- Email: [email protected]
Surgical hospitalism: A perspective from the community hospital
Surgical hospitalism: A perspective from the community hospital Eva Wall, MD, Everett, Wash From the Department of Surgery, The Everett Clinic, Everett, Wash
The general surgeon of yesteryear was a renaissance man. His residency was 5 to 7 years, with typical weeks in training of 100 work hours or more. He managed hernias and gallbladder disease, appendicitis, and colon cancer; he fixed ruptured aneurysms, could drill burrholes, or do a neck dissection, not to mention gynecologic and orthopedic procedures. He managed traumas, put in chest tubes, and took out ruptured spleens. He carried out lung resections in the elderly as well as pyloromyotomies in infants. In the past few decades, the management of operative disease has evolved considerably. As specialization and sub-specialization now prevails, we recognize that outcomes improve when care is rendered by physicians with more experience in particular operations or in managing certain disease processes. For example, perioperative complications in carotid endarterectomies diminish as the volume of cases and operative experience of the surgeon increase.1 Patients injured seriously who receive trauma care in trauma centers enjoy measurably better outcomes.2 Additionally, surgeons feel increasing economic strain as operative technology advances, and as patient age and comorbidities increase, cost pressures rise and reimbursement diminishes. Malpractice costs are recognized at crisis proportions across the nation. With the professional trend toward specialization and worsening economic pressures, surgeons are reluctant to practice trauma care and to render urgent hospital consults. As well, the trauma care and urgent consults either disrupt busy office
Accepted for publication January 10, 2007. Reprint requests: George C. Velmahos, MD, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA 02114. E-mail: [email protected]. Surgery 2007;141:327-9. 0039-6060/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.01.011
schedules or elective operative schedules, or are requested at night time hours. Charity care in surgery has historically been a burden shared by the operative community. Emergency department coverage for unreferred or uninsured patients was a requirement for surgeons to maintain their operating privileges at the local hospital. In our generation precedents are now set in several fields where physicians are demanding compensation for emergency call. In certain circumstances call coverage cannot be met, and patients need to be transferred to facilities where physicians are available to care for them. In short, the renaissance man, the “general surgeon,” is nearing extinction. For all of these reasons in Everett, WA, the burden of operative call generated the evolution of an operative hospitalist. The Everett Clinic is a multispecialty group that 5 years ago had 4 surgeons with an abundance of elective operative work. Their participation in emergency department coverage impaired their ability to manage active operative practices and as a result, 1 surgeon nearing retirement in the community began to work part time during the day, taking only calls for urgent operative hospital and emergency department consults. When this individual ultimately retired, the surgery department had grown to 6 surgeons, and they found the operative hospitalist position had been useful to their practices. They then hired a surgeon who had finished his residency training recently to continue in the position full time, and monitored his work to ascertain the economic feasibility of such a role. His work revenue covered his salary adequately and even allowed for bonus pay based on productivity. When he completed a year of work and went on to fellowship training as planned, a full-time permanent position was created for an operative hospitalist for the Everett Clinic. I was fortunate enough to be hired for that position. I am board-certified in general surgery and in surgical critical care; I finished my residency in 1998. I am the proud mother of 2 boys, aged 6 and 3. My husband is also a physician. I am now part of SURGERY 327
328 Wall
the general surgery department of the Everett Clinic, which has 7 surgeons: in addition to myself, there are 3 general surgeons, 2 operative oncologists, and a fellowship-trained minimally-invasive surgeon. My day begins at 7 AM and ends at 5 PM, Monday through Thursday. I check my voicemail on the drive in to work, as my colleague on call the night before will leave sign outs to me by voicemail. Typically there are 1 or 2 patients that have been admitted to the operative service that will require an admission history and physical, and possibly operation that could be deferred safely. I also round on any patients that I have admitted previously or operated on, or any patients signed out to me by my colleagues (eg, when they have a day off and require coverage). In the event I have a patient that requires operation (eg, someone with appendicitis), I call the operating room and book the case. During the day I also take calls for consultations from other physicians, either on patients already hospitalized by the medicine service (also a hospitalist service), or from outpatient