Surgeons Aren't What They Used To Be

There is a faction of health care professionals who believe hospitalists are at the root of lost continuity of care. I posted previously about how this line of thinking is a myth. I speak from experience and fact. Let's say Mrs Smith has her established doctors as an outpatient. Dr PCP, Dr Heart, Dr Lung, Dr Kidney. You name it. Lets say Mrs Smith gets admitted into the hospital.

Mrs Smith may see Dr PCP if he still goes to the hospital. More than likely, she will see Dr Hospitalist. If she has heart, lung or kidney issues, the likely hood that she sees her own outpatient medical specialist while in the hospital is minimal. You see, Mrs Smith gets whom ever is on call. It may be someone else in their group. It may in fact even be a doctor from another competing group. Your choice, can in fact be quite limited if there is only one group of specialists in town. As a patient, if you hate the gastroenterologist or cardiologist on call and there is only one group of docs, you're out of luck. Or you can go to another hospital. Or city for that matter.

There are many cross covering relationships that exist between groups, to minimize weekend work and disruptions to family lives. Medicine is no longer a 24 hour a day, seven day a week calling. The goal, in the decreasing environment of payment, is to decrease your exposure to headaches and distractions from your personal life. In other words, fewer phone calls.

As a hospitalist, I am asked to admit patients front the ED at the request of the patient's comprehensive care physician. Often times, Mrs Smith's doctor is not on call. Nor is anybody from the group. It is a doctor from another group of doctors, who rarely has any contact with Mrs Smith's doctor. And who has no interest in seeing a patient from another group or even hearing about it. The cross covering relationships that exist, even in the comprehensive care field is a testament to the lost continuity, even among comprehensive care physicians.

The issues of continuity often arise when I am trying to discharge a patient. As a policy of our group, we always call the patient's comprehensive care doctor on discharge to give them a verbal update on the main issues of the hospital stay. I can tell you, on many occasions we are unable to speak personally with the patient's normal doctor. During normal working ours, often the doc is "out on Wednesdays" or is "on vacation". In these situations, we try and speak with a partner, who often times doesn't care either. And I don't blame them. On weekends, it's even harder. Frequently, cross covering relationships exist between groups that never have contact with each other, as I alluded above. They could care less about Mrs Smith. These are doctors who take call, but have no relationship with the doctor or patient for which I am calling about. Continuity in the comprehensive care world? It's a myth. Moving on to the medical specialties (non surgical)...

In the hospital, in my five years, there has never been a continuity in any medical oriented field (GI, Cards, ID, Pulm, Critical Care, Renal, Neuro). They have a rotating schedule, usually with someone in their group. If Mrs Smith is in the hospital for three weeks, she may see four or five different cardiologists, four or five different GI docs, a slew of ID and renal docs as well. They do their hospital rounds and then move on in the calendar of scheduling. Usually a week at a time. Some times more, sometimes less. In the case of the cardiologists, often times the doctor changes on a daily basis. Then they rotate. Either to another hospital or to the much more lucrative outpatient setting or satellite clinics. Just as hospitalists rotate through their schedule.

Continuity? It's a myth across all medical specialties. Hospitalists are not alone. How about the surgeons?

For many surgical groups I have worked with, most round (or send their extender to do their work) on their own surgical patients on the weekdays and split weekend call with their partners. But they round on their patients until discharge day. As opposed to the medical oriented specialities that rotate through their call schedule and then move on. I can tell you, from an economic and financial standpoint, it would be a pain in the ass for a cross covering partner to round on one of their partner's surgeries on a Saturday morning. Because the global fee applies to many surgical interventions (90 days), that cross covering partner takes all the risk and no payment for putting their name on the chart on that Saturday morning. If a mistake in management is made, that risk was free, without compensation. At least, as partners, they can usually contact each other if any questions arise on that Saturday morning.

But, imagine for a moment, if surgical groups were cross covering for each other. Sharing weekend call. Two surgeons who don't associate with each other. Ever. Who compete in the market place for patients. What if that surgeon was on call the night Mrs Smith came in with a possible complication of her surgery two weeks prior? What happens now?

What happens when the surgeon on call has no way of contacting the operating surgeon? To discuss a potentially serious complication. Let's even say life threatening. What happens if the operating surgeon is unlisted and the call service refuses to contact the operative surgeon because they are not on call? What happens?

I found out surgeon's aren't what they used to be. When they operate, they no longer own. They have gone the way of the lifestyle mantra like so many specialties before them. As a doctor, I can understand that. If you're not on call you don't want to be bothered. In a world that has taken the financial glory out of medicine, it is simply not worth the hassle anymore. Call the on call doctor. It's not my problem tonight.

Surgeons are cross covering other surgeons. Without a way to contact them for their own personal interpretations of the surgery or any possible complications that may have arisen. I hear all the time that you really don't know how a patient is going to do post operatively without actually being there in the OR. Seeing the insides for yourself. Seeing the massive inflammatory response. The dead tissues. The infection. The surgeon has the best vantage point in a surgical case and post-operative care is best understood by being in the OR.

So it comes as extra scary to know that surgeons are abandoning that mantra of you operate, you own, in favor of the lifestyle that all other physicians have looked for. Limiting call. Limiting night and ED exposure. Limiting weekends. Lifestyle issues. Limiting access to discuss potentially life threatening complications of their surgery.

I spoke with a surgeon who agreed to see a patient of mine, that I admitted. That had surgery two weeks prior by another surgeon in the same field of expertise, but in a competing group. The call sharing phenomenon. Two surgeons who rarely interact. Who have no way of contacting each other. I was told, the only way the operating surgeon could be contacted was by looking them up in the phone book. Of course, how many surgeons do you know that are listed. To be honest, I found the operating surgeon quite easily by Googling their name. The question is, should I call them? If they aren't on call, do I have an obligation to call them? Legally, ethically or morally? Is that the on call surgeon's responsibility, as an extension of the operating surgeon?

I suspect that the operating surgeon would want to know that their patient was in the hospital with a potentially life threatening complication. Or perhaps they don't want to know. If they aren't on call, they may just not want to be bothered until Monday. The on call surgeon made it clear that they have a sharing of the call for a reason. So they aren't on call "every other weekend". It is implied and accepted that the on call doc shall take care of any urgent issues and hand off on Monday to the operating surgeon.

Like every other field in medicine, the continuity myth has also arrived for our surgeons. They simply aren't what they used to be. And I don't blame them. As a doctor, I understand. As a patient, it would scare the hell out of me.