from general surgery to ortho

Q-Optics, surgical ergonomics - redefined
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Another issue with orthopods is that they dont look at the patient as a whole. They just look at the musculoskeletal problem. Its common to see the theme when patients have bad aortic injury or liver lac or MI ( all of these have happened) and the ortho wants to fix the fracture which can definitely wait. When ortho is consulted and if their note is closely seen, they seldom mention other medical or surgical problems and thats where they miss things.

This sense of dealing with patient as a whole come after SICU/MICU rotations. You look at every system and then try to determine whats wrong and what needs to be fixed. Ortho residents in US dont do SICU. Recently they made the same change in urology. In some other countries, ortho is still old school where you are supposed to do 1 complete yr of GS before starting doing ortho residency. Some of my ortho attendings were GS in their previos life...
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I think there has been sufficient ortho bashing throughout. There are good ortho and bad ortho. Yes, it is not uncommon for ortho to defer everything non-bone related to others. That is how they practice. That has gone on for years. That has all but been facilitated by the other specialists. It is a little disengenuous to bash on ortho for what could be considered a long standing practice facilitated by all the other specialties.

And, I never liked that lack of global involvement by some of my ortho colleagues when I was on trauma. But, it was always supported by attending staff (gsurgery/trauma/SICU/IM/etc...)and everyone else.
 
Actually, it's a little disingenuous to pretend that other specialties "facilitate" how Ortho acts.

I'm actually not sure if this is how it actually went down, but I bet it is: Ortho used to be uncompetitive and it actually WAS for people who didn't qualify for anything else and who really COULDN'T figure out how to manage anything. It has since become extremely competitive and attractive to people because, as a result, Ortho only has to focus on operating. The people who go into Ortho are smart, but because their attendings aren't smart the training is restricted to Ortho stuff. So the cycle perpetuates.

The fact is that we all hate taking care of these "patient issues." When I have to operate on some spindly, malnourished 95-year-old woman who is demented and happens to be a closet alcoholic and she has HTN, DM, CKD, and chronic back pain with chronic narcotic use and, oh yeah, her family doesn't want her so it's going to be placement issues, too, I want to close her door and nail it shut. But we deal with it. Ortho doesn't give two craps. They'll operate on her, then the only order they put in is for a PCA and lovenox and start consulting. And if the PCA doesn't work, they just stand around it and punch the PCA with their fists and go "it no work, why no work?" Then they consult someone to figure it out. And if the patient develops a resultant ileus, they consult someone else. And if the lovenox causes bleeding, they consult someone else. There's literally no thought. Everyone gets the same exact orders and if anything happens, someone else figure it out. Meanwhile, they go back to the OR and start operating on someone else who they shouldn't be operating on but they don't care because it'll be someone else's issue.

That's why people think Orthopods are *****s.
 
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glade said:
I'm actually not sure if this is how it actually went down, but I bet it is: Ortho used to be uncompetitive and it actually WAS for people who didn't qualify for anything else and who really COULDN'T figure out how to manage anything.
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This is true (at least the part about it being uncompetitive). A retired orthopedic surgeon spoke at my school once, and he said they were being literal when he matched when they said you just needed to be "strong as an ox and twice as smart."
 
Yeah, I know that part. I'm just saying, I bet that's where it started that everyone took care of their patients. Like they looked at the cross-eyed, drooling Orthopods and were like, "aww, don't you worry at all, Timmy."

Note: I don't have anything against Orthopods other than the fact that they dump work on everyone. Like I said, I don't feel that their work is any less important than anyone else's. I think they do very important work. I just think they also happen to be total jack-offs, in the professional sense, much as I feel about the ER.
 
The only thing I "settled" for was your mom, tough guy. But nice try. Oh, and don't worry, it was only a few times.
 
The thing is with this entire thread is that it doesn't really matter much in the real world. In residency, general surgeons were trauma kings and ortho just did bone. General surgeons were the dumping ground for everything.

