surgical hospitalist

[tcar18]

So what does everyone make of this surgical hospitalist idea?

see:
J Am Col Surg

ucsf and their surgical hospitalist program.

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[SocialistMD]

There are several programs in the country (ours included) that operate under this system. We have what is called an Acute Care Surgery Service that sees all emergency general surgery patients in the ED. It is staffed by the trauma service attendings and is covered in shifts. They still have clinic, but will leave clinic for any trauma or emergency case that comes in and needs to go to the OR. Since they are trauma attendings, it doesn't really cut into their revenue generating ability in clinic, as most of their clinics are post-op patients with very few new referrals. There are fellowships in Acute Care Surgery (with more in development), which essentially fill this niche.

 

[europeman]

While obviously there are simlarities, I think the OP is specifically referring to the surgical hospitalist, which, while similar to acute care surgeons, is not the same thing. Essentially, from my understanding, they don't cover trauma.

 

[SocialistMD]

While obviously there are simlarities, I think the OP is specifically referring to the surgical hospitalist, which, while similar to acute care surgeons, is not the same thing. Essentially, from my understanding, they don't cover trauma.

Acute Care Surgeons don't have to, either, they just do at my program. If you look at a place that has a much higher trauma volume like UT-Houston, their acute care surgery service is separate from their trauma service.

I see acute care surgery and the surgical hospitalist as synonymous, as the role is essentially the same. With the evolution of the Acute Care Surgical Fellowship, the lines will even blur further. I'd just prefer to call my division "Acute Care Surgery," which sounds tougher and more surgeon-esque than does "surgical hospitalist." 😉

 

[europeman]

haha, i agree Acute Care Surgery sounds cooler.

I read some of the articles, and I'm still not clear what the real difference is then. OP what do you think?

 

[Tex2step]

How is an Acute Care Surgeon any different than a General Surgeon. When you get beyond all the smoke and mirrors, why would you do a fellowship in acute care surgery after 5 years of general surgery? I don't get it.

I think the term surgical hospitalist is more appropriate...general surgeon who doesn't see patient's in the office. If effect, that's how I view acute care surgery. The problem is that the acute care surgeons rotate through the office, so the patients rarely ever see the surgeon who did their operation.

 

[europeman]

that's actually a good point. if one finishing a general surgery residency, why aren't you qualified to be a surgical hospitalist or acute care surgeon?

Now, at my institution, the acute care surgeons are also trauma/critical care doc. Now, I understand why one would need to do a critical care fellowship and even as trauma fellowship (such as if you train at an institution without much trauma).

but just random acute care surgery? why specalize?

 

[Dr. Dukes]

How is an Acute Care Surgeon any different than a General Surgeon. When you get beyond all the smoke and mirrors, why would you do a fellowship in acute care surgery after 5 years of general surgery? I don't get it.

I think the term surgical hospitalist is more appropriate...general surgeon who doesn't see patient's in the office. If effect, that's how I view acute care surgery. The problem is that the acute care surgeons rotate through the office, so the patients rarely ever see the surgeon who did their operation.

As it has been explained to me (a first year med student), the Acute Care Surgery fellowship will be taking over as the Trauma Surgery training track from a year of Surgical Critical Care. Honestly, when I was hearing this (from the Chief of Trauma at our Hospital) I wasn't that impressed with his answer to why there needs to be an extra year or two of fellowship. Granted, I'm still in med school, so I don't appreciate the technical considerations, but it seemed to me to be an indentured servitude and slave labor thing more than anything else...

 

[balaguru]

If the surgical hospitalist doesn't do clinic how is post op care handled? If it's done by someone else how is this billed, since this is normally part of the procedure? What about complications? I don't see how this would work in a private setting.

 

[ESU_MD]

All general surgeons are trauma surgeons, can manage critical care/SICU patients and are "acute care surgeons" -

What general surgeons are NOT- hospitalists. That makes them sound cheap.

I have to admit that having a fully trained general surgeon "hospitalist" to take all the nonsense emergency call, trauma and babysit my patients so I can do my elective cases is tempting.

However, I already see the move towards "shiftwork" mentality invading into the surgery realm. and I just dont think it is a good idea for patients to have a "new" doc every 12hrs.

For instance- imagine you are a hospitalist. your "shift" gets done @ 7pm, a dead gut case comes in and is on the table, a reaction would be to dump it off on your oncoming partner. at least thats what the hospitalists do at my program. that cant be good for patient care.

In some ways, these surgeons could become like er docs- just moving the meat and signing out, etc.. shifting responsibility

Surgeons as whole should be careful, yes it is tempting to promote this fad, but it could backfire. much like our greedy ancestors who gave up nuisance procedures like endoscopy to the gi docs, and caths to the radiologists and the cardiologists. how soon we forget

 

[europeman]

So I think essentially the question boils down into what is best for patient care? Shift work or old style? I suspect it depends on several factors, dependent on the patient population, resources, hospital, etc.

