Bridge the Attending Divide

I always wear a sport coat and tie when I’m speaking, but I thought I knew the orthopedic psyche well enough to know they would be very casually dressed for their conference on a warm Saturday this past fall. I was stunned to see about 40 of the 60 orthopods in attendance wearing jackets and ties—a very dapper bunch. While I misjudged their fashion sense, I’m still confident I’ll fit in wearing a bow tie (borrowed, since I don’t own one) to a neurology conference or a Mickey Mouse tie to a pediatric conference.

I had been invited to speak at the Washington State Orthopedic Association last fall. (Maybe they spell it “orthopædics,” but that seems a little pretentious to me.) They wanted to hear about the latest trends in how orthopods and hospitalists collaborate in the care of patients, and how this interaction might evolve.

It seems to me that the pressure to serve as attending for these patients is similar to surviving a riptide: You shouldn’t try to swim directly against the riptide toward shore, and instead should swim across it or even go with the flow.

Attending or Consultants?

I told them that, in my experience, determining the best doctor to serve as attending for certain types of patients generates a wide range of sometimes passionately held opinions among hospitalists. In my consulting work with practices around the country, I’ve come across some hospitalists who are insistent that they should never serve as attending for patients whose primary reason for admission is:

  • Hip fracture due to osteoporosis and fall from ground level;
  • Nonoperative low-speed or low-impact trauma, such as pelvic fracture; and
  • Limb infection with potential for compartment syndrome.

Interestingly, I’ve found that hospitalists almost universally admit patients with osteoporotic vertebral compression fractures, even if they strongly believe that they shouldn’t admit patients with pelvic fractures.

My own experience leads me to believe that hospitalists in most settings should plan to serve as attending for all of these patient types, if they aren’t already. For example, a hip fracture is essentially a marker for a sick and frail person with complex medical needs. While it is the marquee event of the hospital stay, surgical repair of the fracture is just one of many important things that need to happen before discharge. Most of these patients need attention for medical comorbidities—such as a urinary infection or decompensated heart failure—which often are the proximate cause of the fracture. The patient might need a discussion of medical directives, which usually is an area in which orthopods usually don’t excel (and I’m being kind to the orthopods).

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