Billy Rubin To Orthopods: Man Up or Drop Dead

A rant:

In the pecking order of physicians, both in terms of salary and status, I'm not especially high up there. As an infectious disease doc, I make a bit more than primary care docs, a bit less than hospitalists, a lot less than some of my fellow internal medicine subspecialists such as gastroenterologists and cardiologists, and a whole lot less than general and plastic surgeons. All of which is fine with me, as salary wasn't the main reason I got into medicine in the first place, and I have always put very little stock in status. Moreover, I have always maintained a huge level of respect for the vast majority of cardiologists and surgeons, most of whom are not only consummate physicians but incredibly hard workers as well. I'm content to play the bottom-feeding catfish to their swordfish (cardiologists, in this somewhat strained analogy) or shark (general surgeons, of course).

Also in this metaphorical fishbowl of American medicine are the clownfishes: small but beautiful, always the envy of the other fish in that they draw the admiring stares from people while flitting through the tank. Orthopedic surgeons are the clownfishes. They're not a big subspecialty: of the roughly 22,000 residency positions available last year, only 641 were for orthopedics. But oh, do they do well: the median income of an orthopod is estimated to be over $400,000 (!). Hence, a lot of very good medical students in med schools in the US work very, very hard as they pine for the joys of knee arthroscopy, laminectomy, and hip replacements, to say nothing of the Cabernet Sauvignon or trips to Bermuda that await.

One of the central ironies of American medicine is that several of these very fine students, whom many a prestigious Internal Medicine or General Surgery program would be delighted to train, will have spent an inordinate amount of time and energy learning medicine only to forget the vast majority of it during their residencies. You see, the orthopedic surgery residency takes people who have doctorates in medicine  and turn them into doctors of bones! They spend their residency years un-learning all the medicine that their expensive education gave them in the first place. My experience is that most orthopods can't even deal with the simplest postoperative medical issue for their patients, and they tend to punt problems to a medical consult that even a third-year medical student could handle competently.

Again, bone surgery is not what interests me so I'm not trying to rain on their parade, and I'm not trying to cry about unequal compensation. I do think, however, that with all that compensation comes a few obligations.

Take, for instance, the patient that I saw this weekend while covering for the local ID physician at the nearby community hospital. My pager chirped early Saturday morning and I got one of the hospitalists on the line. "Billy, I'm not sure what's going on with this lady, and she's not even 'mine'," said the hospitalist, meaning that he wasn't the attending of record, but just a consultant managing the medical issues. The attending of record was an orthopedic surgeon from one of those "Sports Medicine Associates"-type groups (not the real name). It turned out that the patient had gotten a new hip eleven days before, and her postoperative course was complicated by a fever that never seemed to go away, even though cultures, x-rays, a CT scan of the hip, and a few other tests turned up nothing. Plus her white count was normal.

I relate this story not because of its "House"-like interest (though MDs out there are welcome to take a crack at the diagnosis), but because during those eleven days she was not once seen by the orthopedic surgeon who put the new hip in. Nor was she seen by the surgeon's partners who were on call; she got visits from three different Physicians Assistants, all of whom assured her that she was on the mend (she wasn't) and would be discharged the next day. Eleven days!

You know what? I don't care that the clownfishes make the big bucks until I see a patient not merely suffering (sometimes that's unavoidable), but feeling abandoned, which is inexcusable! I know that they're just doctors of bones and not real doctors at this stage of their careers, and that they can't manage anything other than deciding between a press-fit stem and a cement-stem, but the patients don't know that! It's fine, let me and the other consultants who actually know how to be doctors of people do the real work of taking care of the patient--I'm handsomely compensated as far as I'm concerned, even if it's a third of what they make. Just try to make the patient feel like you care! So Man Up, you asshole, and see your fucking patient! She's sick!

Lest you think I'm overstating the case, take a look here at this 2007 NYT article about "specialty" hospitals not being able to handle sick patients. Not all of these specialty hospitals are completely orthopedics, but a lot of them are. You know what's really rich about this? These hospitals are often built by the physicians themselves because they want to cut out "traditional" hospitals so that they can receive even higher levels of compensation. Amazing! (And yes, "rich" was an intentional pun.) Physician salaries are often a delicate matter to discuss, because docs want to be well paid, but this isn't just your typical societal working-out of a doc's salary. This is greed! Good grief.

When I signed off for the weekend to the regular ID doc, I related this story. He sighed. "Yeah, we have really had problems with that group over the years," he said. "The amazing thing is that when something goes wrong and the patient doesn't just recover in three days like normal, they tend to get mad at the patients for sticking around."
--br