Clearly, though, the "shift work" surgeon, or acute care surgeon, or surgical hospitalist, is something which is GOING to be a reality at least to some degree, and we should work with.

One nice thing about it is that it helps the lifestyle of the surgeon. Better lifestyle means you get more people willing to do the field that otherwise were deterred. This is important because the REALITY is that this country needs surgeons and the demand is greater than the supply.

 

[SocialistMD]

For instance- imagine you are a hospitalist. your "shift" gets done @ 7pm, a dead gut case comes in and is on the table, a reaction would be to dump it off on your oncoming partner. at least thats what the hospitalists do at my program. that cant be good for patient care.

1. Most people finish the case. Again, simply because you are working a shift doesn't mean you have a shift-work mentality. The trauma/acute care service here has both residents and attendings who work shifts (as do the ICU attendings), yet none of them slouch on their responsibility to the patient or the team.
2. If you haven't started, what more do you really know than the 30 second summary you received from your resident/ED? Nothing more than what can't be signed out in 30 seconds and a look at the imaging.

If the surgical hospitalist doesn't do clinic how is post op care handled? If it's done by someone else how is this billed, since this is normally part of the procedure? What about complications? I don't see how this would work in a private setting.

They do clinic. It is typically a group clinic which results in the fact that they may not always see the patients on whom they operated, but they do have a clinic. They work on a revolving schedule: one week of days, one week of nights, one week of clinic/elective cases (one week of academic time).

 

[geekgirl]

i think a missed point in this discussion is the benefit of having a dedicated service to acute care/trauma at a busy, high throughput hospital. of course, many general surgeons can manage the types of surgeries done by the acute surgical service, but do they want to dedicate all their time to this? the answer, for the most part, is no.

in our hospital, we have a great trauma/acute care service. they augment their operative trauma cases with many of the incoming acute care cases - appys, choles, bowel perfs in patients not already assigned (i.e. already operated on) by private attendings or those who do not request a specific private attending. granted, we have many patients operated on for these same cases by our private attendings, but the bulk of these cases (and there are plenty of them) go to the acute care/trauma surgeons.

this works out for all parties - they continue to operate between large operative traumas and the privates, who already have busy elective cases booked, are not swamped with these urgent cases. and the shift mentality does not seem to permeate. as socialist MD mentions, our trauma attendings stay and do cases. however, unlike the privates, they are rarely called at home to do an acute case when they are not on call. that, to me, seems like a pretty good thing for them.

and they alternate weeks between being on for trauma/acute care and covering the SICU. although i am not going to be a trauma surgeon, i see the benefit in this system. particularly at busy centers where the trend is to specialize somewhat. we all are or will be general surgeons, but when the volume is large, it's easier to subdivide the bulk of cases just for the sake of our sanity and better care for our patients.

 

[Kubed]

I was looking at nevada's acute care surgery fellowship the other day and it looked like one of their selling points was increased experience in ortho and neuro surg. The impression that I got was this was a move by trauma surgeons to keep more of their ortho/neuro patients rather than babysitting them until the specialty service took over.

However, looking at the curriculum, it appears that the fellows only spend a month in each specialty over 2 years, so who knows?

http://www.medicine.nevada.edu/residency/lasvegas/surgery/fellowships/AcuteCareSurgery.asp

 

[tcar18]

I saw that with nevada's program also and did a little digging on changes in the future of trauma surgery.

I think if management of the trauma patient for gs included the ortho and neuro it would make the path much more attractive, from the standpoint of more surgery less babysit.

if that progression happened i think the role of surgical hospitalist might have a place. Although I tend to agree, it doesn't sound that attractive. My guess was that it would fit well in rural areas where it is difficult to lure surgeons.

 

[tacobell]

I am a surgical hospitalist and I love it ...

Just for background, I've been a surgical hospitalist for about 8 months. I spent the three years before that in a "traditional" private practice (non-academic). How my life has changed since becoming a surgicla hospitalist ...

1) A lot more free time. I get every third week off - COMPLETELY. No rounding, no office hours, no call from office or patients. Previously, I usually rounded on weekends (even when not on call becuase we covered two hospitals and the on call guy would round at the "on-call" hospital and I got the other one - junior partner and all that). The other two weeks, I work. One week is light (two call days) and the other sucks (5 out of 7 days on call). With three people in the practice and staggered schedules, we always have two people in house during the day on weekdays.
2) Office hours are not nearly as painful. Almost all post-ops. And only for half-day, two days a week. (Previously, every day of the week office hours. This is the part of private practice you don't learn about in residency - imagine if you had to go to your programs "clinic" EVERY DAY OF THE WEEK. And you want your office hours to be busy because that's what pays the bills. SUCKS.) Works out well because most of the post-ops are seen 1 to 2 weeks post-op anyway; very rarely do our patients see anotehr doc in the practice for follow-up
3) No breast, no colorectal - lots of appy and GB's which means more "immediate gratification" i.e., patient sick, patient gets surgery, patient gets better, follow-up routine
4) On call does suck - we get called a lot after hours (by ED and medical hospitalists) but when it's over.

