Friday, January 23, 2015

Do surgeons still do postop care?

Here's an email I received the other day (edited and posted with the author's permission):

I am a recently retired internist. I have noticed some evolving trends over time and had an interesting experience that illustrates this issue.

A 77-year-old friend went for check up due to urinary incontinence. He was found to have a large prostate and a PSA of only 2 so was given Flomax . This helped somewhat.

At the time, an asymptomatic hernia was found. He was immediately scheduled for surgery which went well. His Foley was removed, and he was sent home.

At home he could not void, called the surgeon, and was told to go to the ER, There the Foley was replaced, and he was to see his urologist in 2 days. The urologist removed the Foley. Later he was in agony and walked the floor all night. He called the urologist and the service said that the office was closed. He was told to drive to the other office in the next town only 15 miles away. They replaced his Foley again.

Two days later he went to the surgeon who did the hernia repair and explained his postop adventures. The surgeon said, "Those things have nothing to do with the surgery. Your wound looks fine."

Things have changed. IN THE OLD DAYS:
  • After surgery, patients were not sent home until they could eat, void, and walk. Those days are history. 
  • Surgeons took care of their patients post op. Those days are gone.
  • Urinary retention was a recognized complication of hernia repair, especially in someone with known BPH. Are those days gone too?
  • If you sent someone home after pulling the Foley, you waited till the patent had voided being aware that massive urinary retention has the potential to induce damage to the bladder muscle itself (He had retained over a liter of urine) as well as cause great pain and distress.
I am aware that surgeons are not paid for postop care, but the global fee includes the surgery and the postop care (Follow the money). Hospitals need beds for new patients (Follow the money). [Don't forget that third-party payers won't fund any extra time in hospital.]

Are surgeons no longer trained in post op care? Are surgeons not exposed to the concept of surgical complications? Isn't it interesting how things change for the worse and nobody notices?

I wondered if the friend had really needed the herniorrhaphy. The writer replied:

I looked up that question and found that only 1% of hernias need surgery by becoming symptomatic. I mentioned this to my friend, but he had been "seduced" by the authority of the surgeon who acted as though not operating was inconceivable.

I once had an echocardiogram for occasional PVCs (probably not indicated). The tech discovered gallstones. Within an hour, a surgeon stopped me in the hall and wanted to remove my GB. (So much for privacy!) As luck would have it, I had had the experience of caring for patients who had had GB surgery and had terrible results involving damage to the hepatic duct resulting in liver failure and jaundice. I looked it up and found that asymptomatic gallstones may not need surgery. I have done fine for 30 years. (Knock on wood.)

I think no postop care by the surgeon is "THE NEW NORM."

As a hospitalist, I was assigned to care for surgeons' postop patients—one reason I finally retired. This was challenging at times. For example, one day a lady had a tummy tuck by a plastic surgeon. I was "consulted" to follow her and noticed her Hct had dropped. After investigating, I concluded that she must be bleeding into her wound. The surgeon never saw the patient post op. A nurse practitioner saw her but was clueless. I called the surgeon but no response came. When her Hct got down to 25, I gave her some blood and she stabilized and went home. A month later the surgeon stopped me in the hall and said when he had taken out her stitches, a huge amount of black gook plopped out. "She had a wound hematoma," he said. "Thanks for taking care of it." He was not embarrassed at all. I guess my caring for this was the new norm.

Stuff like this happened too often. If I called another surgeon for help they always refused. There was nowhere to turn.

In my fairly extensive experience, postop care by the surgeon is now seen as optional. Hospital employed surgeons are expected to operate, and NPs and/or hospitalists [Don't forget the PAs.] are assigned to do the postop care. This permits more surgeries (revenue).

On a more philosophical note, I am fascinated how "standards" change right before our eyes, but the process goes on unnoticed, slowly, almost invisibly. Then a few people speak up. They notice things. But it doesn't pay to agree with those people. Eventually, the process becomes obvious, and everyone says, "You know what? Health care in America really sucks. When did this happen?"

