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.

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.