And because we don't want to get dumped on, we don't dump on each other. We take care of the problems that need to get taken care of when it comes in. Does that mean that at 3am on my last day of call before I'm off for the week, I'm coming in to do the appy? No - that can wait. The perf'ed ulcer or perf'ed tic - yes - that can't wait.

Having seen it from both sides, I like this much better. I feel less burned out trying to balance my elective schedule with the on-call demands. The "regular" surgeons here love it because they don't have to take ER call. And I get to do what I like - taking care of acutely ill patients (usually with "immediate gratification").

 

[SocialistMD]

I am a surgical hospitalist and I love it ...

If you don't mind my asking, did your salary take a big hit?

 

[tacobell]

Actually, I'm making more money now then I was in the previous practice - and working less and overall, less stressed out.

I left the previous practice because after my initial contract expired, based on productivity, I would have had to take a significant paycut. The difference between what i would have made and what I'm making now is significant - $60k.

 

[Mango]

I am very interested in the Acute Care Surgery field. To Tacobell, if you don't mind me asking, what fellowship training (if any) did you have prior to your being hired? I imagine you are involved in critical care of pts who need it, so an ICU fellowship would be helpful.

 

[tacobell]

No fellowship, other than three years of doing general surgery in a community hospital post-residency (learned how to operate efficiently)

I'm at a hospital where we're like a level 3 trauma center - unless you get stabbed by the front entrance to the ED (and even then, we can ship em out at our discretion), we don't get trauma

The ICU's are manned by Pulmonary /Critical Care attendings. I can give them some guidelines but generally, they run the show (and get all the calls from the nurses) 🙂

I would say that in the next few years, there'll be more of these type sof surgicalist jobs (i.e., community hospital that doesn't do trauma). As the average age of practicing general surgeons increases and fewer young ones want to take call, hospitals will have to find a way to cover GS call and this is one solution.

 

[tacobell]

As far as critical care goes, most GS programs expose you to enough critical care where you can manage the basic ICU stuff. as long as you pay attention during your ICU rotation.

 

[RunGlutenFree]

I know it has been about three years since anyone last commented on this topic, and still being in college, I know much can change before I enter any type of specialty, but how do any of you guys feel the fields of acute care surgery or trauma surgery have changed in the past several years?

And just a few questions from a younger pre-med student (me):

If I wanted to work in an academic hospital, how would you see the "shift" scheduling working with conducting research in addition to the clinical duties? I have considered applying to MD/PhD programs, but my heart would be to do more clinical than research, so I don't know if there would be a point to the PhD.

Also, when you all talk about "elective" surgery, what exactly does that mean?

Thanks!

 

[Traumatic Life]

It seems that a big push for "surgical hospitalist" have been smaller community facilities do to the fact there is a shortage of surgeons and the change in mentality of general surgeons who want a more balanced lifestyle. It's not a difficult sell in reality. The elective based general surgeon doesn't have to take unattached call and thus frees their days for elective scheduled procedures and clinic. The surgical hospitalist is usually well compensated by the hospital to provide this service.

I do not think that you will see surgical hospitalist at larger hospitals and certainly not at academic facilities; there doesn't seem to be a need for them in those locations.

 

[Traumatic Life]

All general surgeons are trauma surgeons, can manage critical care/SICU patients and are "acute care surgeons" -

What general surgeons are NOT- hospitalists. That makes them sound cheap.

I have to admit that having a fully trained general surgeon "hospitalist" to take all the nonsense emergency call, trauma and babysit my patients so I can do my elective cases is tempting.

However, I already see the move towards "shiftwork" mentality invading into the surgery realm. and I just dont think it is a good idea for patients to have a "new" doc every 12hrs.

For instance- imagine you are a hospitalist. your "shift" gets done @ 7pm, a dead gut case comes in and is on the table, a reaction would be to dump it off on your oncoming partner. at least thats what the hospitalists do at my program. that cant be good for patient care.

In some ways, these surgeons could become like er docs- just moving the meat and signing out, etc.. shifting responsibility

Surgeons as whole should be careful, yes it is tempting to promote this fad, but it could backfire. much like our greedy ancestors who gave up nuisance procedures like endoscopy to the gi docs, and caths to the radiologists and the cardiologists. how soon we forget

I agree that I'm not sure this is the best idea. The problem is that it is coming. Evidence to that is around: new work hour restrictions for interns (then magically, in July of the following year, it's ok to work more than 16 hrs straight); the ACGME requirements for detailed and monitored checkouts for residents when they sign out; talk of limiting surgeons hours, much like aircraft pilots; talk of mandatory disclosure to your elective patients that you where on call the previous night and giving them the option to cancel their case with you.

Additionally there has been discussion of changing the way surgeons are trained: much like integrated programs---3 years of core surgical rotations followed by a written board then 3 additional years of training to become specialized (acute care surgery, colorectal, breast, gastrointestinal, etc), followed by additional examinations for your compartmentalized training.

It will be interesting to see what plays out in the next 5 years...