt obliged to manage even the intensive care of my patients. For a while, I was probably as good at it as the intensivists (of whom there weren't a lot, early on). As time went on, and I (happily) had only the occasional critically ill patient, I came to realize I wasn't the best one for the job. But surgically -- well, I never felt my partners would take as good care as I did. It might also be true that they felt likewise, in reverse. One would hope that all doctors felt that way. Or so I think. Thought. Wonder....

More than just imagining it, I lived it: I made hospital rounds no less than twice a day, and more commonly three. Except on the critically ill or unstable or as-yet undiagnosed: then it was four or more times. Six a.m. Between cases. Before heading to the office. At the end of the day. Go back in in the evening. I always took calls on my patients, whether I was the "on call" doc, or not. If a patient needed a re-operation, I'd usually do it -- on call or off. Although I think I may have overdone it, I'd say most surgeons of my era have similar commitment, if for no other reason than hearing the admonitions (to put it mildly) of our mentors in our heads. But it's more than that. To choose surgical training twenty or thirty (fifteen, ten) years ago was eye-openedly to enter into a contract; to agree that caring for patients was going to be the prime directive, and that it would be a never-ending commitment. That it was pounded in over and over for six or seven years of nearly twenty-four/seven training simply reinforced what was already implicit.

Considering my behavior mostly in hindsight, I have questions. How necessary was it? Did it really make a difference? Was it essential? Or delusional? An excuse for other shortcomings? In semi-retirement, it's clear my sense of irreplaceability was an illusion. But what of the rest? My younger partners never rounded as much as I. Unlike me, they took their full days off, and their allotted vacation days; weekends off were off. Their patients did well enough. Complications, for the most part, have their roots in the operating room. Data, when they were made public, confirmed my complications were fewer; but I think it had little to do with my post-op care. I do think those habits were part of why my over-all costs were less: in rounding frequently, I was able to expedite necessary testing and to get orders written sooner, discharge more efficiently. (Bureaucracy alert: the powers that be once decided to review afternoon discharges, intending to encourage doctors to make rounds in the morning to get patients out earlier. Afternoon discharges were to be some sort of black mark. Making rounds multiple times, I often discharged patients in the afternoon because some mornings they weren't ready but were later. I pointed this out to the medical director, asking if he'd rather I not make those afternoon rounds and wait till the next day, in order to avoid being dinged. The plan ended.) If my patients didn't have to get to know another surgeon during their hospital stay, if their hospital bills were lower, to whom did it really matter? No one mentioned it to me, much.

So what's my point? This: if any of this stuff actually did matter, I think it's moot. It's my sense that, as a generalization, things are changing fast. I'm not the first to blog about the recently restricted hours of trainees. In fact, nothing I'm saying is particularly original. I do, however, have several friends who are surgical professors in some high-level training programs, and I'd say it's unanimous among them that they are concerned about the surgeons of the future. "Shift-worker mentality" is a common theme in our conversations. The current crop of trainees, they say, aren't as committed as we were. They're happy to diddle around until the next shift arrives to solve a lingering problem. More importantly (but maybe a bit off the subject of this post), there's concern that the restricted hours lead to less experience, which works its way up the hierarchy: fewer hours means fewer operations. Senior residents are less likely to let the juniors do cases, which means those juniors, when senior, are less experienced. The need for formal mentoring after training is a concept being discussed seriously.

It's not entirely clear-cut: are patients better served by doctors less single-minded? The restrictions on hours resulted from a lawsuit over a death presumably due to mistakes by a fatigued resident. Avoiding fatigue, clearly, is desirable. But limiting experience? Selecting people less willing to make a full commitment? I imagine patients prefer a well-rested doctor. But one that plays the piano? Skis like a maniac? Coaches Little League? Not sure. Really. Not sure.

I burned out. After twenty-five years, chronically tired, dreading the phone-calls, missing family gatherings, I managed to wangle a temporary (I thought) leave of absence. It felt so good, I couldn't convince myself to go back to full practice. Had I been less crazily compulsive, maybe I'd have lasted longer; maybe I'd have, over a longer career, cared for more people (part of my problem was never saying "no." I did twice as much surgery as my partners, more or less.) So maybe it's better, from a cost-benefit sort of calculation, to have docs who want and have a life. And this: whatever else is true, the new crop aren't idiots. Surely they hear the cries; they know about decreasing reimbursement, malpractice, interference from all points of the compass. If there's much about the job that's become abhorrent, why give up your life for it? That's my point: is the current trend a bad thing, or a good one? Honestly, I don't know. Until a few years have passed, no one else will, either. And if it's true that the people choosing medicine now are different from those of a couple of decades ago, or have different expectations, I don't blame them. The essential rewards of being a physician, the privilege of caring for people, remain at the core: but the pleasures have become elusive, diluted by the myriad of impediments disguised as controls. It's illogical to expect docs to walk in the same way on ground that has fundamentally shifted under them.