Are surgical residents being trained in postop care? Do surgeons no longer take care of their patients? I think this is true in orthopedics and plastics. Has it spread to general surgery too?

40 comments:

Anonymous said...

Wow .
Just... WOW.

William Reichert said...

The process started back in the 1980's when "Quality Assurance" descended on doctors and while some of the recommendations (wash your hands) were on target, docs suddenly realized that the ownership of the trajectory of the practice of medicine had moved from physicians to government and insurance bureaucracies.Over time the takeover has grown exponentially. Everyone knows that if you own your own house you take better care of it than if you rent.
The owners are not living in the house any more.

DrWes said...

Welcome to the unintended consequence of "bundling" and the "90-day" global fee structure.

Anonymous said...

This is NOT the new norm. As a general surgical resident we are trained to and take pride in our ability to manage our patients and their complications post op.
As far as the experience of the author - urinary retention IS a known complication of hernia repair and in fact we had an MM last month going over this. Also it is well known that you should not operate on asymptomatic cholelithiasis. We cannot apply isolated instances of surgical laziness to the profession in general.
I have however seen other surgical specialties unload their complications or post op care on either medicine or general surgery i.e. "you guys know how to manage ileus better than we do". I have been frustrated on countless times having to deal with other specialties complications but perhaps thats becomes I'm in a hospital with GS residents but no other surgical specialty residents - its always easy to dump on a resident...

Jeff Thompson said...

The post above illustrates the negative consequences when providers and hospitals are not aligned when attempting to improve quality and efficiency with postoperative care. There are physicians and hospitals that are leading the way in how to deliver care efficiently using NP/PAs up to the skill of their license while having surgeons and other physicians manage the more complex postoperative care. Ultimately, our physicians in the United States will need to lead care redesign efforts working with hospital clinical and administrative personnel to be successful.

Skeptical Scalpel said...

Thanks for the above comments. I hope more people will chime in. I realize many surgeons do follow their patients closely, but more than a few do not.

Vamsi Aribindi said...

Personally, as a 3rd year medical student on Ob/Gyn and Gen Surg, the post-op milestones were drilled into me. Bowel movements (or at least flatus), voiding, walking. eating, pain control- on EVERY patient before sending them home. The only exception occasionally is elderly patients with ICU/hospital delirium. I'd be appalled if what is described above is now common practice throughout America...

artiger said...

Scalpel, in the rural areas surgeons still do their own postop care (amongst a lot of other things, like endoscopy, paracentesis, and taking care of pancreatitis). Still, like Wes pointed out earlier, long global periods led to diminished interest in dealing with the patient afterward.

At the risk of sounding defensive, I'd like to point out that the author was a hospitalist, a position that was born when primary care doctors lost interest in taking care of inpatients. So maybe he should have taken a look in the mirror before he wrote to you. (Also, for his information, walking, peeing, and eating/drinking are all in our criteria for dismissal from outpatient surgery.)

Anonymous said...

I found a group of surgeons that had brags printed online that had their case load number, but know of a good number of post ops with complaints. If you weren't smooth sailing, all perfect, didn't appear they wanted to deal with you.

I do not have the impression Skep, that you are like that, but the problem is that these guys make ALL surgeons look bad. I've seen OUTSTANDING care from docs that had to pick up after surgeons like what you wrote about. Makes me mad. One of the reasons I took my compliments to the board of the medical group and a few admin levels of another one is because I want them to know the value of the care, and the fact they're putting forth the effort to try on top of not having the specialist background.

I encourage people not to fill out that comment card crap but to make a difference and send a personal letter and hunt up the admin/deans of these docs. I did. They deserve the kudos - and I'm going to be asking if they got some $$$ out of it too. Be mad if they don't, as one admin person I straight out asked how can I make sure they benefit from this. The admin, believe it or not, told me. I followed the instructions to the letter.

