Changing your practice to fit into the community

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dpmd

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I am new to private practice, but I know that it is important to not alienate the referring providers or fellow surgeons. I was wondering if anybody has any advice on how to deal with when what you do is different than what everyone else expects. The reason I ask is because it has come up that my application of nonoperative management of early uncomplicated appendicitis has ruffled feathers in the community. I lease my overhead and participate in a shared call schedule that is basically run by one guy and he let me know that he was been getting called by PCP's about some patients I have managed this way (none of the patients had any problem with it since I presented it as just another option besides surgery and only have been doing it for those that want to, also none of them have had any issues after leaving the hospital). He asked me to stop offering nonop management and to just take all those appys out. Since it is such a new and not universally accepted thing, I don't really think it is worth arguing about. However, perhaps there will be something else that I do and feel more strongly about that will be called into question as well. How do I decide when to stick to my guns, and how do I go about it without getting blackballed in the community. Also, am I wrong to roll over on the appy issue.

Keep in mind this is a community where a lot of the surgeons just do open appys, and where interval management of perfed appy is not really done either (although I will keep doing that)

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I don't know anything about appys anymore. But I presume your position is supported by the literature. If that's the case I would share the new literature with the call group and leave it with that. Tell them you know it's a new and maybe somewhat controversial approach but you have had good experience with it and would appreciate the ability to practice an evidence based approach. You aren't saying their approach is wrong, just that you prefer a different one. At the end of the day you've got to feel like you're doing the right thing. Someone else can't decide that for you. Appy isn't something you get referred so it shouldn't hurt in that regard. How do envision this hurting you financially?


And what the hell do the PCPs care about how you manage pts? Tell them to stick to diabetes and htn. It's really not their place to tell you how to practice just as you wouldn't tell them how to practice. Stand your ground.

I can't stand the old guard and their antiquated BS. Things change. Deal with it. I had a similar deal with my senior partner about my management of a common ent problem shortly after I started in practice. He told me I needed to do it the "way this practice always has". Wrong answer bud. I stood my ground and gave him supporting literature. He backed off.
 
I am new to private practice, but I know that it is important to not alienate the referring providers or fellow surgeons. I was wondering if anybody has any advice on how to deal with when what you do is different than what everyone else expects. The reason I ask is because it has come up that my application of nonoperative management of early uncomplicated appendicitis has ruffled feathers in the community. I lease my overhead and participate in a shared call schedule that is basically run by one guy and he let me know that he was been getting called by PCP's about some patients I have managed this way (none of the patients had any problem with it since I presented it as just another option besides surgery and only have been doing it for those that want to, also none of them have had any issues after leaving the hospital). He asked me to stop offering nonop management and to just take all those appys out. Since it is such a new and not universally accepted thing, I don't really think it is worth arguing about. However, perhaps there will be something else that I do and feel more strongly about that will be called into question as well. How do I decide when to stick to my guns, and how do I go about it without getting blackballed in the community. Also, am I wrong to roll over on the appy issue.

Keep in mind this is a community where a lot of the surgeons just do open appys, and where interval management of perfed appy is not really done either (although I will keep doing that)


Please elaborate on what you mean by "interval management of perfed appy" not being done by the other surgeons (versus what you believe is appropriate). Also, please comment on your preferred approach to early appendicitis, the average LOS, and any US literature on the subject. A lot of the SDNers are students and junior residents, and I'm not sure they always know what we are talking about at the attending level.

I would recommend that you choose your battles wisely. One of the hardest parts about private practice is dealing with the consequences of saying "no," or simply going against the wishes of your referring docs. If you rock the boat over every little thing, they will find you difficult to work with, and they simply won't use you. That being said, patient safety and outcomes have to be in the forefront.

I ran into a problem with an oncologist who didn't like how long I waited to operate on rectal cancer after neoadjuvant chemoXRT. I wait 8-12 weeks (closer to 12) to increase chances of a pCR, and the oncologist wanted the surgery done in 6-8 weeks so chemo would not be delayed. Rather than raise a big fuss over it, I simply agreed, as I think the literature is mixed on the subject, and I need to be a part of the team. It didn't hurt that this particular oncologist sends me lots of rectal cancer.

Importantly, when questions do come up, and you plan to manage something different than the local norm, you have to have a clear, simple, non-condescending way of explaining your rationale.

