Academic vs. Private- do surgeons respect comorbities?

[Ignatius J]

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I want to bring up for discussion an issue I seem to commonly have as a resident.

Let me start by giving an example: I was to pre-op a patient at the end of the day who was scheduled for an elective laparascopic hysterectomy- first case in the AM. After seeing this middle-aged lady, I quickly found out she had classical angina symptoms- pressure/heavy pain, occurs with activity/stress, radiates to her left arm, etc. She had exercise intolerance limiting her to less than 4 METS secondary to CP/SOB, etc. She was on no medications and mentioned that she had been told she had "angina" (even knew the medical term- zing!), and that she needed to go see a "heart doctor" per an old PCP several years ago but she never went. She had no work up whatsoever from the surgery team. May I repeat, no work up whatsoever. Not even a review of systems from a clinic note.

I wish I could say this is an isolated incident, but it isn't a one-time situation for me.

My question is- how often does this come up in private practice- a patient shows up for surgery, has a glaring and inadequately worked up comorbidity, and the case is cancelled pending further work up (as this case was)? Are there institutional mechanisms in place to prevent this from happening as frequently? Can anyone go into detail about the difference between academic vs. private in this regard?

Thanks in advance. I'm just curious and think it would be an interesting compare/contrast thread.

 

[Patron]

In my humble experience in private practice (two years), I have not seen a scenario like this.The patient is obviously needs to be seen by a cardiologist and probably have cardiac investigations, even if she is not having surgery.

She is not optimized. She will need investigations and B Blocker.

 

[periopdoc]

You are going to find a wide variety of responses as there is more intra-institution variability than intra-setting variability. In my situation, things are better in private practice than they were in academics.

This biggest misconception in academics is that they take care of sicker patients. They don't I have had equally sick patients here. The difference is that we don't make as big a deal about it. Be realistic about the risks, minimize them, and proceed.

I think the difference between my academic setting and my private setting is that things like your example just don't happen in my practice. In my training institution, it was not at all uncommon that the attending meets the patient for the first time in preop. It was up to the trainees to ensure that the patient was appropriately worked up. Ownership of the patient became problematic so things could slip through the cracks. Here, the attending has ownership and his PA's understand that issues need to be worked up. So I still see the same level of disease, but when the studies I need are readily available. Sometimes things will fall through the cracks, but it is far less frequent here.

This is certainly NOT ubiquitous in private practice as I have heard about problems my friends in other practices have had. The key is to learn to uncover the land mines without being blown up in training and then find a practice where the surgeons know how to reduce the number of land mines you encounter.

-pod

 

[cchoukal]

Many academic centers and some private practices have anesthesia pre-op clinics. The goal is two-fold: to create a brief write-up of all the relevant issues to increase efficiency for the anesthesiologist on the day of surgery, and to identify conditions that, if optimized, would improve care/safety/outcomes. My sense is that the former is achieved almost all the time, whereas the latter is rare; in my world, most patients are tuned enough. It's hard to justify the cost of the staff and resources to run such a clinic, although some places (including where I did residency) are able to bill for SOME of the visits, but derived most of their funding from the fact that they were able to demonstrate an reduction in case cancelation and delays.

 

[Ignatius J]

Thanks for the very interesting replies, guys. I'm glad, as I suspected, that there is perhaps a little light at the end of the tunnel in regards to this matter.

 

[jetproppilot]

I want to bring up for discussion an issue I seem to commonly have as a resident.

Let me start by giving an example: I was to pre-op a patient at the end of the day who was scheduled for an elective laparascopic hysterectomy- first case in the AM. After seeing this middle-aged lady, I quickly found out she had classical angina symptoms- pressure/heavy pain, occurs with activity/stress, radiates to her left arm, etc. She had exercise intolerance limiting her to less than 4 METS secondary to CP/SOB, etc. She was on no medications and mentioned that she had been told she had "angina" (even knew the medical term- zing!), and that she needed to go see a "heart doctor" per an old PCP several years ago but she never went. She had no work up whatsoever from the surgery team. May I repeat, no work up whatsoever. Not even a review of systems from a clinic note.

I wish I could say this is an isolated incident, but it isn't a one-time situation for me.