There are still some of us out there. :)

Anonymous said...

Urology resident here - voiding is a criteria for discharge from ambulatory surgery, the patient probably voided a small amount postop in PACU but then at some point at home went into frank retention, which is a risk of really any surgery due to the anesthesia and narcotics during and after of the surgery on top of his baseline BPH. It happens, not much that can be done to prevent it, not much that can be done to manage it other than keeping the Foley in and then trying again to remove it a few days later in the office for trial of void. Then sometimes people pass the trial of void in the office and go home without a catheter but still come back hours later in retention again, that happens too unfortunately. Doesn't mean that the hernia repair wasn't done well, although sounds like the surgeon was insensitive about the patient's postop difficulties. And the plastic surgeon seemed too hands off in the case with the wound hematoma.

But in my experience I've seen that surgeons still provide good postop care, although this experience has been limited to hospitals with residents where the fact that there are residents to round on the patients helps ensure that someone with knowledge of the expected postoperative course and potential postoperative complications is around to keep a close eye on things. Don't know how difficult it is to keep closely involved in things when you might have postop patients in multiple hospitals and you're bouncing around between different offices and surgicenters during the day.

On another point, I think having a hospitalist involved in postop care is never a bad thing, unless its a patient in their 40s-60s with no medical problems at all that's only staying for a day or two postop. Doing big cases on 70 and 80 year olds with multiple multiple medical problems, we'd rather have an internist dealing with the hypertension, diabetes, CHF, arrhythmias and making adjustments to those medications as needed. Because so many patients undergoing surgery in hospitals and staying as inpatients nowadays have so many medical problems.

Skeptical Scalpel said...

Vamsi, I'm afraid it's much more common than you think.

Artiger, if you are the only one, then you will do postop care. Lots of surgeons now employ PAs and NPs to round, take out sutures etc

I agree that not seeing patients and not returns calls make all surgeons look bad.

The perspective from a teaching hospital is much different than at a non-teaching hospital. I have no problems with hospitalists being involved with postop care, but the surgeon should still see her patients every day.

Anonymous said...

At my hospitals, medicine consults for post-op management of all orthopedic inpatients is routine. The government, insurers, and patients want lower costs? This is how it's being done.

Anonymous said...

Several years ago, my now 90-year-old father had to undergo evacuation of a subdural hematoma and was flown by helicopter (during a blizzard) from our small town hospital to a large teaching hospital about an hour away. The surgery went well but neither he nor any family member ever saw the surgeon. Surgery began before a family member could get there. Follow-up was done by a resident. His inpatient rehab was handed off to another department, to someone we finally managed to track down by phone to get the details of his care. Lots of drop-out between services and it was frustrating as family to figure out who (if anyone) knew the whole story. Despite a recommendation from a knowledgeable family member (that would be my spouse, who is a neurosurgeon but not licensed where my dad lives) about putting him on an antiseizure drug (knowing dad's history), he wasn't given one. No surprise when, two weeks later, he ended up back at the same hospital with what looked like stroke symptoms but turned out to be seizures. Had there been some consistent care and someone listening to our recommendation for the drug, we'd have been saved much worry and fear and the hospital and Medicare saved much money for that second trip.

I thought that was an isolated incident.

My spouse actually tried to keep up the practice of thorough follow-up care on his patients in the large system he used to work for (7th largest in the country). When new administrators arrived on the scene, they saw the beauty of cutting care because of the bundled payments, and mandated that PAs do follow-up in the hospital. That way, they could keep the surgeons in the OR and still bill for the PAs' work. My spouse objected. At that hospital he was known among the 4 neurosurgeons as "the only one who takes care of his patients." When it was clear the administrative bulldozer wasn't going to stop, he insisted that at least the PAs should be supervised. That was a no go from the administrator's point of view, and he was deemed "not a team player" despite the fact that they'd had one of the other neurosurgeons called up before the hospital ethics committee for a horrible situation in which her patient ripped out his feeding tubes not once, but three times, in the ICU. She never bothered to see him after the surgery. The last notes on the patient's chart were by the PA. The patient was discharged to a rehab facility where he died a month later. On his consent form, he had specifically refused any artificial feeding.