I hope that helps. How are you liking practice so far?
 
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And what the hell do the PCPs care about how you manage pts? Tell them to stick to diabetes and htn. It's really not their place to tell you how to practice just as you wouldn't tell them how to practice. Stand your ground.

Just saw your post after I posted mine. I have to disagree with this. It might be easier for surgical subspecialists in high demand, but a general surgeon in the community can burn a lot of bridges with this attitude. Certainly, you should stand your ground when appropriate, but the verbage should be a little gentler.
 
I don't know anything about appys anymore. But I presume your position is supported by the literature. If that's the case I would share the new literature with the call group and leave it with that. Tell them you know it's a new and maybe somewhat controversial approach but you have had good experience with it and would appreciate the ability to practice an evidence based approach. You aren't saying their approach is wrong, just that you prefer a different one. At the end of the day you've got to feel like you're doing the right thing. Someone else can't decide that for you. Appy isn't something you get referred so it shouldn't hurt in that regard. How do envision this hurting you financially?


And what the hell do the PCPs care about how you manage pts? Tell them to stick to diabetes and htn. It's really not their place to tell you how to practice just as you wouldn't tell them how to practice. Stand your ground.

I can't stand the old guard and their antiquated BS. Things change. Deal with it. I had a similar deal with my senior partner about my management of a common ent problem shortly after I started in practice. He told me I needed to do it the "way this practice always has". Wrong answer bud. I stood my ground and gave him supporting literature. He backed off.
If they don't trust what I do on call I can see them not referring me elective stuff.
 
Please elaborate on what you mean by "interval management of perfed appy" not being done by the other surgeons (versus what you believe is appropriate). Also, please comment on your preferred approach to early appendicitis, the average LOS, and any US literature on the subject. A lot of the SDNers are students and junior residents, and I'm not sure they always know what we are talking about at the attending level.

I would recommend that you choose your battles wisely. One of the hardest parts about private practice is dealing with the consequences of saying "no," or simply going against the wishes of your referring docs. If you rock the boat over every little thing, they will find you difficult to work with, and they simply won't use you. That being said, patient safety and outcomes have to be in the forefront.

I ran into a problem with an oncologist who didn't like how long I waited to operate on rectal cancer after neoadjuvant chemoXRT. I wait 8-12 weeks (closer to 12) to increase chances of a pCR, and the oncologist wanted the surgery done in 6-8 weeks so chemo would not be delayed. Rather than raise a big fuss over it, I simply agreed, as I think the literature is mixed on the subject, and I need to be a part of the team. It didn't hurt that this particular oncologist sends me lots of rectal cancer.

Importantly, when questions do come up, and you plan to manage something different than the local norm, you have to have a clear, simple, non-condescending way of explaining your rationale.

I hope that helps. How are you liking practice so far?
Perforated appendicitis can be managed with immediate operation (which can be associated with more complications) or delayed operation after the inflammation resolves (sometimes people are too sick for this or they don't get better in which case earlier surgery would be done). A newer approach is to treat with antibiotics plus or minus percutaneous abscess drainage and not take the appendix out except for certain circumstances(like when a fecalith is present or in a patient with hindrances to appropriate future medical care).

For early appys without fecalith (because those tend to need operation) there is literature supporting treating with antibiotics alone (on a phone now so will have to put up studies later). The benefit is avoiding the costs and risks from surgery but the risk is failure to improve (so the appy gets delayed by however long you wait and could be more complicated) and recurrence (although this isn't felt to be very high). I like to give people both options, let them know it is a newer thing that not everyone believes in, and let them decide. Of the 10 or so that were candidates, 2 opted for surgery (los 2 and 3 days) and the rest had successful nonop management with los 2-3 days. I have seen them all post disharge and everyone is doing well. In the literature los can be longer, but part of that may have to do with the protocol.

I am liking practice so far but still have trouble remembering to ask about insurance before making post discharge plans for my nonop patients. I have also done a bunch of free care due to not being on medi-cal yet that I could have avoided by giving it to someone else, but I am making enough money so whatever.
 
Along the lines of this discussion, what do folks think of this one:

http://www.ncbi.nlm.nih.gov/pubmed/23740174

The rates in this study were so out of whack with what is expected that its hard to buy. But an interesting thing to think about in the interval appy discussion
I wonder how many of these neoplasms would have been associated with an abnormal finding on colonoscopy (which I always do for older patients I am managing nonoperatively, although how old is old enough for a colonoscopy is debatable)?
 
