Sunday, April 29, 2007

I dub thee....Sir Flea the Small-Minded!

It's a pejorative term, really. Not very nice, in the grand scheme of ecumenicism with one's fellow physicians. But it is also freely used throughout medical school, residency, and (occasionally) beyond. I suppose in this day and age of pst-Imus hypersensitivity, it is a term which I should avoid at all costs. However, since it is a word that I am about to use to describe myself, perhaps a little leeway is in order.

flea

I'm a flea. Not by calling. Not by training. Certainly not by nature. But, there it is. I'm a flea, if only as a matter of necessity.

What the &*#% is a flea? Certainly in my context it's not one of these. And if my pediatric colleague (who writes things at times that make him appear to be my twin brother from another mother) doesn't take offense, I'm not a kiddie flea. A flea, in the parlance of medical students, is an internal medicine resident. And, by way of further explanation --- here's where the pejorative nature comes into play --- a flea is "the last thing off a dying dog." Nasty, n'est ce pas? But who ever said that medical students and residents in training had either the time or inclination for the proper social interplay between adult human beings?

How can a middle aged guy who has spent the last 19 years training and then working as a general surgeon be a flea underneath his scrubs? I am afraid that it is because the economics of medicine, and the lifestyle choices of (many) physicians, have foisted the hospitalist era upon us. Gone are the days when a patient's internist would help ensure that they received the best possible medical care in the perioperative period --- an all-too-frequent question I recieve is "Dr. Aggravated DocSurg, why won't my doctor come see me in the hospital? His office is less than a mile from here." I haven't been able to come up with an answer that leaves my lips without a little sarcasm, so I just shrug my shoulders.

Many, including academic hospitalists like Dr. Centor, strongly feel that the hospitalist movement is a very positive one, and certainly have a host of studies to back them up. And they can supply us with a tit-for-tat series of anecdotes that are excellent counterpoints to my own. I just know that I am spending an inordinate amount of time dealing with untreated hypertension, out of control diabetes, undiagnosed sleep apnea, and the like --- because our hospitalist system is inefficient and poorly organized. Many of my general surgery colleagues across the country are seeing the same thing. Perhaps the hospitalists are tied up admitting purely orthopedic patients or dealing with somebody else's failed procedures (see this excellent rant), but in my experience they are folks who did not flourish in the world of office practice seemingly due to an inability to address patient problems in a time efficient manner. Despite the comments in the above-mentioned rant, in our hospital surgeons admit surgical patients. Period. But hoping to get timely help with the surgical patient with numerous comorbidities is quixotic at best. Additionally, one of the unspoken problems with the hospitalist system is that many patients are so P.O.ed at not being able to see their "real" doctor that they develop an intense animosity towards the hospitalists called in to see them....and then fire them.

So, to get back to the beginning, I have become a flea. I manage a whole host of perioperative medical problems because I can now do it more expediently, more safely, and with a better degree of success than my patients could get the same care through the system that has been handed to us. When cardiac problems get out of my league, I call a cardiologist ---- just like the hospitalists do. Ditto for pulmonary issues. And I get some degree of satisfaction from the job.

What I don't get from all of this extra work is --- you guessed it --- better reimbursement. You see, for major surgeries, the operative fee covers all postoperative care for the next 90 days. So, if granny comes to the hospital with COPD, CHF, is anticoagulated due to chronic atrial fibrillation, and has diabetes that's a bit out of control --- and has perforated diverticulitis --- yours truly must tune her up like a '57 Bel Air that's burning oil and has leaky brake lines; then operate on her, which is sort of like walking a tight rope across Niagara Falls while reading Shakespeare; and then guide her through the next 90 days of recovery, all for the price of an admission history and physical and operative procedure.

Is that all bad? No, not really, because I really enjoy taking care of patients. But I must admit that I'd prefer to spend more time in the OR, or even (God forbid) in the office. I must also admit that I don't see anything changing for the better in the near future, so aside from this rant, I'll just have to man up and deal with it!