In private practice, it doesn't really work like that. Rarely I'll admit a multi-system trauma who needs ortho (I don't work at a heavy trauma place). But even when I was at a heavy trauma place those patients were admitted to me if they had general surgical trauma, got a critical care consult on admission to the ICU, and they consulted ortho. I took care of the general surgical issue only just like ortho.

Most hip fractures (or whatever) get admitted to medicine/F.P. at my facility and ortho is the consult. Better for the patient and financially better for the F.P. who get's to charge for the admit, daily rounding, and the discharge.
 
True. A lot of things are different in "the real world" than in residency. And maybe that's even more the point. I mean, why would anyone set up residency to be THE OPPOSITE of the real world? How pointless and futile and idiotic is that? I say this a lot, but when you're in residency it's like the ER is your boss and basically get away with doing almost nothing. In real life, the ER is your total biatch, like eternal interns. That's really why there's "ER burnout." They go into it thinking they're going to be doing nothing and someone will always be around to make up for it, then they realize it's the complete opposite and depression rapidly sets in.

The reality is that a lot of things that happen in residency only happen because residents are the wall between the attendings. I mean, I have attendings go ON and ON about Ortho, for example, and I'm like "STFU, all you have to do is see the patient for two seconds, say that we're doing nothing, and then complain for ten minutes out in the hallway about it." Meanwhile, the residents are the ones who have to arrange social work, discharge planning, visiting nurses, fill out disability, give them time off, etc etc. If the attending had to do that, Ortho would be eating its own crap roughly thirty minutes afterwards.
 
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glade said:
In real life, the ER is your total biatch, like eternal interns. That's really why there's "ER burnout." They go into it thinking they're going to be doing nothing and someone will always be around to make up for it, then they realize it's the complete opposite and depression rapidly sets in.
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Hold the phone, there, champ. For residency-trained docs in the ED, burnout is a myth - not higher than in any other specialty. The "burned out" are those that trained in another specialty and were working in the ED. It's the IM docs, anesthesia, and - yes - general surgeons, among others. That's only logical. However, for people trained in EM, it's a pretty satisfied group (or as satisfied as to any others).

And last time I called a general surgeon? For 2 patients at once - one was a small bowel obstruction, and the other was a fever in a liver transplant patient that the on-call surgeon had done. In practice, in the real world, a general surgeon will only get called to come in if there's a patient for the OR. They'll get called for patients for follow up in the office. I had one patient for whom I called the general surgeon on-call just to inform him, and did NOT ask him to come in, but he did, and told me it was "a good thing you didn't cut that hemorrhoid, because it's an internal that's protruding". Oh my - I used my head, didn't "cowboy up", and didn't make something mildly bad majorly worse. The "hmm...I don't know...I didn't examine the patient...the patient just looks surgical" doesn't happen. It just doesn't. Hell, I had a guy with a spontaneous pneumo that advanced to a tension. I decompressed the patient and placed a chest tube with thoracotomy. The surgeon didn't even have to come in - he just phoned in orders and saw the patient 4 hours later when he rounded.

So I hear you, and you love to rag on docs in the ED. Great! You're in your forum and can do so with impunity. I can tell you that there are a number of academic attendings that do it because they can't cut it in private practice - oh, wait: doesn't that sentence apply across the board? It's not unique to academic EM. I hear it on SDN all the time - academic surgeons, EM docs, IM docs, anesthesiologists, psychiatrists - people in respective fields that say they have attendings that couldn't cut it (never tried or tried and failed) at PP. Burnout, though? The numbers just ain't there. If anybody has told you otherwise, they're selling you a bill of goods. (Or, alternately, they're urinating on your leg and telling you it's raining.)
 
All you're doing is proving my point. In the "real world," the ER can't just go "abdominal pain ...SURGERY!" But I can tell you that in a lot of residency programs, that's exactly how it goes. It's like with nurses. You think as an attending you're going to get that special 1:36 AM phone call about "can you tell me why this patient is on this medication?" Ha ha. No, because that nurse would immediately be fired at 1:38 AM.

And like I said, when the ER calls attendings in private practice, it's like you say: they just say "admit the patient and do a CT scan and call me with the results." Now, they can be more or less polite about it, but that's the long and short of it. Hence my statement that the ER essentially acts as eternal interns. Great, you put in a chest tube. So can our interns.

