Thursday, September 8, 2011

Sign Out

Weekend sign out between Dr. Venable, who will be covering for Dr. Fresh over the weekend:

Dr Fresh, a young surgeon, who finished residency one month ago and came to work for General Hospital with a salary guarantee of $300,000/yr.: “Thanks you so much for covering for me this week end, Dr. Venable, my husband made plans to take me shopping and I don’t want to disappoint him and my nanny is off on Sunday, so I need to stay home with my daughter.”

Dr. Venable, a surgeon in his sixties who came to General Hospital 30 years ago and started in private practice with only his congenial smile, two hands and $2500 in the bank: “I’m happy to do it, Louise; I have to stay around anyway, to check on Mr. B. I did an esophagectomy today and he’s a bit frail. I want to make sure he’s OK.”

Dr. Fresh: “I’m surprised you still do big operations like that. I usually call the Foregut Surgeon to do such cases.”

Dr. Venable: “Well, I’ve always done them and I can’t remember having any serious problems, so I see no reason to quit. How many patients do you have in house?”

Dr. Fresh: “Only four, so it shouldn’t be too much work for you. First is Mrs. G. She had a mastectomy and is doing fine. Took me a while to do the surgery, however.”

Dr. Venable: “Big tumor?”

Dr. Fresh: “Not really, but I had never done a mastectomy before, so it took a bit of time, feeling my way around the anatomy.”

Dr. Venable: “You could have called me for help, I’m happy to assist.”

Dr. Fresh: “You’re right, I should have called you. Anyway, next is Mr. P; he had a colectomy ten days ago. He had a bit of fever today, 102 and is a little tachycardic, but otherwise he’s OK. Dr. Bug from Infectious Disease is supposed to see him today.”

Dr. Venable: “Ten days post op, do you think he’s leaked his anastamosis? Is he very tender when you examine him, is he eating, having BM’s?”

Dr. Fresh: “He was fine yesterday. I only saw him briefly today. I noticed the fever, that’s why I called Dr. Bug. He’ll sort it out; that’s what he gets paid for. In 312 is a young guy, Mr. X. I saw him in the ER with belly pain. His work up is in progress, CT Scan, Ultrasound, MRI. Results should be available tomorrow; just do whatever’s appropriate. He doesn’t have insurance anyway.”

Dr. Venable: “Oh, yes, his PCP asked me to take a quick look at him. I stopped and chatted for a few minutes and felt his belly. He said he’s had pain for three days and is pretty tender in his right lower quadrant. Probably has appendicitis.”

Dr. Fresh: “Can you take care of him? I need to get ready for this weekend and I don’t want to disappoint my husband. I’ve been so busy; I haven’t seen him all week. My last patient is in the ICU, Mrs. Q. I admitted her last night. She was in an MVA, has a few fractured ribs and CT showed a small splenic laceration. She’s stable, however. But, if you think she needs surgery please call me. She’s the wife of Mr. Q, who’s on the Board of Trustees, but I think she’ll be fine; her last hemoglobin was 9.5, only down one gram from the previous one, but her vital signs are stable.”

Dr. Venable: “Certainly, I’ll take good care of all your folks. Say hello to your husband for me.”

He smiled at her and patted her on the back, but as she walked away he shook his head and then turned to take the elevator to the third floor to see Mr. P.

The above scenario is only slightly exaggerated. I asked several physicians and nurses if they perceived any differences between younger physicians and older ones. Although there are many exceptions, the general consensus was that younger doctors are more likely to spend less time on history and physical exam, depend more on imaging and lab studies to establish a proper diagnosis, and be more concerned with lifestyle and financial benefits. The reason for these differences, in my opinion, traces back to the limitations that were placed on residency programs in the late 1980’s and early1990’s.

It seems that, at least in surgery, the physicians coming out of residency have had less opportunity for responsibility, less experience and more limited operative caseload. It may be as one older Ob-Gyn said to me:

“The young physicians say that ‘being a doctor is what I do’; older ones are more likely to say ‘being a doctor is what I am.”

Think about the difference.