Tuesday, January 18, 2011

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."


  1. I have always said "Smartest medical students, dumbest doctors."

  2. Orthopedics may be "clownfishes," but with them filling up their pockets on that rate, that wouldn't be any problem.

    summit orthopedics

  3. I don't doubt that there are bad doctors out there (of every kind including the orthopods you described) I could tell you about IM docs that have nearly killed their patients even though they were seeing them every day. These orthopedic surgeons are without a doubt horrible people but I would like to make clear that it is not the orthopedic surgeons do not know how to manage diabetes (its not very difficult). but it is time consuming and there is no reimbursement. Plus if the surgeon puts in a consult the IM doc WILL get paid for his extra effort. Lastly, dumb and smart is intrinsic and is only lost with pathology(i.e. dementia). Knowledge on the other hand will escape you with time. I challenge any doctor to read any page Miller's orthopedic review book and honestly ask themselves if they really understood what they read.

  4. Thanks, Anon, for your thoughts. It's been interesting to see people giving feedback on pieces written 18 months ago! The magic of the internet.

    I had not thought of the reimbursement angle, to be honest. I tend to live in a cocoon about reimbursement, approaching my job with a child-like naivete about billing and just take care of whatever damn issue I think I can with medical competence. But that's because I generally get paid flat fees, either per shift or per weekend coverage, so I don't fret much over billing, letting someone else deal with that. Had I to be a workaday doc, I suspect my perspective would change. So I'm mindful of your point.

    Though that said, I fear the darker side of your point about reimbursement is that we have collectively shifted as a profession to the aptly-but-scarily named "health care providers" and away from "doctors". This orthopod in question was caring for a patient who was suffering a complication, and he did not visit her for eleven days. No good doctor would have allowed such a thing to happen.

    Thanks for reading up, and best, Billy

  5. Billy, I completely understand your frustrations. As Anon said, this isn't a strictly orthopedic problem but an individual problem. To extrapolate Anon's point, would you like the Orthopedic surgeon operating on your family member to be calling and looking up what another patient's Magnesium or blood sugar is with your family member asleep on the table? It's not that we don't know how but we do not have the time and that is not what we are trained in. Like the old adage goes, "If you don't use it, you lose it." We do not continue to maintain our competency in reading EKGs, for instance, and would be hesitant to not consult medicine for a patient with chest pain or uncontrolled blood sugars.

    It is interesting when other residents from other specialties spend time with us and leave with a new understanding of how hard we work and how in depth orthopedics is. It may not be "medicine" by your definition and may just be "bones" but we also understand our limitations and want to do what is best for the patient. A prosecutor would drool when reading a chart about an orthopod treating a post op complication medically on their own just as he would an ID doc who splinted a fracture (it's easy, right? I did it as a third year medical student). They also realize that it isn't as simple as they thought (i.e. press-fit vs cemented). When I get consulted about something I see as "simple" I try to see the consulting physician's perspective and it is easy to see their reason for the consultation.

    As an ortho resident we have experienced the same frustration you have. Patients have not been seen by a general surgeon, vascular surgeon, hospitalist, ID doc for days. Unfortunately it happens. There is no excuse, but it is a problem that is widespread throughout every specialty and seems to be provider and sometimes group dependant. I would be pissed if any provider didn't visit a patient for eleven days.

    1. Thanks for your feedback, Doctor Week. Another year passes and still getting feedback on this piece! I'm just awestruck by the internet.

      I agree with everything you said with one exception. I don't dispute that, in the highly specialized, Balkanized world of modern American (Canadian? European? Japanese? can't comment, but probably) medicine there are all sorts of issues raised by who-should-care-for-what and what happens when you lose even basic medical knowledge when you don't use it on a daily basis. Likewise, I agree that every specialty requires a wealth of knowledge that outsiders may be clueless about, with a naïve take about, say, orthopods as being dumb jocks. (I was surprised when coming into medicine about how many stereotypes play out that one normally associates with high school, as I can't tell you the number of times I've heard slip about the nerdy, know-it-all ID folks.)

      That being said, my point--and I still think this holds true, unfortunately--was that I have found the problem, in private/community hospitals at least, to be -disproportionately- represented by these Sports Medicine types. Whence the source of my rant, which a) I wasn't seeing for the first time in this instance, and b) I've calmed down about mostly over the last two years. I do fret over the culture of Orthopedic Surgery and what leads someone to behave this way, and as I noted, the full time ID guy whom I was covering for didn't even blink when I told him this story in signout. I gather from your thoughtful reply that you are less likely to end up like this, and God Bless for that. I suspect that I would be served well in your care, which, by the way, are you in the southern New England area? I think I have completely fucked up my left rotator cuff and need an eval. Just in case.

      Best, Billy