My question is- how often does this come up in private practice- a patient shows up for surgery, has a glaring and inadequately worked up comorbidity, and the case is cancelled pending further work up (as this case was)? Are there institutional mechanisms in place to prevent this from happening as frequently? Can anyone go into detail about the difference between academic vs. private in this regard?

Thanks in advance. I'm just curious and think it would be an interesting compare/contrast thread.

I'll tell you how often this comes up in

Private Practice.

ZILCH, DUDE.

Never seen your

"SCENERIO."

So....Uhhhhhhhhhhhhhhhhh....

who are you and

what's your

M.O.?

Dude?

You ARE TO ME

An

INHONEST DUDE.

There's many out there like you.

I teach my children about people like you.

 

[bullard]

Haven't seen it much in private practice. I'm guessing it's because if a surgeon books a case and it doesn't get done, he's not getting paid, and I'm not getting paid, and OR time is wasted. You do that enough and your block time can come into question. In academics, most everyone is salaried, not production-based, and so you see the idiocy of incomplete workups.

 

[ssmallz]

I'll be the lone descendant then.....I see this pretty frequently, maybe not frank angina w/no work up but frequently I'll see pts who have supposedly been worked up with zero documentation, just a generic surgery H&P and a pt saying "I had an echo but I don't know the results". Look in the chart and maybe I'll have a cbc and an ekg if I'm lucky. Othertimes pts come down w/O2 sats of 92% on a 3L NC huffing and puffing with no pulm note in the chart.

Me: Have you ever seen a heart or lung doctor?
Him: Nope, why do you ask?

My pts were much better worked up in residency then in private practice. Maybe I'm just in the wrong gig😕

 

[WholeLottaGame7]

If it were up to the surgery residents, the patients would have either way too much or way too little workup. Thankfully, we have a pre-op clinic at my institution that seems to do a pretty good job.

I don't really get what makes the OP an "inhonest dude," though. What an odd place for an ad hominem attack.

 

[tracheatoedoc]

You delay the case for a proper workup. I've seen similar situations, and they all revolved around a horrible surgeon.

 

[IlDestriero]

You delay the case for a proper workup. I've seen similar situations, and they all revolved around a horrible surgeon.

I would agree, it's not an academics vs PP problem, it's a sh¡tty surgeon problem. One can trust the residents, PAs and fellows will handle the details, but the boss needs to follow up. We have one, world class, huge "name", has no idea about what's going on with his patients, barely knows the details. It's all the same to him.

 

[Patron]

I'll tell you how often this comes up in

Private Practice.

ZILCH, DUDE.

Never seen your

"SCENERIO."

So....Uhhhhhhhhhhhhhhhhh....

who are you and

what's your

M.O.?

Dude?

You ARE TO ME

An

INHONEST DUDE.

There's many out there like you.

I teach my children about people like you.

Are you addressing me calling me inhonest ! Yes I have not seen a patient coming for elective surgery with typical angina that have not worked up in my 2 years in private practice.

That is my experience and my opinion.

I might be practicing in a place where surgeons are doctors not mechanics. Or may be patient population is different.

But you can not call me dishonest ! and calling me names

Grow up .


You must be 50 years old if your have 16 years experience. so act as an adult

Why are you trying to intimidate people from posting there experience? This is a public forum . Everyone has the right to express there opinion freely.

People like you are called bullies .

There are many out there like you.
I teach me children how to kick there asses once they see one.

Thank you

 

[Nooblet]

Are you addressing me? calling me inhonest ! Yes I have not seen a patient coming for elective surgery with typical angina that have not worked up in my 2 years in private practice.

That is my experience and my opinion.

I might be practicing in a place where surgeons are doctors not mechanics. Or may be patient population is different.

But you can not call me dishonest ! and calling me names

Grow up .


You must be 50 years old if your have 16 years experience. so act like an adult

Why are you trying to intimidate people from posting there experience? This is a public forum . Everyone has the right to express there opinion freely.

People like you are called bullies .

There are many out there like you.
I teach me children how to kick there asses once they see one.

Thank you

I'm pretty sure he was talking to Ignatius J, the OP. Not you...

Awkward!

 

[Gern Blansten]

I'm pretty sure he was talking to Ignatius J, the OP. Not you...

Awkward!

The overall point is the same. Calling someone inhonest is something that should be excouraged here. It would certainly be gooder if people were nicer to each other. Is that so unpossible?