My spouse fought the good fight over this and other issues of care. One month later, this same surgeon did a wrong site surgery. That patient was also only followed by the PA, until my spouse questioned the case, having been on call and seeing the CT scan and the surgeon's op note. (He actually goes in and checks on *all* patients on the service when he's on call, and reviews cases when his call starts to minimize the chance of surprises when he gets paged.) Things got really ugly after that. Thankfully, my spouse no longer works there. BUT -- as I mentioned, this hospital is part of the 7th largest healthcare system in the country. It is the dominant player in our town, and we know that this approach to care continues.

These are not isolated incidents. My fear is that this is now standard operating procedure.

Skeptical Scalpel said...

First anon. Yes, medicine consults for everyone. You can bet they aren't brief (at least the documentation isn't brief).

Second anon. Thanks for the very interesting stories. I had a similar incident with my late mother. I may blog about it. It is quite a tale.

Your spouse's experience is a good example of what happens when one doesn't want to play the game and reduce one's standards. That happened to me too, but I can't blog about it because it might blow my cover. I am amused by some of the comments here from people in academic medicine. I hope this is serving as a reality check for them.

A question for the urology resident who commented above. Voiding a small amount might be fine or it might be a symptom of an over-distended bladder. Should the patient have to go to an ED to have the Foley replaced at a cost of $1000 or more?

Anonymous said...

2nd Anon, doesn't surprise me. The mega monopoly in my area, seems some "documents" got "rewritten" or some "timelines" got "modified" in some way. Not happy I'm putting it out there but that's business as usual. When it is the lucrative specialties, they think risk management and lawyers will mop it up. Not everyone is willing to be paid off. Some of us want the decent care others provide.

The worst part is that it is a slap in the face to people like Skep and others I know that are doing their best in an extremely tight and tough situation. Another reason to speak up. The good guys don't deserve this mess or the reputation.

Anonymous said...

As a hospitalist,I would like to comment on "the PA's should at least be supervised" suggestion . Yes, of course. But the administration of hospitals require that because if supervised by a physician who actually "saw"the patient, the charge can be increased somewhat. SO hospitalists, are supposed, for example, to supervise the care of 12 PA patients in addition to admitting 3 and following 21. This volume of patients often mandates that the supervision often consists essentially of listening to a 2 minute presentation by the PA and then by walking into the room and looking at the patient for 2 seconds and then moving on. The patient was "seen":. Something has to give and that is often the result.. . Not all PA's have enough experience to perform well. If they did, they should be licensed to perform on their own. To say that they need to be supervised is the same as saying you think they are not really qualified to be talking care of patients in the first place.

PA's are NOT the same as experienced surgeons in the delivery of
post op care...... even if "supervised". Using this logic pretty soon we will; have PA surgeons operating on patients with a supervising surgeon operating next door and talking via phone to the PA asking
"how are things going?".

frankbill said...

This was in the news this morning. Question is it going to help or hurt how all providers treat patients.

WASHINGTON — The Obama administration outlined ambitious new goals Monday to transform over the next four years the way that the gargantuan Medicare program pays doctors and hospitals, rewarding providers that achieve better outcomes for patients rather than those that just do more.

The move away from so-called fee-for-service medicine is a central, if little recognized, goal of the Affordable Care Act, which the president signed five years ago.

Most experts believe that this shift is crucial to improving the quality of care that patients receive, while also restraining costs at a time when millions of baby boomers will be entering the nation's primary insurance program for the elderly.

Under the goals announced Monday, Medicare will make 30 percent of its direct payments to doctors, hospitals and other providers through alternative payment models by next year, up from nearly nothing four years ago.