Here is a meta analysis from the UK on nonop management in early appy. There is a lot more non US literature on it. At my last job I was actually the contact person for a multicenter study that is planned. Should give some good US data, but I think the UK data is still relevant.
 
Just saw your post after I posted mine. I have to disagree with this. It might be easier for surgical subspecialists in high demand, but a general surgeon in the community can burn a lot of bridges with this attitude. Certainly, you should stand your ground when appropriate, but the verbage should be a little gentler.


I see your point. And believe me I would never deliver my message that way. But do your PCPs stick their nose into your business? Our guys have enough to do running their practice without managing mine too. I certainly cave now and again ( I'm in PP, I get it) but I'm not doing something I don't believe in. I'm sorry that you have to practice that way. Btw, I think this is different than working with an oncologist to hit a happy medium in terms of initiation of chemo or rads, etc. that's just being a team player.
 
How do I decide when to stick to my guns, and how do I go about it without getting blackballed in the community. Also, am I wrong to roll over on the appy issue.

Yeah, you are wrong to roll over on the appy issue. If you know there's an alternative, your duty is to present it to the patient so that they can make an informed decision on whether they want to undergo an operation. The guy telling you not to present it is essentially withholding information from the patient and therefore is being a deficient surgeon.

As far as getting black-balled, that's a possibility. It's your call between you and your conscience. It's not about "picking your battles." It's about whether you're a surgeon or a technician. I had that issue at my first job and I left it because I didn't view myself as a technician. If you don't mind being told what to do by other doctors, then just do what they tell you to do.
 
One thing that I've found helps is a phone call. If it's not the middle of the night, or if you are following up the next day, a quick phone call to the PCP to explain your plan and rationale can go a long way to make them comfortable with your plan. It also puts a voice with a name and helps to smooth their concerns. I'm sure the PCPs are envisioning recurrent appendicitis showing up in their busy clinic on a Friday afternoon, which you and I know is very unlikely but is what they fear. Knowing that you will follow up with these patients and that you are comfortable and prepared to manage the possible complications may reduce their angst.
 
I wonder how many of these neoplasms would have been associated with an abnormal finding on colonoscopy (which I always do for older patients I am managing nonoperatively, although how old is old enough for a colonoscopy is debatable)?

I'm not sure much would be seen on colonoscopy for patients with appendiceal neoplasms. Occasionally you'll see a mass effect pushing into the cecum (normal overlying cecal mucosa), but in general you don't see much at all.

Since my practice focuses a lot on colorectal cancer, my referral patterns are not normal, but I see plenty of appendiceal neoplasms. I have plenty of anecdotal stories as well about going in for interval appendectomy after a previous perforation and finding carcinomatosis. However, I still believe that interval appendectomy is not always necessary.

I have to put in the disclaimer that I take very little general surgery call anymore, and I did maybe 5 or 6 appendectomies last year. However, I'm aware of all the literature on non-operative management, and I still put most inflamed appendices in a bucket. My interpretation of the literature when I first read it was that non-operative management had a respectable success rate, but the LOS was longer and the readmission rate was high (20% in the meta-analysis you quoted). Laparoscopic appendectomy in an otherwise healthy patient is a very safe, quick, and non-morbid procedure, and most patients go home in less than 24 hours. When patients have perforated, but there's no phlegmon, then I still just do appendectomy to simplify care (i.e. I don't withhold surgery just because there's extra-luminal air). Of course, if there's an abscess or phlegmon, then I manage non-operatively. I believe I'm a reasonable person and that I'm up to date on evidence-based surgery. Therefore, I'm not sure your approach is necessary for patient safety, etc, and the other surgeons in town are not necessarily out-of-touch grey-hairs.



Pir8DeacDoc: I'm in academics, so I've maintained my ability to say, "no," which is one of the great things about academics. That being said, I still feel pressures similar to private practitioners. Regardless of practic environment, I would opine that most new surgeons are surprised by their sudden need to conform, and by their new image as a technician. As the first colorectal surgeon at my institution, I was met with a lot of opposition for things such as how I conduct operations, my operative decision-making, and my non-operative care. I certainly didn't roll over and conform for most things, but I chose my battles, and I made sure to explain things well to my surgical partners and referring physicians.
 