 

[urge]

😕

WTF is going on here?

 

[Impromptu]

Dusty: “What does that mean? inhonest?”
Ned: “Ah, Dusty! Inhonest is when you're more than honest! This guy El Guapo is not just honest, he's IN-honest!”

 

[Gern Blansten]

Dusty: “What does that mean? inhonest?”
Ned: “Ah, Dusty! Inhonest is when you're more than honest! This guy El Guapo is not just honest, he's IN-honest!”

That actually made me think of Three Amigos as well...ha ha. Infamous!!
That movie and also Roadhouse (the king of the unintentionally hilarious movies).

 

[scotchnwater]

The overall point is the same. Calling someone inhonest is something that should be excouraged here. It would certainly be gooder if people were nicer to each other. Is that so unpossible?

One of the best posts I've seen on here in awhile 👍

 

[IlDestriero]

The overall point is the same. Calling someone inhonest is something that should be excouraged here. It would certainly be gooder if people were nicer to each other. Is that so unpossible?

🤣 🤣 🤣

 

[scarshapedstar]

The overall point is the same. Calling someone inhonest is something that should be excouraged here. It would certainly be gooder if people were nicer to each other. Is that so unpossible?

It's a highly unlikely scenerio.

 

[Patron]

The overall point is the same. Calling someone inhonest is something that should be excouraged here. It would certainly be gooder if people were nicer to each other. Is that so unpossible?

 

[jwk]

The overall point is the same. Calling someone inhonest is something that should be excouraged here. It would certainly be gooder if people were nicer to each other. Is that so unpossible?

Instant SDN Anesthesiology classic post!

 

[Planktonmd]

It does happen occasionally in private practice to see a patient in the holding area who has an obvious problem that has been missed by a number of people including surgeon, internists, cardiologist...
It's not the end of the world because the patient is going to see a doctor (anesthesiologist) who will look at everything and decide if the surgery is a go or not.
If every patient was guaranteed to be optimized for surgery then there is no need for anesthesiologists and nurses could do the job.

 

[scudrunner]

I feel like Jet may be guilty of PWI (posting while intoxicated),

 

[cchoukal]

The overall point is the same. Calling someone inhonest is something that should be excouraged here. It would certainly be gooder if people were nicer to each other. Is that so unpossible?

If Gern were a hot girl, I'd be so in love right now.

 

[Ignatius J]

I'll tell you how often this comes up in

Private Practice.

ZILCH, DUDE.

Never seen your

"SCENERIO."

So....Uhhhhhhhhhhhhhhhhh....

who are you and

what's your

M.O.?

Dude?

You ARE TO ME

An

INHONEST DUDE.

There's many out there like you.

I teach my children about people like you.

I'm sorry? Are you calling me a liar?

I don't know you, and you don't know me. So can we lay off personal attacks.

This was a story that happened to me yesterday at my place of training. Calm down, dude.

 

[cchoukal]

It's a highly unlikely scenerio.

I think you mean dislikely.

 

[Ignatius J]

😕

WTF is going on here?

Well, it was a pretty interesting and civil thread until Jet decided to butt his ugly head into here.

Could be worse- could have to work with him in real life.

 

[fakin' the funk]

I feel like Jet may be guilty of PWI (posting while intoxicated),

Drunk Jet: spelling goes out the window but the arrogance and formatting are unchanged!

 

[WholeLottaGame7]

Dusty: “What does that mean? inhonest?”
Ned: “Ah, Dusty! Inhonest is when you're more than honest! This guy El Guapo is not just honest, he's IN-honest!”

"Would you say that I have...a plethora...of pinatas?"

 

[Gern Blansten]

Three of my favorite Chevy Chase lines from the movie:

Dusty: (would you like to kiss me on the verandah?) The lips would be fine.

_________________________________________________________________________

Dusty: (can't eat tacos at santo poco village.) Do you have anything besides Mexican food?

_________________________________________________________________________

Dusty: (as they are dying of thirst in the desert) Lip Balm?

 

[Impromptu]

Just to be fair, we all make grammatical mistakes at times.

 

[Arch Guillotti]

The overall point is the same. Calling someone inhonest is something that should be excouraged here. It would certainly be gooder if people were nicer to each other. Is that so unpossible?