These models include bonuses for doctors to coordinate patients' care and programs that set a budget for patient care and reward physician practices, hospitals and others who deliver the care under budget while achieving good outcomes for patients.

Skeptical Scalpel said...

Anon hospitalist, I appreciate your candid comments. I don't see how anyone can truly supervise a PA who is taking care of 12 patients. It's a joke.

Frank, I guarantee you that doctors will find a way to get around this new payment plan. It will be interesting to see how it evolves.

frankbill said...

They most likely will find a way to get the most money from the bonuses.

Anonymous said...

"I think this is true in orthopedics and plastics." Plastic Surgery resident here -- As part of my integrated residency program, we are expected to take care of our post-operative patients and even spend several months in the ICU learning how to take care of critically ill patients. In my experience, we will consult Medicine at times to manage patients that are especially medically complex (which I personally think is appropriate for optimal patient care), but we remain the primary team. It is unfortunate that incidents like these happen.

artiger said...

Frank, what unfortunately will happen is that patients who are exceptionally complex or are markedly noncompliant will be released from practices, after which they will wind up in the ER (repeatedly). Then costs will go up. The idea of pay for performance is not a bad one, but the unintended consequences could make the situation even worse. I do agree that fee for service is not sustainable, but like Scalpel said, there will be ways to game pay for performance.

Plastic surgery Anon, I'm not surprised that you are still taking care of your postop patients, but I'd be surprised if you continue to do so for very long once your fellowship is complete.

frankbill said...

I am one of the complex patients. I am in the VA system. I can tell you they don't put the veteran first. Have been trying to get a DX since 2005. The VA I go to is part of the Dartmouth system. So should be one of the best.

artiger said...

Frank, sorry to hear that. Well, the VA can't fire you, but are they subject to pay for performance? If so, and they perform poorly, what will happen to them?

frankbill said...

VA providers are Government employees. They also have a union. almost impossible to fire them.

frankbill said...

I know this post is about postop care but what about preop care? If one like me has unresolved problems. How close does the surgeon look at medical history?

artiger said...

Frank, I'm afraid preop care may be following the postop route in a lot of places (not here, mind you, but in larger areas). My wife's experience with her ACL repair was good though. We were initially evaluated by the PA, but not long after that the surgeon himself came in, repeated a good portion of the exam, and spent a good deal of time discussing the plan, outcomes, etc. I think he is something of an exception, but that is the reason we chose him.

You can go to some GI practices to be evaluated for upper or lower endoscopy, get your scope done, and return for follow up (if any), and have no idea who the person was that performed your endoscopy. I am probably old fashioned in this regard, but I think that is shameful.

William Reichert said...

Artiger,
I had a somewhat amusing experience regarding pre op care.And that is regarding "expectations". For example, my sister went to see a surgeon regarding a knee replacement for arthritis. She asked me about it as I am a physician. From my experience with others I said that she should expect it to take about a year to get full recovery. She
said no , that the surgeon said it would take only two months and that a year was "silly". OK . Well she had the surgery and did well and
now three months later she is doing pretty well but not back to
playing tennis. We were talking yesterday after she saw her surgeon and asked him when she could go back to tennis. And he said
"well it takes about a year......"

Skeptical Scalpel said...

Interesting. A friend had a knee replacement at age 64 and was back to playing tennis in 4 months.

Anonymous said...

Skeptical -- Anonymous #2 here again. One last comment on our respective situations. After my spouse kicked up a fuss over the unsupervised PAs, the wrong-site surgery and other disturbing events he was seeing in the hospital, he was forced out in a nasty series of exchanges with administrators. In the separation contract, admin. included a gag order (a.k.a., "confidentiality clause") that forbids him to speak of what he knows, unless required to by law. The admin was short-sighted though. They didn't include me in the gag order. So I have the right to speak.

And I do.