Good points that you make. I agree that it's difficult to say no especially when the patient is sent to you specifically for an operation. It's a little easier for me because I run into this problem mostly over tonsillectomy. While it is generally an uneventful operation, anyone who has ever seen a good post-tonsillectomy hemorrhage knows how badly things can go. I have to know a patient needs that operation before I put them at risk. I suspect it's a little different for us too because we do a lot of medical management of things so trying a few things and seeing them back is routine for us and surgery is still an option, if necessary. Good discussion of an issue I haven't seen brought up on here before and that I hadn't considered before starting practice.
 
While it is generally an uneventful operation, anyone who has ever seen a good post-tonsillectomy hemorrhage knows how badly things can go.

That's the problem. It's the whole "success has multiple fathers, failure only has one mother" syndrome. It's no skin off the PCP's back to send you someone and tell you do an operation because if it goes well then they just go "see, I was right, oh, I'm sending you another one just like it tomorrow" and if it goes poorly they run for the hills and go "well, I sent you the case, but of course you have your clinical judgement and you're a doctor and can say no and blah blah blah." You may think I'm exaggerating or kidding, but I've seen many a physician from many a specialty talk authoritatively and demand that everyone listen to them and then when the s**t hits the fan they run for cover and mysteriously none of their demands had ever appeared on the chart so it looks like everyone else just spontaneously decided to do something.
 
I'm not sure much would be seen on colonoscopy for patients with appendiceal neoplasms. Occasionally you'll see a mass effect pushing into the cecum (normal overlying cecal mucosa), but in general you don't see much at all.

Since my practice focuses a lot on colorectal cancer, my referral patterns are not normal, but I see plenty of appendiceal neoplasms. I have plenty of anecdotal stories as well about going in for interval appendectomy after a previous perforation and finding carcinomatosis. However, I still believe that interval appendectomy is not always necessary.

I have to put in the disclaimer that I take very little general surgery call anymore, and I did maybe 5 or 6 appendectomies last year. However, I'm aware of all the literature on non-operative management, and I still put most inflamed appendices in a bucket. My interpretation of the literature when I first read it was that non-operative management had a respectable success rate, but the LOS was longer and the readmission rate was high (20% in the meta-analysis you quoted). Laparoscopic appendectomy in an otherwise healthy patient is a very safe, quick, and non-morbid procedure, and most patients go home in less than 24 hours. When patients have perforated, but there's no phlegmon, then I still just do appendectomy to simplify care (i.e. I don't withhold surgery just because there's extra-luminal air). Of course, if there's an abscess or phlegmon, then I manage non-operatively. I believe I'm a reasonable person and that I'm up to date on evidence-based surgery. Therefore, I'm not sure your approach is necessary for patient safety, etc, and the other surgeons in town are not necessarily out-of-touch grey-hairs.



Pir8DeacDoc: I'm in academics, so I've maintained my ability to say, "no," which is one of the great things about academics. That being said, I still feel pressures similar to private practitioners. Regardless of practic environment, I would opine that most new surgeons are surprised by their sudden need to conform, and by their new image as a technician. As the first colorectal surgeon at my institution, I was met with a lot of opposition for things such as how I conduct operations, my operative decision-making, and my non-operative care. I certainly didn't roll over and conform for most things, but I chose my battles, and I made sure to explain things well to my surgical partners and referring physicians.

The nonoperative management of acute appy is definitely something which is new and I don't consider it a must or that it is better than an operation. That is why I have no issue going with the flow on it. Maybe in the future it will get sorted out who it is best to operate on and who might be better off without an operation, but right now it is more something that is ok to do with some caveats. The fact that it isn't unreasonable is why I was offering it, but as every surgeon knows it is all about how you explain the alternatives. I can still present it as an option but guide people towards an operation to keep in line with what the community does (and if someone feels strongly about avoiding an operation I can then go out on a limb-with a nice letter to the pcp about why, which might have helped avoid the calls or it might not have made a difference).