sites—internal medicine clinic, walk-in clinics, and the like. I also take calls from the emergency department. As my day unfolds and the 5:00 line approaches, I accomplish what I can and any work left over I sign out subsequently to the person on call. My 6 operative colleagues rotate evening call. I do participate in weekend call, therefore one Friday, Saturday, and Sunday every 7 weeks I am available. I do not share in weekday call, therefore, have 3 days of call every 21 days. My peers cheerfully agree to allow me this “perk” because in my role as operative hospitalist, they are not burdened by phone calls during their scheduled day. While in the office, they do not receive calls for consults as their call actually does not begin until 5 PM. Likewise, while in the operating room, they are not called to the emergency room because that is my primary responsibility during the day. Given our referral base and the number of surgeons in our group, there is plenty of work for me during the day as a rule. Besides the obvious benefits of this arrangement to myself and my colleagues, several side effects also became apparent to me after I started working. The emergency department staff is thrilled to have a general surgeon available immediately. They know me and my practice preferences, instead of having to contend with the variability of seven different individuals whose practice styles differ. Patients do not have to wait for hours on end to be admitted or to meet the surgeon to whom they are
Surgery March 2007
admitted. From the surgeon’s side, it’s more difficult for patients with “soft” criteria for admission to get slipped in inappropriately because I see them immediately on request for consultation and screen out non-operative patients (eg, the obstipation being billed as a bowel obstruction). The operating room also enjoys the rewards of operative hospitalism. Typically surgeons with regular office hours or scheduled surgeries will put urgent cases into the “add-on” list at the end of the day. In the meantime, because surgeons have their regularly scheduled day, when openings appear in the operating schedule, there are no surgeons that can “move up” to fill them. A queue forms at 5 PM that can run all night. Surgeons want the hospital to staff multiple rooms at night; hospitals want to manage costs and also struggle with staffing shortages after hours. In my situation, when holes appear in the operating schedule (eg, cases canceling or blocks unfilled), I take the open spot and get urgent cases done while improving operating room utilization. Everyone benefits. On Fridays, I see follow-up patients in the office. I have Friday afternoons off. The other surgeons in the group accept Friday as a part of the weekend, and on their one Friday in 7 lighten their office schedules or operating room schedules appropriately to leave room for the anticipated urgent calls. I have been in this position for 1.5 years now, and I can report that it is a sustainable role. I do an interesting mix of cases: many cholecystectomies and appendectomies, bowel obstructions (both benign and malignant), incarcerated hernias, perforated ulcers, and the occasional ruptured spleen. I do colonoscopies and upper endoscopies as my training and experience are permissive of this, and our gastroenterology colleagues have reviewed and approved of this as well. I put in pneumoencephalograms and percutaneous tracheostomies in the intensive care unit. This system works because I enjoy a collegial and supportive relationship with my surgeon peers. They are happy to tend to their scheduled days while I take the daytime consults, and they graciously accept my sign-outs at 5 PM. Because I am there the next morning, generally the call night winds down for them by around midnight, and calls thereafter usually do not require them to drive in. For new patients after midnight, the emergency department staff fills out admission orders, the surgeon on call leaves me a voice mail, and calls to advise the operating room for anticipated daytime add-ons (eg, appendicitis admitted at 3 AM). Hospitalism has taken hold in internal medicine across the nation. I understand also some hospitals
Wall 329
Surgery Volume 141, Number 3
are turning to obstetric hospitalists as well. The concept works in surgery too, and I wish to express my gratitude to my partners at the Everett Clinic for giving me the opportunity to join them, and for offering me the job of my dreams. I have a rewarding operative practice with a broad range of cases, my patients enjoy continuity of care, and I basically do not take call at night. I earn a living, and I get to see my family every day; I have most weekends to myself, secure in the knowledge that my patients are well-cared for in my absence. What could be better? Surgery is a wonderful profession. My hope is that this hospitalist construct will afford other
young surgeons a chance at finding a place in a noble profession while still able to enrich their lives outside it.
REFERENCES 1. Wennberg DE, Lucas FL, Birkmeyer JD, Bredenberg CE, Fisher ES. Variation in carotid endarterectomy mortality in the Medicare population: trial hospitals, volume, and patient characteristics. JAMA 1998;279:1278-81. 2. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354:366-78.
