Those dumb, greedy bone crunchers

My orthopedic surgery colleagues sometimes facetiously say to me “You're the real doctor. I'm just a dumb bone cruncher.” We know that isn't really true. Well, most of us. Billy Rubin, an ID doc and part time hospitalist, rants:

One of the central ironies of American medicine is that several of these very fine students, whom many a prestigious Internal Medicine or General Surgery program would be delighted to train, will have spent an inordinate amount of time and energy learning medicine only to forget the vast majority of it during their residencies. You see, the orthopedic surgery residency takes people who have doctorates in medicine and turn them into doctors of bones! They spend their residency years un-learning all the medicine that their expensive education gave them in the first place. My experience is that most orthopods can't even deal with the simplest postoperative medical issue for their patients, and they tend to punt problems to a medical consult that even a third-year medical student could handle competently.

He goes on about how much money they make and how greedy they are, assuring the reader all the while that he bears no economic envy.


Happy Hospitalist largely agrees with him. He noted:

There is no reason for a hospitalist to follow a patient with stable medical issues any more than there is for an orthoapedic patient [sic] to follow my CHF patient for stable osteoarthritis.

That's clever, but I would offer this caution. Many patients on the ortho service are there for elective surgery, eg knee replacement. Our medico-legal culture these days tends to be very unforgiving when nasty post-operative complications such as MI and PE follow elective surgery. So it's not hard for me to understand why the orthopedic surgeon would want to have a hospitalist “on board.” Now, that must be distinguished from having the hospitalist take over the details of post-operative care as I'll explain below.


But back to Dr. Rubin's post. He relates a story of a lady who was not seen by her attending surgeon for eleven days in the hospital following a joint replacement.


Although his rant will contain a ring of truth for many hospitalists (especially his illustration of the “I've done my procedure, I'm outta here” mentality) I take issue in part. First, to borrow a popular saying today, he might have turned down the vitriol. His post is titled “Billy Rubin To Orthopods: Man Up or Drop Dead.”


Second, from what I have observed Dr. Rubin's criticisms might apply equally to many specialties, at least the procedural specialties. I see no reason to single out the orthopods. (Or could it be that I'm just very lucky to work with a uniquely good group of orthopedic surgeons?).


Yes, it's true that in the procedural specialties there's too great a focus on the procedure and not enough attention to general patient care. But I've been in practice a long time and I don't think it's always been that way. In fact, it was once the opposite. Post operative care with all its little details, from the TPN to the pain management to the discharge instructions, was once a source of great professional pride for the surgeons. This has changed in recent years and I think I know one of the reasons. I think (OK, I'm about to drop a bomb here) the hospitlaist movement is largely to blame. We, thanks in part to our very presence in the hospital and to our poorly defined and ill conceived comanagement initiatives, have been the enablers.


Let's look for a moment at comanagement. Bob Wachter, writing in his Google Knol (yeah, remember those things?) about hospital medicine, had this to say about comanagement:

Post-operatively, in addition to obvious issues like wound care and pain control, patients often need their diabetes or blood pressure managed, their infections treated, and a variety of strategies implemented to increase their probability of recovery (for example, prevention of post-operative blood clots).

Just as the primary care doctor’s busy office practice meant that he or she could not be physically present to coordinate hospital care, so to [sic] does the surgeon’s busy operating room schedule. Moreover, although surgeons have superb training in the technical aspects of their trade and the pre- and postoperative surgical aspects of care, their training (and often their interests) are less focused on medical management. So once hospitalists were present in the majority of U.S. hospitals, the stage was set for hospitalists to expand their patient population to “co-management” of surgical patients.

Yes, and the stage was also set for the procedural specialties to become disengaged from the details of patient care. It's the law of unintended consequences. Having hospitalists hang around the wards so surgeons can spend more time in the OR (one of the original selling points for comanagement) just made economic sense to some. To the more skeptical among us it opened the door to a whole host of problems in patient care. And to the really cynical folks like Dr. Rubin it just fueled the surgeons' greed.


Hospitalist leader Eric Siegal, interviewed in The Hospitalist, took the contrarian view and noted this about comanagement (my emphasis):

So, little by little, co-management evolved from a strategy for managing only the most complicated cases to a routine practice at many institutions—even when hospitalists actually added little to a patient’s care. For example, a “patient with a stable GI bleed who needs little more than an endoscopy I would argue does not need co-management,” Dr. Siegal says. In fact, he points out in his paper, inserting the hospitalist into the situation above might work against the patient if it delays the gastroenterologist’s involvement and the endoscopy. A gastroenterologist who assumes a hospitalist is running the show may pay insufficient attention to the patient, Dr. Siegal writes.

Back in the day the surgeons proudly took ownership of perioperative care. When I was a medical student I recall a surgical house officer telling me “I may not be the world's greatest diagnostician but I know how to take care of post-operative patients.” When I first showed up in town to begin a traditional IM practice many years ago I was given a tour of the hospital. We arrived on the surgical floor and I was introduced to one of the surgeons. This is my floor, he informed me.


The orthopods are not dumb. They haven't forgotten what they learned in medical school any more than the rest of us. Hospitalist leaders came along and promoted this new idea of comanagement. “We'll look after the patients on the surgical wards so you guys can spend more time in the OR doing what you do best,” we told them. And, guess what? They bought it. Under today's economic pressures how else would you expect them to respond? Is is any surprise things have deteriorated to where they are now?