What does an internist do and what is the role of an internist? A healthy 34 year old pig farmer presented as a direct admit for disc removal after injuring his back while playing softball. A healthy guy with no chronic conditions. A non smoker a non drinker, the man takes no medications. Has no family history of concerning disease. A hard working functional male who needs his back operated on.
This is about as healthy a human specimen as you can get. So I get called to see for preoperative evaluation. What I found in the chart was quite telling. A very thorough H&P from the surgeon's office, performed by the surgeon's physician assistant, just three hours earlier. It had every component of a level 3 H&P.
- Four components of HPI
- Past medical, family, social histories complete with allergy and medication histories
- A complete 12 point review of systems.
- A high level physical exam
- All components to meet a high complexity decision making process
What was the final plan? Admit to hospital for surgery. Consult hospitalist for pre operative evaluation. Here's what I don't understand. PA's presumably trained in an acute care setting. They have been exposed to many disease processes. They frequently cover emergency rooms with limited and remote oversight. If PAs are capable of doing that, should they not be able to risk stratisfy a healthy 34 year old for a preoperative opinion on a non vascular surgery?
Is this a risk thing or a laziness thing. I understand the laziness thing. Patients who present to the hospital for semi emergent semi elective surgeries who "couldn't get in to see their PCP". We are asked
for our opinion on preoperative "clearance". to produce an H&P by 8 am. I know it's not the patient's fault. The surgeon is often too busy in surgery to meet their obligations as a surgeon. I can even understand the medical evaluation thing. Patients with multiple comorbidities should see an internist for elective stratification of their disease.
But not two hours before their scheduled surgery? Is it ignorance? Is it fear? Is it reflex medicine? Is it their lack of faith in the abilities of the PA who trained to know this stuff? In this case, there was already an H&P done. A beautiful level 3 H&P by the surgeon's PA. A note that will probably pay $250 in addition to the bundled fee for the surgery itself.
So why does the patient need a consult from me? I just don't get it. What a waste of my time and your premium dollars. I'll get paid. And I'm sure the private insurance will pay quite well. Why will I get paid? Because I was asked to see the patient. And my documentation supports the request. And your premiums will go up to pay for my consult.
This is a classic example of the presumed 30% wasteful spending in American health care. Do we need an internist or a hospitalist to see a healthy 34 year old pig farmer for semi elective nonvascular surgery. And if so, does the public Treasury or your insurance company have an obligation to provide what I think is a medically unnecessary request? The answer is no. But they will. Every time.
Imagine if the surgeon's fee was reduced to pay for such an opinion. How much risk do you suppose the surgeon would be willing to accept if their bundled fee was reduced to pay for an internists opinion on "clearance." How much extra time do you think they would find in the day to screen their healthy patients for a low risk surgical intervention.
I can only suspect that if you provided payment for episodes of care, this kind of waste would go away. The good doctors who practice sound medicine would benefit by reducing the waste and the bad ones would either quit or accept a reduced fee for their need to have others cogitate.