The general surgeon of yesteryear was a renaissance man. His residency was 5 to 7 years, with typical weeks in training of 100 work hours or more. He managed hernias and gallbladder disease, appendicitis, and colon cancer; he fixed ruptured aneurysms, could drill burrholes, or do a neck dissection, not to mention gynecologic and orthopedic procedures. He managed traumas, put in chest tubes, and took out ruptured spleens. He carried out lung resections in the elderly as well as pyloromyotomies in infants. In the past few decades, the management of operative disease has evolved considerably. As specialization and sub-specialization now prevails, we recognize that outcomes improve when care is rendered by physicians with more experience in particular operations or in managing certain disease processes. For example, perioperative complications in carotid endarterectomies diminish as the volume of cases and operative experience of the surgeon increase.1 Patients injured seriously who receive trauma care in trauma centers enjoy measurably better outcomes.2 Additionally, surgeons feel increasing economic strain as operative technology advances, and as patient age and comorbidities increase, cost pressures rise and reimbursement diminishes. Malpractice costs are recognized at crisis proportions across the nation. With the professional trend toward specialization and worsening economic pressures, surgeons are reluctant to practice trauma care and to render urgent hospital consults. As well, the trauma care and urgent consults either disrupt busy office
Accepted for publication January 10, 2007. Reprint requests: George C. Velmahos, MD, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA 02114. E-mail: [email protected]. Surgery 2007;141:327-9. 0039-6060/$ - see front matter © 2007 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2007.01.011
schedules or elective operative schedules, or are requested at night time hours. Charity care in surgery has historically been a burden shared by the operative community. Emergency department coverage for unreferred or uninsured patients was a requirement for surgeons to maintain their operating privileges at the local hospital. In our generation precedents are now set in several fields where physicians are demanding compensation for emergency call. In certain circumstances call coverage cannot be met, and patients need to be transferred to facilities where physicians are available to care for them. In short, the renaissance man, the “general surgeon,” is nearing extinction. For all of these reasons in Everett, WA, the burden of operative call generated the evolution of an operative hospitalist. The Everett Clinic is a multispecialty group that 5 years ago had 4 surgeons with an abundance of elective operative work. Their participation in emergency department coverage impaired their ability to manage active operative practices and as a result, 1 surgeon nearing retirement in the community began to work part time during the day, taking only calls for urgent operative hospital and emergency department consults. When this individual ultimately retired, the surgery department had grown to 6 surgeons, and they found the operative hospitalist position had been useful to their practices. They then hired a surgeon who had finished his residency training recently to continue in the position full time, and monitored his work to ascertain the economic feasibility of such a role. His work revenue covered his salary adequately and even allowed for bonus pay based on productivity. When he completed a year of work and went on to fellowship training as planned, a full-time permanent position was created for an operative hospitalist for the Everett Clinic. I was fortunate enough to be hired for that position. I am board-certified in general surgery and in surgical critical care; I finished my residency in 1998. I am the proud mother of 2 boys, aged 6 and 3. My husband is also a physician. I am now part of SURGERY 327
328 Wall
the general surgery department of the Everett Clinic, which has 7 surgeons: in addition to myself, there are 3 general surgeons, 2 operative oncologists, and a fellowship-trained minimally-invasive surgeon. My day begins at 7 AM and ends at 5 PM, Monday through Thursday. I check my voicemail on the drive in to work, as my colleague on call the night before will leave sign outs to me by voicemail. Typically there are 1 or 2 patients that have been admitted to the operative service that will require an admission history and physical, and possibly operation that could be deferred safely. I also round on any patients that I have admitted previously or operated on, or any patients signed out to me by my colleagues (eg, when they have a day off and require coverage). In the event I have a patient that requires operation (eg, someone with appendicitis), I call the operating room and book the case. During the day I also take calls for consultations from other physicians, either on patients already hospitalized by the medicine service (also a hospitalist service), or from outpatient sites—internal medicine clinic, walk-in clinics, and the like. I also take calls from the emergency department. As