As for ER burnout being a myth, I'm willing to concede that. All I know about that is that several ER attendings told me about it and it's also what we were "cautioned" about in med school. Not that I gave a crap because I wasn't interested in ER. So that's definitely second-hand information and I could be completely wrong about it. The rest of it, however, is completely true.

Despite what you may think, this isn't my attempt to denigrate the ER. This is merely conveying the true statement that the ER cannot and does not act the same in the "real world" as it does in residency. It's not tolerated by attendings. The same attendings who tell RESIDENTS to take any call from the ER and encourage random lame consults would never tolerate that to them. And the ER doesn't get away with half-assed B.S., no physical exam, calling you before the patient is registered, "can you see the patient for no reason other than I'm worried?" stuff like they do in residency.
 
glade said:
This is merely conveying the true statement that the ER cannot and does not act the same in the "real world" as it does in residency.
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This is local/regional. I trained at a place with high-powered IM and surgery, and I had attendings that would let me and my colleagues swing in the wind, when we weren't sure or needed guidance (hell, I had an attending sandbag me for a patient that just needed phone consent for comfort care - he convinced the family to go for full code except defibrillation - first and goal at the 1, and we get a field goal), while having an über-brainy come up with reasons to not admit a patient (at least to their service) (one gorgeous but nasty woman was especially adept at "this patient isn't right for internal medicine" - as a colleague said, "If they're not going directly to the OR, they're right for IM!"). One ***hole that had done the trauma fellowship at ShockTrauma many times (i.e., more than 3) take procedures away from residents first-off (that is, not let a resident try first). However, my program director was hands-on plus - she would not let us cut corners, and seemed to be there at every moment when one screwed up. If/when she heard someone on the phone with a consultant (or heard peer-to-peer from the attendings) that didn't know data they should, she was correcting them.

Residents are an available resource. My first job out, I had surgery residents, but no EM program. One guy was a total douche, and the attending beat him to the patient bedside (and the attending wasn't running) to put in a chest tube for hemo/pneumothorax. This resident was always "no, no, no", and was wrong more than once (he was a senior - PGY4 - that had transferred to this program), despite his stridence. I don't know what happened to him, but we predicted a difficult path for him in practice. However, most of the surgery residents were good, and, if they were MFing me, they did a REAL good job of hiding it. Despite me saying "I can **** on a resident", I only called emergently once when I had an old lady that fell and had a scalp lac that was gushing and I couldn't stop. No flak from the senior - he came down, and did a bang-up job closing it. I didn't call surgery for my lacs, except to ask if there was a student that wanted to sew. I did, once, in fast track, call for an abscess in the groin on a female, because I didn't want to mutilate her genitalia (it was groin, but low, but not in the vag and not a Bartholin's). The surgeons took care of it, and the attending (who is one of those old, grizzled, 60-some year old guy still taking Q4 call, and wears a bow tie when he's in the office) would needle and rib me about it, asking if I had any abscesses for him, but, if that's what it took - me having the **** taken out of me, and me not turning this lady's gear into a hacked mess - then I'll take it every time.

Sum total - some residents learn it earlier, some learn it later - and some don't learn it until they're attendings.
 
Maybe I missed this, but what's "it"?
 
glade said:
Maybe I missed this, but what's "it"?
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The cosmic "it" is going around the wheel once, and knowing what to do when, what is politically expedient, and when to stand your ground - when to pick your battles, and when to stand up for patients when you need to, even if that will ruffle feathers or offend someone's sensibilities or sense of entitlement. It has been said many times about surgery, but the general idea ("it") can be extrapolated: "The first 2 - 2 1/2 years of general surgery residency is learning to operate. The last 2 1/2 - 3 years is learning when not to". Medicine is a big hammer, no matter what you do - when you get the power, you want to wield it. Then, the power gets reined in. Whatever is your power, it's the restraint. That what some residents learn early, some learn late, and some never learn until they are attendings.
 
