Published in the October 2015 issue of Today’s Hospitalist
YOU NEED THEIR HELP with operations and bedside procedures, and you’re happy when they consult you for medical management. But working with the surgeons at your hospital can bring both opportunities and problems, and handling both can be a challenge. Let’s look at a few.
“He’s going to the OR in an hour”
Dr. Neuro loves your group, and you appreciate her patient care and ready availability. But this is the third time this month that you’ve been called to clear a patient right this minute for a surgery that was scheduled two weeks ago. How can you change this?
A good place to start is with the surgeon’s office manager or a nurse who works closely with her. Ask about having patients’ primary care providers dictate an H&P to be placed in the preadmission records; this is especially helpful with out-of-towners.
If a surgeon won’t come in when his own patient has a problem, how can you be sure he’ll be there for somebody you admit?
Another possibility if the surgeon’s office is close to the hospital is to see the patient there yourself. There will be examining rooms and pleasant office assistants, and the patients will be reassured to know who will be helping with their perioperative care.
Other stat preop consults are unavoidable: this morning’s hip fracture, the acute abdomen belonging to somebody with diabetes or a previous MI, and many more. Make sure your note contains not only major problems and recommendations, but also the magic words anesthesiologists look for: “Cleared for procedure under local or general anesthesia.”
If you cannot clear the patient (active pulmonary edema, recent MI “you know the list), notify the surgeon by phone right away. If another consultant can help, offer to call that doctor. It may be possible to get the patient to the OR after all if a subspecialist will write a note saying that a finding can be safely disregarded.
One elderly hip-fracture patient had an unexplained pericardial effusion; the cardiologist gave the go-ahead for surgery, and anesthesia went ahead as scheduled. The added benefit: My partner was in the clear when the patient arrested as she was intubated.
“Just check up on him this weekend”
You took care of chest tubes during your surgery rotation … how many years ago? But now the nurses are worried about an air leak and the thoracic surgery intern or PA doesn’t know what to do.
If Dr. Surgeon hasn’t given you his cell number, the hospital operator can probably give it to you. If you are sure you need a surgeon for the problem, ask him to come in and tend to it himself. If he refuses, you need to have a talk with your group about whether to continue the relationship. If he or a partner won’t come in when his own patient has a problem, how can you be sure he’ll be there for somebody you admitted?
Keep in mind that problems that develop a day or three after surgery are very likely related to something that happened during the operation or went wrong as a result of it. If the surgeon says those issues aren’t his fault, you can often order a scan or X-ray that will either reassure you or convince the surgeon that the benefits of a second procedure exceed the risks. If the scans suggest a problem and the surgeon still denies that there is one, you may have to get support.
Talk to one of his partners, or find an additional consultant to help encourage him to re-evaluate the situation. Protect yourself by writing your impression in the chart, because a plaintiff’s attorney is likely to name every doctor who saw the patient. A note from you suggesting the possibility of postop bleeding or a leak from an injured bile duct makes it clear that you are trying to protect the patient.
When the ball is in your court
Medical problems “from blood sugar fluctuations and PEs to alcohol withdrawal “can happen anytime. If the surgical condition is stable and Dr. Surgeon says the operative site is ready for discharge, do everybody a favor by transferring the patient to your service. You can check the incision once more before the patient finally goes home, and everybody will feel better about the care you’re giving. Having you on record as the primary physician will make it easier for the staff because there will be no argument as to who is in charge.
It’s more complicated when the patient develops additional problems during postop recovery. If the surgeon is primary on the case, he will usually be OK with you doing everything up to calling consultants without asking him. But it’s a good idea to ask first, or at least have the nursing staff clear major orders with him.
Some surgeons, especially older ones, go ballistic if you don’t clear everything with them. I know that sounds annoying, but as long as they return your calls promptly, you can still work together.
When the surgeons own the hospital
Small surgeon-owned hospitals are legal in many states, and they give the surgeons who work in them the kind of control that some of us can only dream of. You may be asked to provide coverage or even a full-time presence there.
This is profitable because the patients will all be insured, and it should be a comfortable arrangement for you because all the patients will have been cleared before admission, right? Sad to say, the surgeon may not realize the patient hasn’t given him a complete history (“You mean, insulin is considered a medicine?”), or he may have figured the hepatitis C could be handled after discharge. Make sure you know before you start where patients with problems should be transferred if those issues can’t be handled on-site. Also, get the surgeon’s assurance that he will accept your recommendations.
The big pluses
Some of those surgeon jokes are partly true; they really do have a different mindset from those of us who work outside the OR. But they know a lot of stuff that we’ve forgotten or never seen: complications to watch for after common operations, tricks for diagnosing an acute abdomen, and many bedside procedures that we may or may not have been taught during training.
Yes, you have other chores. But if a surgeon you trust is in a teaching mood, pull up a chair and listen. Your present hospital may let you call interventional radiology for invasive procedures, but practice groups come and go, and in your next job you may have to put in those central lines yourself.
Hospital administrators have believed for decades that, “Surgeons bring money in and internists take it out.” As third-party payers reduce coverage and the pressure is on to control costs, having the surgeons in your corner can ease your relationship with the hospital’s front office. (That front office is desperate to keep surgeons from opening or deserting to one of the above-mentioned surgical hospitals).
Contracts for ED coverage don’t last forever, and your hospital privileges need renewing regularly too. A smooth relationship with fellow physicians in all specialties helps ensure your group’s future.