my day unfolds and the 5:00 line approaches, I accomplish what I can and any work left over I sign out subsequently to the person on call. My 6 operative colleagues rotate evening call. I do participate in weekend call, therefore one Friday, Saturday, and Sunday every 7 weeks I am available. I do not share in weekday call, therefore, have 3 days of call every 21 days. My peers cheerfully agree to allow me this “perk” because in my role as operative hospitalist, they are not burdened by phone calls during their scheduled day. While in the office, they do not receive calls for consults as their call actually does not begin until 5 PM. Likewise, while in the operating room, they are not called to the emergency room because that is my primary responsibility during the day. Given our referral base and the number of surgeons in our group, there is plenty of work for me during the day as a rule. Besides the obvious benefits of this arrangement to myself and my colleagues, several side effects also became apparent to me after I started working. The emergency department staff is thrilled to have a general surgeon available immediately. They know me and my practice preferences, instead of having to contend with the variability of seven different individuals whose practice styles differ. Patients do not have to wait for hours on end to be admitted or to meet the surgeon to whom they are
Surgery March 2007
admitted. From the surgeon’s side, it’s more difficult for patients with “soft” criteria for admission to get slipped in inappropriately because I see them immediately on request for consultation and screen out non-operative patients (eg, the obstipation being billed as a bowel obstruction). The operating room also enjoys the rewards of operative hospitalism. Typically surgeons with regular office hours or scheduled surgeries will put urgent cases into the “add-on” list at the end of the day. In the meantime, because surgeons have their regularly scheduled day, when openings appear in the operating schedule, there are no surgeons that can “move up” to fill them. A queue forms at 5 PM that can run all night. Surgeons want the hospital to staff multiple rooms at night; hospitals want to manage costs and also struggle with staffing shortages after hours. In my situation, when holes appear in the operating schedule (eg, cases canceling or blocks unfilled), I take the open spot and get urgent cases done while improving operating room utilization. Everyone benefits. On Fridays, I see follow-up patients in the office. I have Friday afternoons off. The other surgeons in the group accept Friday as a part of the weekend, and on their one Friday in 7 lighten their office schedules or operating room schedules appropriately to leave room for the anticipated urgent calls. I have been in this position for 1.5 years now, and I can report that it is a sustainable role. I do an interesting mix of cases: many cholecystectomies and appendectomies, bowel obstructions (both benign and malignant), incarcerated hernias, perforated ulcers, and the occasional ruptured spleen. I do colonoscopies and upper endoscopies as my training and experience are permissive of this, and our gastroenterology colleagues have reviewed and approved of this as well. I put in pneumoencephalograms and percutaneous tracheostomies in the intensive care unit. This system works because I enjoy a collegial and supportive relationship with my surgeon peers. They are happy to tend to their scheduled days while I take the daytime consults, and they graciously accept my sign-outs at 5 PM. Because I am there the next morning, generally the call night winds down for them by around midnight, and calls thereafter usually do not require them to drive in. For new patients after midnight, the emergency department staff fills out admission orders, the surgeon on call leaves me a voice mail, and calls to advise the operating room for anticipated daytime add-ons (eg, appendicitis admitted at 3 AM). Hospitalism has taken hold in internal medicine across the nation. I understand also some hospitals
Wall 329
Surgery Volume 141, Number 3
are turning to obstetric hospitalists as well. The concept works in surgery too, and I wish to express my gratitude to my partners at the Everett Clinic for giving me the opportunity to join them, and for offering me the job of my dreams. I have a rewarding operative practice with a broad range of cases, my patients enjoy continuity of care, and I basically do not take call at night. I earn a living, and I get to see my family every day; I have most weekends to myself, secure in the knowledge that my patients are well-cared for in my absence. What could be better? Surgery is a wonderful profession. My hope is that this hospitalist construct will afford other
young surgeons a chance at finding a place in a noble profession while still able to enrich their lives outside it.
REFERENCES 1. Wennberg DE, Lucas FL, Birkmeyer JD, Bredenberg CE, Fisher ES. Variation in carotid endarterectomy mortality in the Medicare population: trial hospitals, volume, and patient characteristics. JAMA 1998;279:1278-81. 2. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354:366-78.