Um, OK. I'm not sure what that had to do with either your lengthy anecdotal stories of ER interactions with surgeons or my equally lengthy posts about sundry other things, but I guess you had to get that off your chest.
 
Apollyon said:
In practice, in the real world, a general surgeon will only get called to come in if there's a patient for the OR. They'll get called for patients for follow up in the office.

The "hmm...I don't know...I didn't examine the patient...the patient just looks surgical" doesn't happen. It just doesn't. Hell, I had a guy with a spontaneous pneumo that advanced to a tension. I decompressed the patient and placed a chest tube with thoracotomy. The surgeon didn't even have to come in - he just phoned in orders and saw the patient 4 hours later when he rounded.
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That's interesting. I guess there are differences in training, but where I am, I often get consults with literally nothing but a nurse triage report and vitals. Painful, but it's a good learning experience for surgery residents to know how to evaluate surgical patients early in presentation and direct the work up.

On the other hand, this is bad for the EM residents. I just assumed that EM docs out in practice would do the same thing, but if they suddenly need to evaluate and work up these patients themselves and only consult at the point of "needs OR", then there is a rude awakening awaiting EM graduates.

I'm having a hard time getting my head around the concept that once I get out in practice, everyone will stop dumping their work on me and stop bothering me for stupid things in the middle of the night. Is there another specialty where there is as big of a difference in quality of life from residency to practice?
 
Woah, don't misunderstand.

a) Keep in mind that EM is a relatively new specialty. The "prime" spots for their attendings are at places with residents (for other specialties) because that's where they can basically function at any level they want. As I said, and we all know, if you're an ER attending at a training program, you can consult at will at any time you want. We've had ER consults for people based solely on their chief complaint to the registrar. If you care to ask the patient, they were never seen or examined or talked to by the ER attending. Some of them don't even have vital signs because you were consulted so quickly that the nurse hadn't even gotten to the patient yet (and not because they were exsanguinating and needed someone to see them stat).

I'm not absolutely sure of this, but I get the sense that what has happened thus far is that EM grads basically all took spots at training programs for the most part. And now that they have filled those spots, the new grads are filtering to other hospitals in major metropolitan areas sloooowly. For example, where I trained, they're STILL hiring new EM attendings. It's not saturated yet because by this point there's turnover of EXISTING attendings. So I doubt most EM guys are looking at jobs in, you know, the middle of nowhere yet.

b) "Good" is all relative for EM physicians. Nobody is saying they are all focused diagnostic machines or whatever in "real life." They just do what they do at training programs. Our EM attendings, the ones who are considered "good," shotgun tests all the time. Everyone gets every single lab imaginable and they all get CT scans. Then, they'll get a consult. The "bad" attendings call you before they get the results. So let's not kid anyone here. It's not like the "good" attendings are THAT much better than the "bad" ones for EM. I'm not trying to bust on them, that's just the fact of the matter. If you order every single test on everyone, you're going to get a diagnosis at some point. Or, if you're dealing with chronic medical problems, like CHF or whatever, you have the diagnosis essentially as soon as the patient returns. The dirty secret of EM is that, as I said, it's not about being a physician. It's more about facilitating patient admissions. That's it. You do that, you're an EM superstar.
 
thunder hawk said:
Another issue with orthopods is that they dont look at the patient as a whole. They just look at the musculoskeletal problem. Its common to see the theme when patients have bad aortic injury or liver lac or MI ( all of these have happened) and the ortho wants to fix the fracture which can definitely wait. When ortho is consulted and if their note is closely seen, they seldom mention other medical or surgical problems and thats where they miss things.

This sense of dealing with patient as a whole come after SICU/MICU rotations. You look at every system and then try to determine whats wrong and what needs to be fixed. Ortho residents in US dont do SICU. Recently they made the same change in urology. In some other countries, ortho is still old school where you are supposed to do 1 complete yr of GS before starting doing ortho residency. Some of my ortho attendings were GS in their previos life...
Click to expand...


