February 13, 2012
Dr. Anu Bajaj, M.D.
Plastic Surgery, patient care

The Changing Healthcare Landscape: The Surgeon’s View from the Patient’s Bedside

patient careThis blog is supposed to discuss issues that the young plastic surgeon may face and how PRS applies to our lives. That said, it will sound cliché to say that I looked at the calendar and realized that January was half over, but it is true. The past six weeks have been a whirlwind, where I have barely been able to keep my head above water – managing my practice, covering for my father, and running from one family emergency to the next. So as I write my blog this month, my thoughts have been about how to navigate the changing healthcare system and what it means for the patient and the physician.

When I read this month’s editorial on the itinerant surgeon, my mind immediately started to wander. All of us will agree that surgery is more than just performing a procedure – the pre-operative and post-operative judgment and management are frequently the most critical aspects of the procedure.

But the fundamental issue with this practice – whether it is the patient or the physician who travels — is appropriate follow-up care and the existence of a long-term relationship between the patient and the physician. As healthcare has changed, the ways that we follow our patients have changed as well.

I said earlier that the past few weeks have been chaotic for every member of my family. We have been very fortunate when we have had to navigate the healthcare system – trusting our doctors was never an issue, nor was being able to see them when we needed to. But all of us were bewildered during the past few weeks, and I learned first- (or rather second-) hand how terrifying it can be from the patient’s perspective.

Having trained in the era before the 80-hour work week, and hearing war stories of how the only bad thing about every-other-night call is that you missed half the cases, I have struggled with the changes occurring including hospital employment, and more limited work hours.

As healthcare has changed, the ways that we follow our patients have changed as well.

My sister has had a very complicated pregnancy, culminating in an admission for complete bedrest, followed by the urgent transfer to a hospital with a more advanced NICU to deal with an impending premature birth, and ultimately premature delivery at 27 weeks. She had to transfer care from an OB whom she has known for the past seven years, and who had delivered her other two children, to a group of OB hospitalists at this new facility.

As most of you know, my father is a plastic surgeon. When I joined him in practice, I asked him how he dealt with patients after-hours or during the weekends. My previous practice had been an academic practice, so the on-call attending physician or the residents received the calls. I learned that my father no longer had an answering service. Instead his patients had his cell phone number. My father assured me that most patients respect you and don’t call you unless they need to. So, I also give my patients my cell phone number for issues that may arise after hours.

Compare that approach with an employed physician. As an OB hospitalist, each physician works several shifts during the week at many different hospitals. From my sister’s viewpoint, this meant there was a new physician every day and night at a critical point in her pregnancy. For a patient who had already lost one baby and was terrified of losing the second, it was a scary time. Every physician during the course of the 5 days had a different opinion and would say or manage things just a little differently. It may not have been drastic, but it was just enough to confuse and scare her. And the patient and the patient’s family may not have the same rapport with each physician.

As a physician myself, I can’t help but compare that with the way we manage our own patients. I see them pre-operatively, intra-operatively, and post-operatively. If I am out of town, the covering physician (usually my dad) calls me to discuss how I would like to manage the problem. From speaking with my patients, I don’t believe that they have any doubt as to who their doctor is.

One of the crucial components of the doctor-patient relationship is trust. How do you develop trust? And how do you develop trust quickly and every day – in other words, how does a patient in the hospital trust every physician that walks in the door? And how does the follow-up care work when you leave the hospital? Most patients will continue to follow with their outpatient physician, not the hospitalist, so the treatment plan may actually change.

My other sister is an Ob/Gyn in practice in the DC area. She told me that when people had mentioned OB hospitalists in her area, she and her partners had wondered who would want that job? She loves the fact that OB/Gyns had an outpatient component and a surgical/inpatient component, and that she could do both every day.

How does a patient in the hospital trust every physician that walks in the door? And how does the follow-up care work when you leave the hospital?

With the quickly changing healthcare landscape, I have to wonder how these changes will affect plastic surgery? As a member of the YPS steering committee, I have observed that many younger physicians are choosing hospital employment over private practice – the financial risks are less and the lifestyle is usually more secure, at least initially.

Does this trend mean that we will see a further division between cosmetic and reconstructive surgery? How will it affect our patients?

I’m not sure about the answers. My brother-in-law asked me why I was so against it. And maybe the answer is that I’m just afraid of change.

This blog post by Oklahoma plastic surgeon Dr. Anu Bajaj previously appeared in Plastic and Reconstructive Surgery.