Perioperative Surgical Valet

[deleted171991]

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In the latest ASA Newsletter, the ivory tower and AMC luminaries share with us their vision about our future (i.e. the Perioperative Surgical Home):

The current perioperative system consists of discrete episodes of preoperative, intraoperative, postoperative and post-discharge care. This system is disjointed and characterized by significant variability of care, driven by volume and individual surgeon and physician anesthesiologist preference. One way to reduce variability is to treat the entire perioperative episode of care as one continuum of care. This continuum can be achieved by having one perioperative team, headed by the physician anesthesiologist, who coordinates and manages all aspects of care from the minute the surgeon decides to operate until 30-days post-discharge. At each step of the process, patient-centered care and shared decision-making will replace the current physician-centered care. Through the PSH model, physician anesthesiologists have a unique opportunity to improve outcomes and quality of care, improve service to patients and reduce costs.

Last time I checked, most anesthesiologists went into this specialty exactly so they wouldn't have to deal with crap like this.

Have fun: https://www.asahq.org/For-Members/P...ogist-in-the-perioperative-surgical-home.aspx

 

[deleted126335]

It is good to develop alternative strategies. Do we really want to put 100% of our resources into defending the position that we should be involved in administering every mg of midazolam everywhere in the hospital and every podiatrist's office? That ship is in the process of sailing.

 

[deleted171991]

I agree with alternative strategies. I even agree with periop medicine (meaning true preop, intraop, 48-72h postop). But I definitely don't like the part about "manages all aspects of care" for 30 days post-op. Excuse me? This doesn't happen anywhere else in the world.

 

[HollATme]

I agree with alternative strategies. I even agree with periop medicine (meaning true preop, intraop, 48-72h postop). But I definitely don't like the part about "manages all aspects of care" for 30 days post-op. Excuse me? This doesn't happen anywhere else in the world.

So, we're perioperative primary care physicians up to 30 days post-op? Are we to ensure each of these patients follow-up with Dr. x, y, z? Or are we to do what hospitalists do and set up appointments at discharge? Isn't that something the primary team - i.e. surgery - should be doing? I'm confused here.

Hospitalists will help coordinate care at discharge, but once discharged it's up to the patient and PCP. No hospitalist is out ensuring the patient complies with follow-ups and appointments.

 

[HollATme]

So, we'll be the primary team and the surgeon will just be doing what he/she does best -- cut, daily wound change, dress?

 

[deleted171991]

So, we'll be the primary team and the surgeon will just be doing what he/she does best -- cut, daily wound change, dress?

That's the "dream".

Next phase: PAs doing surgeries in 2-3 rooms, surgeon moving between rooms for "key elements". 😛

The only ones who will profit out of all these "improvements" are the big corporations who take the profits, "while making a physician into this":

 

[HollATme]

I don't see the point in us taking over what surgeons already do. Will we be having clinics now? I'm not interested in running a clinic that manages every aspect of a patient's pre-op and post-op care. I'd much rather run a pain clinic, even if all I end up doing is medical management.

 

[loveumms]

We had a very interesting grand rounds by Dr. Zain recently. He is one of the forefathers of the surgical home and he has a really amazing program running at his institution.

I think there is a difference between managing every problem and managing the perioperative issues. I think we need to start making sure we are viewed as part of the solution. The government is trying to cut payments every where we turn. If a patient is readmitted within 30 days of their surgery, guess what you don't get paid. We all need to work together to prevent this and a lot of the issues that occur in the postoperative period that cause these readmissions start with us in the preoperative period (diabetes management, hypertension, etc). If we can impact the readmission rate by helping to manage the patients care (even out to 30 days), the hospital will benefit and WE as a specialty will benefit too.

 

[Planktonmd]

Here is the deal:
The anesthesiologist IS the perioperative physician... he or she should see the patient pre-op, suggest or order what needs to be done to optimize the patient for surgery, take care of the patient intra-op and watch the patient Post-op until discharge.
This is the role of the anesthesiologist in all the advanced countries except in the good old US of A!
Unfortunately the old generation of anesthesiologists did not want to be bothered so they started delegating responsibilities: they gave the pre-op phase to the internists and other specialists and they gave intra-op care to nurses, and they delegated post-op care to surgeons and hospitalists.
Now that they realize that they really screwed up this specialty they come up with this mutant concept (the surgical home) hoping they will be able to recapture the money and prestige they gave away.
These are the same ass holes who sold us out coming up now with this silly concept in an attempt to reclaim what they lost.

 

[@JackShephard]

Here is the deal:
The anesthesiologist IS the perioperative physician... he or she should see the patient pre-op, suggest or order what needs to be done to optimize the patient for surgery, take care of the patient intra-op and watch the patient Post-op until discharge.
This is the role of the anesthesiologist in all the advanced countries except in the good old US of A!
Unfortunately the old generation of anesthesiologists did not want to be bothered so they started delegating responsibilities: they gave the pre-op phase to the internists and other specialists and they gave intra-op care to nurses, and they delegated post-op care to surgeons and hospitalists.
Now that they realize that they really screwed up this specialty they come up with this mutant concept (the surgical home) hoping they will be able to recapture the money and prestige they gave away.
These are the same ass holes who sold us out coming up now with this silly concept in an attempt to reclaim what they lost.

Interesting informative post.

 

[deleted171991]

Except that I don't remember the anesthesiologist being the surgical hospitalist anywhere in the world, including the "advanced countries". Critical care? Yes. Surgical floor? No.

We are neither surgeons nor internists. We are great at optimizing a patient preop/intraop, however I feel that we are neither prepared nor the right people to deal with non-pain issues once the patient leaves the PACU. This has nothing to do with the US, this just doesn't happen anywhere, AFAIK.

I am a big lover of internal medicine, and might even enjoy doing this in a shift setting, but many people will drown. And looking at how medical hospitalists are treated, somehow I don't think many anesthesiologists would be happy doing this. But it will pay the rent/mortgage.

 

[Random Anesthesiologist]

There is a lot they don't say about the expected role of the anesthesiologist and postop care. Unless I'm in an ICU or trauma bay, I'm do not want to open up infected wounds or do anything their surgeon or PCP should be doing. Talk about liability...