Several points:
1. All ortho programs require an SICU month. Mine required a MICU month as well.
2. Consultant specialists are supposed to focus on a specific problem. We're not going to comment on a patient's cardiac output when we're consulted to deal with a fracture.
3. The reason the ortho people are quick to get people to the OR is usually because they want to perform a procedure that stabilizes the fracture, such as an external fixation, so that the soft tissue surrounded the high energy fracture can begin to cool from an inflammatory stand point.
 
irie said:
3. The reason the ortho people are quick to get people to the OR is usually because they want to perform a procedure that stabilizes the fracture, such as an external fixation, so that the soft tissue surrounded the high energy fracture can begin to cool from an inflammatory stand point.
Click to expand...

Additionally, people tend to forget all the bad things that go along with prolonged immobilization (PNA, DVT, deconditioning, decubitus ulcers, UTI, ileus, prolonged elevation of (pro)inflammatory cytokines, etc...). So when medicine tells us we can't operate on the hip fracture in the demented old lady with a sodium of 131, we get pissed.
 
Guile said:
Since the point doesn't seem to have gotten across to everyone, the issue isn't that you guys consult medicine for patients with lupus, liver disease, etc., it's that you refuse to even try to take care of things that anyone with an MD should be able to manage. Patient a little hypertensive? Why don't you try restarting his home atenolol before consulting medicine. Type 2 diabetic? Try a standard SSI order. It's crap like this that make everyone pissed at you guys. Let's face it. You just want those pages to go to medicine or surgery so you only have to write your four line note daily that consists completely of abbreviations.
Click to expand...


We're too busy seeing the consult for the sprained ankle/chronic shoulder pain/ rule out septic joint in the kid jumping around on the bed/L5 transverse process fracture. Or we're in clinic seeing the neck/back/shoulder/knee pain that hasn't been attempted to be treated by their PCP with NSAIDS or physical therapy. They do probably have an MRI though with findings that don't correlate with their symptoms that we now have to explain to them isn't relevant.
 
irie said:
Several points:
1. All ortho programs require an SICU month. Mine required a MICU month as well.
2. Consultant specialists are supposed to focus on a specific problem. We're not going to comment on a patient's cardiac output when we're consulted to deal with a fracture.
3. The reason the ortho people are quick to get people to the OR is usually because they want to perform a procedure that stabilizes the fracture, such as an external fixation, so that the soft tissue surrounded the high energy fracture can begin to cool from an inflammatory stand point.
Click to expand...
Regarding #2, the issue isn't when you're a consulting service. It's an issue when it's a patient with ONLY ortho issues, yet they're still on a general surgery or medicine service and you guys are the consult team. It pisses us off when we have to round on your patients, answer the pages for them, and write notes on them when they're just in to get their femur nailed.
 
skiz knot said:
We're too busy seeing the consult for the sprained ankle/chronic shoulder pain/ rule out septic joint in the kid jumping around on the bed/L5 transverse process fracture. Or we're in clinic seeing the neck/back/shoulder/knee pain that hasn't been attempted to be treated by their PCP with NSAIDS or physical therapy. They do probably have an MRI though with findings that don't correlate with their symptoms that we now have to explain to them isn't relevant.
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Oh, wow. You guys see patients and take of people, too? I had no idea. Well, I wouldn't except you guys talk about how hardcore you are and how much you operate. Yeah, we do that, too. We operate, we have our own patient census, we are consulted on patients, we get BS consults, and we have clinic. AND we take care of your patients. Sorry you have to actually do anything other than hold a hammer and chisel. Being a doctor does actually involve explaining results to people and reassuring parents that their kid doesn't have a life-threatening illness.

We could consult medicine every time one of our patients gets post-op a-fib for example. But we don't. We manage it because we're capable and willing. It appears you are neither.
 
skiz knot said:
Additionally, people tend to forget all the bad things that go along with prolonged immobilization (PNA, DVT, deconditioning, decubitus ulcers, UTI, ileus, prolonged elevation of (pro)inflammatory cytokines, etc...). So when medicine tells us we can't operate on the hip fracture in the demented old lady with a sodium of 131, we get pissed.
Click to expand...

