In this era of increasing synergy between the surgical and hospital medicine services, Minnesota hospitalist David Frenz, MD, has taken perioperative management of surgical patients a step further.
One or two days a week, Dr. Frenz can be found in the operating room (OR) of St. Joseph’s Hospital in St. Paul, assisting on multilevel spine surgery cases.
Although Dr. Frenz may be a one-of-a-kind hospitalist acting as first assistant in the OR, the approach offers many advantages to his hospital and hospital medicine service, says Robert C. Moravec, MD.
“It seems more efficient having one assistant surgeon [rather than several scrub technicians] who knows exactly what’s going to happen next,” says Dr. Moravec, medical director for both the hospital service and St. Joseph’s Hospital. “More importantly, it’s a way to develop some expertise in the perioperative arena and to develop collaborative relationships with the surgeons.” In addition, the hospital service is able to bill for an assistant surgeon’s fee, which covers much of Dr. Frenz’ salary. And when he’s not on the medical floors seeing patients, Dr. Frenz is engaged in a monthslong quality improvement (QI) project to improve perioperative care and reduce same-day surgery cancellations at his institution.
The effectiveness of this QI project, which Dr. Moravec believes will go to HealthEast’s other two acute care hospitals in nine months, would not be possible without Dr. Frenz’ conversance with problems in the OR.
“When you are involved in this type of process improvement project, you don’t want, as a do-gooder, to create more cancellations and delays,” says Dr. Frenz. “And you don’t want to screw up their referral relationships. You’ve got to be super-sensitive to those issues as you’re trying to slowly bring about change. The fact that I’m known to the surgeons and that I’m in the OR getting dirty lends credibility to our efforts to bring change.”
Value in Surgical Assisting?
In medical school, Dr. Frenz had considered becoming a general surgeon before switching to family-practice medicine, so he is comfortable in the OR and finds assisting to be a stimulating change of pace. Although this long-standing pilot project is unique, it raises provocative possibilities for other hospitalists.
“Having a hospitalist go into the OR to assist with cases creates an interesting situation,” says Richard Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in Cortland, N.Y. “The hospitalist is then able to engage with more surgical aspects of the case, as well as the medical management.” Adding surgical assisting to the hospitalist’s role—although it could complicate scheduling and malpractice coverage—might dovetail with some hospitals’ difficulties retaining general surgeons, he says.
Combining the two functions could add to the hospital medicine group’s bottom line if relevant malpractice costs could be worked out, says hospitalist Kenneth Patrick, MD, the ICU director at Chestnut Hill Hospital in Philadelphia. Dr. Frenz’ malpractice is provided by his hospital, and pre-certification for his assistance on cases is handled by the neurosurgeon’s office staff.
In Dr. Patrick’s experience, there could be benefits to the patient if the hospitalist has direct involvement in the OR. For instance, the hospitalist would be better able to anticipate and deal with pre- and post-operative problems.
—David Frenz, MD, hospitalist, St. Joseph’s Hospital, St. Paul, Minn.
Surgery and ‘Outer Space’
Whether or not surgical assisting could become a new frontier for hospitalists, it illustrates the multiple collaborative roles the specialty increasingly offers.
David A. Hoffmann, MD, is medical director of a hospitalist group in Chambersburg, Pa. The group is made up of half family practice and half internal medicine hospitalists. Like so many other hospitalists, he’s seen tremendous growth in the number of surgical co-management cases his group handles at Chambersburg Hospital (see “The Surgical Surge,” December 2007, p. 1). His group tries “to make inroads with the surgeons,” he says. “We send a member of our group to their meetings, and we work with them on management protocols [such as DVT prophylaxis]. I can see the benefits of getting to know what’s going on down there [in the OR]. The truth of matter is, [despite co-management], sending the patient to the OR is like sending someone into outer space for the hospitalist. The rocket goes off, and you don’t see the patient until they come back in for a landing.”
Depending on the location of hospitalist groups, involvement as first assistants could represent additional opportunities for family medicine physicians, Dr. Hoffmann believes.
Air Force Maj. Heather Cereste, MD, agrees that the degree of symbiosis between surgeons and hospitalists likely will continue to be a location - and hospital-specific phenomenon. While serving in Iraq, she had significant experience with surgical procedures, and felt that from an internist’s perspective, she was more valuable to the surgical team. During her third-year residency in Maine, she observed many who planned to go into family practice assisting with gastrointestinal procedures and the like. “Certainly, in a smaller setting, with fewer available resources, the more autonomous a hospitalist can be, the better,” says Dr. Cereste, co-director of the geriatric medicine service at Wilford Hall Medical Center, Lackland Air Force Base, Texas, and chair of the bioethics committee.