As for the perfed appy issue, I am referring to patients with large phlegmons still being operated on (and people with abscesses too for all I know, I just know that the last patient I did nonop for had a big abscess and everyone from the hospitalist to the nurse was asking what time the pt was going to the OR when I showed up to see the pt). I guess they are getting away with it a lot otherwise they would be more likely to be doing something different, but I have had enough issues with patients that I either didn't realize were perfed at the time (I hate it when the CT underestimates the amount of inflammation and the patient underestimates how long they have been having pain for) or when I felt pushed to operate even though I knew it was perfed (the floridly septic patient with diffuse peritonitis from her perfed appy that ended up with a reoperation and several recurrent abscesses who was sick as **** for the majority of her 3 week hospital stay sticks in my mind) that I want to avoid that if I can.
 
.... or when I felt pushed to operate even though I knew it was perfed (the floridly septic patient with diffuse peritonitis from her perfed appy that ended up with a reoperation and several recurrent abscesses who was sick as **** for the majority of her 3 week hospital stay sticks in my mind) that I want to avoid that if I can.

Well, playing devil's advocate is in my DNA, so I have to point out that if a patient has a perforated appendix and is floridly septic with diffuse peritonitis, that would mandate immediate exploration (after resuscitation) to control the sepsis, and there's no debate about the appropriate move. Of course, when somebody is that sick, they will have multiple issues including abscesses or a need for reoperation, but this is a function of their disease severity, not an inappropriate operative decision.

For the other scenario, though, I can totally understand your frustration. If I go in for appendicitis, and I find an unexpected big phlegmon, I don't feel obligated to make a large incision and do a right colectomy. I think it's very reasonable to just leave laparoscopic drains and get out.

I think you'll find balance as you get to know the other surgeons better. Depending on the competition and financial relationships you have with the other surgeons in town, you may benefit from asking for their help with some bigger cases (to assist you), or curbside them for advice on some things in the surgeon's lounge. These small relationship-building activities can help you out. Also, I know you probably already do this, but I would be sure to treat EVERYONE very well. The OR teams (scrubs, nurses, anesthesia) and the floor teams (nurses, desk clerks) can make or break your new reputation, and your perceived competence as a surgeon is often based more on how much people like you than on your actual talent.

And finally, the lunchroom is an excellent place to generate referrals. If you have a doctor's lounge where the PCPs routinely eat lunch, you should be sure to get there every day and sit with them. Trust me.
 
Well, playing devil's advocate is in my DNA, so I have to point out that if a patient has a perforated appendix and is floridly septic with diffuse peritonitis, that would mandate immediate exploration (after resuscitation) to control the sepsis, and there's no debate about the appropriate move. Of course, when somebody is that sick, they will have multiple issues including abscesses or a need for reoperation, but this is a function of their disease severity, not an inappropriate operative decision.

Yeah, she definitely needed an operation, but I worry that would happen for someone who is a candidate for nonop management if they get operated on instead. Most likely just my own paranoia.
 
Sorry, but I would agree with your colleagues in town and the risk/reward ratio on that kind of management is waaaaaaay too high to be using it on all but the poorest candidates for surgical intervention. Trying to finesse this condition is just a recipe for disaster on a practical level as it is only going to take a single adverse event or poor outcome to ruin your reputation locally and/or bankrupt you in court. You do NOT want to be having this debated in court as to what represents standard of care for management of acute appendicitis.

Unless you are in a submarine, in low Earth orbit on the space station, or stranded in Antarctica the answer to this question should probably be appendectomy if you want to be perceived as a safe surgeon.
 
And finally, the lunchroom is an excellent place to generate referrals. If you have a doctor's lounge where the PCPs routinely eat lunch, you should be sure to get there every day and sit with them. Trust me.

There are a few medicine folks in town that trained in residency with me (some were my students) and I wasn't a mega bitch or anything so they have been calling me up for stuff. I am also a bit of a drug rep dinner ***** so I am meeting more of them that way. Haven't seen them really sitting in the lounge and eating lunch, though. Will keep my eyes out for where they hang, although honestly I am already as busy as I need to be in order to earn a good living.
 
This is obviously a way way oversimplified view of the legal system...but I just imagine a jury of slack-jawed yokels going "Wait...he DIDN'T TAKE OUT THE APPENDIX???"

It's pretty hard to overcome on a patient to patient basis. I have had patients and families freak out because it takes a couple hours to get them into the OR with their appendicitis. The societal view of an appendix is that of a ticking time bomb waiting to perforate, and that perforated appendicitis leads directly to death. Can't imagine dealing with that in a courtroom...large studies from Europe or not.
Makes sense, which is why I didn't have a problem going with the flow on it.
 
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