Invalid argument. First of all, those issues occur AFTER the ortho operation, as well. In fact, lots of your patients get PNA, DVT, deconditioning, decubitus ulcers, UTI, ileus, etc. Not to mention the "one size fits all" orders that ortho puts in totally effs up a lot of the patients.

Oh, and when medicine tells you that you can't operate on a demented old lady with a sodium of 131, that's your own fault because you CONSULTED medicine for that reason. OH SNAP. If you don't like it, evaluate your own patients and then decide to take them to surgery like the rest of us. Oh, and you operate on the demented old lady and then dump her on someone else to take care of, like heroes. There should be some official "thanks, Ortho, for giving me another train wreck" card that is sent to Ortho every day, except that:

a) Orthopods can't read; and
b) Nobody could physically carry that much mail.
 
Wow there's a lot of love between ortho and gen surg....

What do general surgeons think of spinal fusions for back pain?
 
naus said:
Wow there's a lot of love between ortho and gen surg....

What do general surgeons think of spinal fusions for back pain?
Click to expand...

It's not about any specific procedure or type of problem, it's that the general surgeons shouldn't have to be primary on a patient without any true multisystem surgical issue. The orthopods are just the worst offenders, and they get away with it because their trauma patients usually start off on the general surgery service, and can't be transferred to ortho unless the ortho service accepts the patient.
 
naus said:
Wow there's a lot of love between ortho and gen surg....
Click to expand...

actually it might be jealousy. quite a few general surgeons would be very content being pure technicians. admit all the patients to medicine/hospitalist: let them do all the H&P's, meds, consult all their buddies and do the discharges.
tell me what operation you want done, let me do it and only call me if there is bleeding, wound problems, etc..
of course in surgery residency we all learn to do the job of any specialist in the hospital, but who wants to do that in private practice??
I guess if you have residents, PA's and nurses to fill the role of the hospitalist then its fine, maybe even better.
Surgeons have better things to do with their time than adjust the rate of the LR infusion and replace magnesium levels.
 
naus said:
What do general surgeons think of spinal fusions for back pain?
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I think the data are pretty damning of back surgery, so no need for us to pile on.
 
ESU_MD said:
actually it might be jealousy. quite a few general surgeons would be very content being pure technicians. admit all the patients to medicine/hospitalist: let them do all the H&P's, meds, consult all their buddies and do the discharges.
Click to expand...

If that's what people want to do as surgeons, it's quite possible to do this as an attending. Of course -- and this isn't directed at you, unless you hold that view -- being a technician is looked down upon by any general surgeon worth his salt. Anyone can operate and people who only know or want to do that are generally worthless. That's the entire point: hell, I could ignore someone's medical issues and just start sawing away, too. All I'd have to do is lose all of my ethics, medical training, and intellect.
 
Guile said:
Yeah ENT takes care of some really sick patients with lots of issues on head and neck.

Since the point doesn't seem to have gotten across to everyone, the issue isn't that you guys consult medicine for patients with lupus, liver disease, etc., it's that you refuse to even try to take care of things that anyone with an MD should be able to manage. Patient a little hypertensive? Why don't you try restarting his home atenolol before consulting medicine. Type 2 diabetic? Try a standard SSI order. It's crap like this that make everyone pissed at you guys. Let's face it. You just want those pages to go to medicine or surgery so you only have to write your four line note daily that consists completely of abbreviations.
Click to expand...

Amen. It's deplorable how much extra labor ortho generates for other services. Period. I agree that the brittle diabetic/active CHF/dialysis patient should have a medicine consult before you electively replace a knee. But how many times have your turfed your 95 year old lady who fell and broke her hip, her wrist, and a couple of ribs to General Surgery for POLYTRAUMA because you didn't feel comfortable managing her after you pinned her femur??? If you want to consult a hospitalist, fair enough but we're surgeons too--- and we didn't even operate on YOUR patient yet we take the pages about starting her lovenox, and dosing her vanco. Etc. Like the poor gen surg intern has all the time in the world and the appropriate expertise to be doing this. Most of the time I think it's about dumping the patient to someone, ANYONE rather that really doing what's best for the patient. And frankly, it's just disrespectful to your collegues.
 
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