Friday, January 21, 2011

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?


Billy Rubin said...

Thanks for the shout-out, R Dub!

You assert that I could have turned down the vitriol; if anything, I felt like I was reasonably restrained (only two truly rude words used out of several hundred) and thought about cranking the anger up. Though this reflects, I suppose, a difference in approach that you and I may have in terms of taking umbridge on behalf of our patients. I can assure you that the patient in question was a good deal more mad than me.

You also assert that my criticism could just as easily apply to other surgical subspecialties, and I agree completely. That said, my own sense is that orthopods in particular have developed a culture that is very much at odds with the hidebound traditions that physicians have always proudly trumpeted: our paternal/maternal sense that patients should be protected and never abandoned. You note that you have orthopedic colleagues with whom you are proud to work, which I think is great, but if they really are as groovy as you say, to me they seem the exception these days. I admitted up front in my piece that my observations about orthopods are subjective impressions, so we will have to see if my comments resonate with other internists and hospitalists, or if they would side more with you. It is certainly possible that the culture I'm decrying may be peculiar to my region of the country, but I'm skeptical.

I think you also missed my point about the "comanagement" aspects of the piece. At the hospital where this incident occurred, there are no longer patients who are primarily under an orthopod's service unless they are elective or day surgery patients--all the s/p fall hip fracture patients, regardless of complexity, are sent to the hospitalist service with ortho consulting. That's the way this hospital does business and for the most part I don't have any quibbles. But the woman about whom I wrote was in for elective replacement and lingered for days feeling abandoned, and I think most of our internal medicine colleagues would find that the lack of even one visit during this period a breach of the sacred trust between a physician and patient. I also learned from informal chats with my colleagues at this hospital (where I'm not full time) that issues like this weren't isolated when dealing with the physicians from that group, which is responsible for at least 50% of the orthopedic surgery traffic at this hospital. The fact that you even feel the need to rush to their defense is disturbing to me.

We do concur about one thing, however: you totally caught me red-handed when I tried to pull the wool over everyone's eyes by writing that I wasn't envious at their wealth. Alas, your psychoanalysis has proved too prescient once again! Foiled again. And now I must return to my glass of Yellow Tail Shiraz, pining for the joys of Far Niente that the Bone Guys sip with such regularity. Drats!

Billy Rubin said...

Oops--"umbrage," of course. I had a Harry Potter moment.

R. W. Donnell said...

Thanks for the comments, Billy.

My eyebrows sometimes go up when I see criticism of how much money someone else makes, but there's no psychoanalysis going on here. I make no claim to know where you're really coming from, and for all I know it's merely your highly developed sense of social justice.

The patient you described in your post was being comanaged in that there were hospitalists in consultation "managing the medical issues." I'm NOT defending the orthopods in this particular case (their actions should be judged on their own merits) but I wonder if this situation could even exist if hospitalists weren't available.

The Medical Contrarian said...

If all we do is train narrowly focused and technically adept practitioners who are incentivized to forget their broad medical knowledge, why make all that investment to send them to medical school in the first place. If the training they need is to learn how to use their hands, they should just go to trade school and leave the difficult management work to those who maintain their broad knowledge base.