Though surgical assisting is an intriguing idea, such a set up “could have its own set of unintended consequences,” especially for a private model hospitalist group, says Brian Bossard, MD, medical director of Inpatient Physician Associates in Lincoln, Neb.
Dr. Bossard has personal experience with this configuration. When an internist in his hospitalist group began to do surgical assisting, the privately owned group (which contracts with Bryan LGH Hospital in Lincoln to provide hospitalist services) did not find this advantageous. The physician’s surgical participation was at times disruptive for the group, since he was unable to be immediately available and on call or to run codes while in the OR.
“It’s not clear to me that there would be an advantage to have a hospitalist [assisting in the OR], as opposed to another physician extender such as a physician assistant or a nurse practitioner,” says Jack M. Percelay, MD, a pediatric hospitalist at Saint Barnabas Medical Center in Livingston, N.J. Co-management of surgical patients is another matter, however, and Dr. Percelay does see value in having hospitalists help with maintenance of lines, wound care, and other post-surgical management duties.
“There is a certain set of procedures we’re supposed to master, such as vascular access and airway support,” Dr. Percelay continues. “But our value as hospitalists is in our cognitive skill set. I don’t know any hospitalists who consider a scalpel as one of their routine tools.”
Bryan Fine, MD, a pediatric hospital at Children’s National Medical Center in Washington, D.C., recently joined a general hospitalist group after spending three and a half years as the hospitalist in charge of medical management for the gastroenterology service. His opinion of hospitalists assisting in surgery? “I think it’s definitely valuable if it’s done in the context of a larger goal and to gain credibility from a hospital administrative level,” he suggests. However, he said, professional satisfaction for a hospitalist might be limited since he or she essentially would be serving as a physician extender.
Family-practice physicians often are differentiated from their internal medicine colleagues by their skill sets in procedures.
“To the extent that a family-medicine physician may want to demonstrate that they can have a skill set that adds value in order to be hired or accepted, I think surgical assisting could have very specific application in specific places,” says A. Neal Axon, MD, assistant professor in the departments of internal medicine and pediatrics at the Medical University of South Carolina in Charleston. “I’ve certainly tried to market myself as a med-peds person, and as somebody who’s good at more than one thing.”
Dr. Axon concedes hospitalists as surgical assistants would not work at his institution. “In academic medical centers, the dividing lines between divisions and disciplines are very concrete,” he explains. “I think many people carry those cultural barriers or dividers—even if they are somewhat artificial outside the academic environment—when they leave and go into community practice.”
Those divisions are not felt as keenly in the Midwest, according to Dr. Frenz, where “family medicine has a long tradition.” St. Joseph’s Hospital has a family - medicine residency program, and more than half the credentialed physicians there are family- medicine trained.
“We think that family-medicine physicians have a skill set that is valuable in certain clinical settings,” he says. “For example, we do a lot of work on the behavioral health floors and are the principal medical providers on a 28-bed chemical dependency unit.” Dr. Frenz had a patient who was pregnant and alcohol dependent. Because of his expertise in addiction medicine (another of his self-described “insurgencies”) and residency training in obstetrics, Dr. Frenz is managing the patient without incurring an ob/gyn consultation.
How to Prepare
Every hospitalist’s path and skill set is unique, but for those medical students or residents who might be interested in combining some surgical work with hospitalist skills, Dr. Frenz advises adopting a calculated approach to electives. Besides taking as many surgical electives as possible, trainees should try to pick small community hospitals where they will not have to compete with surgical residents for time in the OR.
Although she thinks expanding into surgical assisting could improve recruitment (offering a varied hospital experience), Dr. Cereste also emphasizes that many questions regarding training standards, care standards, and expense hurdles would have to be addressed.
The bottom line, says Dr. Hoffmann, is that hospitalists “need to be able to play a lot of different roles. I think we’re like a utility infielder. If [surgical assisting] improves patient care, is a valuable service to the health system, and is viewed by consultants, specialists, and family doctors as an additional skill, it’s clearly going to benefit your program and your hospital. The key is to see what works in everyone’s little pond and try to be a team builder.” TH
Gretchen Henkel is a medical writer based in California