As we all should. We probably can't stop the train wreck that medicine is quickly becoming, but we can call out what the truth is, an I appreciate your willingness to do so.

Skeptical Scalpel said...

Thank you for commenting. It added a lot to the discussion.

Anonymous said...

This nurse wants to know who sends a patient home before they void at least a 100 ml?

After a foley is removed you expect 100 ml at a minimum. The pt who only voids 50-75 ml will go home and not void....and we know what happens next.

As far as the rest...we've lost out on continuity of care, something I suspected when I first heard of "hospitalists" the concept sort of works for middle age adults who, if they do need hospital care, are likely also in need of a surgeon or a specific specialist. Younger and older patients who are admitted for non surgical complaints are best cared for by physicians who know them as individuals.

Skeptical Scalpel said...

If everyone had followed your plan, the poor patient described in the post would have had a much more pleasant postop course.

You make a good point about hospitalists and continuity. However, I don't see it ever going back to the old model.

artiger said...

I agree, Scalpel, that horse is way out of the corral at this point. However, I read something not too long ago about the 10- and 90-day global periods after procedures, that CMS was looking at maybe phasing them out in the next year or two. The article implied that surgical fees would be reduced (what a surprise), but that postop visits would be reimbursed once again. I wonder if that would have much of an effect? Currently, after a basic procedure like a lap chole, I see the patient once after surgery and release them. If the changes noted above get put into place, I would have to resist the temptation to have two or three postop visits, except that I am employed, so I don't have the incentive anyway. Still, surgeons are not known for enjoying clinic time, so the reimbursement for postop visits would have to be substantial before the gaming would begin.

Skeptical Scalpel said...

I had not heard about this. You can bet the payments won't be substantial.

artiger said...

Scalpel, I read about it in one of those coding newsletters by email, but a Google search provided quite a few sources, one of which I've included below:

http://www.advisory.com/daily-briefing/2014/11/13/a-nightmare-for-surgeons-medicare-is-ending-global-payments-for-surgeries


When reimbursements went down, surgeons responded by finding other people to provide postoperative (and sometimes preoperative) care, to allow for increased volume to make up the difference. As so often happens, the payers wise up to the game and change the rules. Part of the global fee includes pre- and postop care; if that is provided by someone other than the surgeon, the payer feels the overall fee should go down.

That's why I suggested that surgeons might develop a renewed interest in postop visits.

Skeptical Scalpel said...

Thanks very much for the information. I don't know how I missed hearing about this, but I did. I believe chaos will ensue for a while after this becomes the rule. This might be worthy of a blog post.

artiger said...

A blog post about this would dovetail nicely with this one.

Chaos would ensue for a bit, but after everyone figures it out, we'll see lots more (unnecessary) postop visits than we currently do. Then global periods will come back in play.

Skeptical Scalpel said...

I agree. Surgeons with time on their hands will create work to do and that includes extra postop visits.

Anonymous said...

Whatever happened to the physician/patient relationship?
As a patient and a Registered Nurse who just had In Patient Incisional Hernia/s Laprascopic surgery 10 days
ago I saw my surgeon for what I thought was a first postop visit but which the surgeon said that would be the only visit and I could call and speak with her for any questions. I am doing well, thank God,but would have liked a follow up visit in month or so since I will have to remain on restricted activity no heavy housework and no lifting for a month. Professionally and as a human being I would feel much better to be checked and totally cleared by my surgeon! By the way I checked the Medicare Global Guidelines for surgeon reimbursement and I was just on Day 10 postop! As a
nurse since 1963 I am so disappointed in what Health Care Delivery HAS BECOME! I LIKE MY SURGEON AND SHE IS VERY COMPETENT BUT I MISS OUR HEALTH CARE DELIVERY OF THE PAST!
Joana RN,BS,MS

Skeptical Scalpel said...

Joana, I appreciate your comment and agree with you. I can't explain the behavior. It would have taken your surgeon less than 5 minutes to see you again.

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