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The Surgical Hospitalist

Posted Oct 30 2008 11:54am
In an article in this month’s Journal of the American College of Surgeons (with a companion cover piece in the ACS’s Bulletin ), four of my surgical colleagues – and this internist, perhaps to add a “cognitive” spin – describe UCSF’s “surgical hospitalist” program. It is an impressive story.

When Dr. John Maa and his friends speak of a “surgical hospitalist,” they are referring to real-live surgeons – you know, the “sometimes wrong but never in doubt” types – taking on the role of inpatient generalists. They are not referring to another type of surgical hospitalist, the internist-hospitalist co-managing hospitalized surgical patients. That model, which I believe will be the source of much of the hospitalist field’s growth in the coming decade, will be the subject of a future posting. [We’re going to have to clean up this nomenclature; for now, you’ll be able to tell the two models of care apart because the surgeons will be the better looking ones, as shown in this BMJ study.]

Our surgical hospitalists station themselves in the hospital for a week at a time. For that hellish week, they are constantly available to the emergency department for consults. As a result, the average time between an ED consult request and their appearance in the ED was – I hope you’re sitting down – 16 minutes. Heck, I didn’t know the elevators were that fast! The ED docs and nurses were nearly euphoric with this responsiveness.

The team cared for patients with a wide variety of clinical problems, ranging from cholecystitis to bowel obstruction. When the patient needed an operation that the hospitalists felt was within their comfort zone (more than 90% of the time), they did the case, shortening the time from diagnosis to incision for appys by half. When the case was hyperspecialized or the patient had a longstanding relationship with another surgeon, they handed the patient off to a colleague. Although the service did receive some medical center support dollars, they also generated substantial new revenue through a marked increase in consultations.

There is a national shortage of general surgeons (as described in a commentary in this week’s JAMA ), and the surgical hospitalist may be an important part of the solution. Their constant availability allows their colleagues to focus on their office practices or the OR without distraction, making everything work a little better. And it helps decompress the ED, mitigating another national crisis.

What are the downsides? I do worry about burnout – our surgical hospitalists seem to be in the hospital all the time – but Dr. Maa assures me that he and his compadres catch their breath during their non-hospitalist weeks (two weeks in three, spent in office practice and on academic pursuits), that they love what their doing, and that they enjoy the warm afterglow of a job well done. More importantly, they’ve added four new surgeons to the group this year, so things may work out.

The surgical hospitalist model extends my original concept of a hospital-based generalist who offers full-time availability, the ability to personally handle a wide variety of problems and coordinate the care of others, and a focus on improving both the care of individual patients and hospital systems. Like all medical innovations, it is bringing out the usual naysayers and skeptics. But I say let’s give it a try, measure its effect on key outcomes, and then decide whether it is a better mousetrap. I’m guessing it is.

And, to my brave surgical colleagues willing to buck tradition in one of healthcare’s most traditional fields, I can only say: Bravo!
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