Time was critical. He needed surgery right away to remove his gallbladder. But for that, he needed a surgeon.
“There was a surgeon on call, but the surgeon was not picking up the phone,” Dr. Singh says. “I’m scratching my head. Why is the surgeon not calling back? Where is the surgeon? Did the pager get lost? What if the patient has a bad outcome?”
Eventually, Dr. Singh had to give up on the on-call surgeon, and the patient was flown to a hospital 45 miles away in downtown Sacramento. His surgery had been delayed for almost 12 hours.
The man lived largely due to good luck, Dr. Singh says. The unresponsive surgeon had disciplinary proceedings started against his license but retired rather than face the consequences.
Today, hospitalists at Sutter Amador no longer have to anxiously wait for those responses to emergency pages. It’s one of many hospitals that have turned to a “surgicalist” model, with a surgeon always on hand at the hospital. Surgicalists perform both emergency procedures and procedures that are tied to a hospital admission, without which a patient can’t be discharged. Although it is growing in popularity, the model is still only seen in a small fraction of hospitals.
The model is widely supported by hospitalists because it brings several advantages, mainly a greater availability of the surgeon for consult.
“We don’t have to hunt them down, trying to call their office, trying to see if they’re available to call back,” says Dr. Singh, who is now also the chair of medical staff performance at Sutter Amador and adds that the change has helped with his job satisfaction.
A Clear Delineation
Arrangements between hospitalists and surgicalists vary depending on the hospital, but there typically are clearly delineated criteria on who cares for whom, with the more urgent surgical cases tending to fall under the surgicalists’ care and those with less urgent problems, even though surgery might be involved, tending to go to hospitalists.
When a surgery-related question or the need for actual surgery arises, the model calls for a quick response time from the surgicalist. Hospitalists and surgicalists collaborate on ways to reduce length of stay and prevent readmissions since they share the same institutional goals. Hospitalists are also more in tune with the needs of the surgeons, for instance, not feeding a patient who is going to need quick surgery and not administering blood thinners when a surgery is imminent unless there’s an overriding reason not to do so.
One advantage of this collaboration is that a hospitalist working alongside a surgicalist can get extra surgery-related guidance even when surgery probably isn’t needed, says John Nelson, MD, MHM, a hospitalist at Overlake Medical Center in Bellevue, Wash., a hospitalist management consultant, and a past president of SHM.
“Maybe the opinion of a general surgeon could be useful, but maybe I can get along without it because the general surgeons are busy. It’s going to be hard for them to find time to see this patient, and they’re not going to be very interested in it,” he says. “But if instead I have a surgical hospitalist who’s there all day, it’s much less of a bother for them to come by and take a look at my patient.”
The model is not without its hurdles. When surgicalists are on a 24-hour shift, the patients will see a new one each day, sometimes prompting them to ask, “Who’s my doctor?” Also, complex cases can pose a challenge as they move from one surgicalist to another day to day.
John Maa, MD, who wrote a seminal paper on surgicalists in 2007 based on an early surgicalist model he started at San Mateo Medical Center in California,1 says he is now concerned that the principles he helped make popular—the absorption of surgeons into a system as they work hand in hand with other hospital staff all the time—might be eroding. Some small staffing companies are calling themselves surgicalists, promising fast response times, but are actually locum tenens surgeons under a surgicalist guise, he says.
Properly rolled out, surgicalist programs mean a much better working relationship between hospitalists and surgeons, says Lynette Scherer, MD, FACS, chief medical officer at Surgical Affiliates Management Group in Sacramento. The company, founded in 1996, employs about 200 surgeons, twice as many as three years ago, Dr. Scherer says, but the company declined to share what that amounts to in full-time equivalent positions.
“The hospitalists know all of our algorithms, and they know when to call us,” Dr. Scherer says. “We share the patients on the inpatient side as we need to. We keep the ones that are appropriate for us, and they keep the ones that are appropriate for them.”
The details depend on the hospital, she says.
“Whenever we go to a new site, we sit down with the hospitalist team and say, ‘What do you need here?’ And our admitting grids are different based on what the different needs of the hospitals are.”
To stay on top of complex cases with very sick patients, the medical director rounds with the team nearly every day to help guide that care, Dr. Scherer says.
At Sutter Amador, the arrival of the surgicalist model has helped shorten the length of stay by almost one day for surgery admissions, Dr. Singh says.
Reported outcomes, however, seem to be mixed.
In 2008, Sutter Medical Center in Sacramento switched from a nine-surgeon call panel to four surgeons who covered the acute-care surgery service in 24-hour shifts. Researchers looked at outcomes from 2007, before the new model was adopted, and from the four subsequent years. The results were published in 2014 in the Journal of the American College of Surgeons.2
The total number of operations rose significantly, with 497 performed in 2007 and 640 in 2011. The percentage of cases with complications also fell significantly, from 21% in 2007 to 12% in 2011, with a low of 11% in 2010.
But the mortality rate rose significantly, from 1.4% in 2007 to 2.2% in 2011, with a high of 4.1% in 2008. The study authors note that the mortality rate ultimately fell back to levels not statistically significantly higher than the rate before the service. They suggested the spike could have been due to a greater willingness by the service to treat severely ill patients and due to the “immaturity” of the service in its earlier years. The percentage of cases with a readmission fell from 6.4% in 2007 to 4.7% in 2011, with a low of 3% in 2009, but that change wasn’t quite statistically significant.
“The data’s really bearing out that emergency patients are different in terms of the care they demand,” Dr. Scherer says. “So the patient with alcoholic cirrhosis who presents with a hole in his colon is very different than somebody who presents for an elective colon resection. And you can really reduce complications when you have a team of educated people taking care of these patients.”
Dr. Nelson says adopting the model “just means you’re a smoother operator and you can provide better service to people.” He adds that for any hospital that is getting poor surgical coverage and is paying for it, “it might make sense to consider it.”
Thomas R. Collins is a freelance medical writer based in Florida.
- Maa J, Carter JT, Gosnell JE, Wachter R, Harris HW. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007;205(5):704-711.
- O’Mara MS, Scherer L, Wisner D, Owens LJ. Sustainability and success of the acute care surgery model in the nontrauma setting. J Am Coll Surg. 2014;219(1):90-98.