Blame the patient

The other day some cardiologists on Twitter were discussing whether a patient should be blamed if a permanent pacemaker lead became displaced. The consensus seemed to be that it was probably poor placement (i.e., operator error), rather than patient behavior that caused leads to dislodge.

The discussion reminded me of an attending plastic surgeon of mine during my resident days. He was one of the most obsessive-compulsive people I ever met. When he applied a dressing, he always cut the tape with scissors instead of tearing it. He felt that torn tape looked sloppy, and that if a patient saw a ragged edged of torn tape, she might think that the surgical procedure itself had been done without meticulous care too.

When he wrapped a hand, he used a very bulky dressing with yards and yards of carefully cut, not torn, tape over the ace bandage to prevent from slipping or unraveling.

But my favorite eccentricity was what he told patients who had any sort of facial surgery. He had a thing about the role of movement of skin possibly causing scars to separate and permanently widen.

So he gave this written instruction to every patient who had so little as a facial mole removed, "Do not talk or chew for 10 days."

Think about it. Could any patient possibly comply with that? Some of us more cynical types figured that should a scar not have turned out perfectly, the conversation might have gone like this.

Surgeon: "About your scar, you must have talked or chewed during the first 10 days after surgery."
Patient (sheepishly): "Well doc, I must admit I did say a few words, and I had to eat something."

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Do surgeons still do postop care

Heres an email I received the other day (edited and posted with the authors permission):

I am a recently retired internist. I have noticed some evolving trends over time and had an interesting experience that illustrates this issue.

A 77-year-old friend went for check up due to urinary incontinence. He was found to have a large prostate and a PSA of only 2 so was given Flomax . This helped somewhat.

At the time, an asymptomatic hernia was found. He was immediately scheduled for surgery which went well. His Foley was removed, and he was sent home.

At home he could not void, called the surgeon, and was told to go to the ER, There the Foley was replaced, and he was to see his urologist in 2 days. The urologist removed the Foley. Later he was in agony and walked the floor all night. He called the urologist and the service said that the office was closed. He was told to drive to the other office in the next town only 15 miles away. They replaced his Foley again.

Two days later he went to the surgeon who did the hernia repair and explained his postop adventures. The surgeon said, "Those things have nothing to do with the surgery. Your wound looks fine."

Things have changed. IN THE OLD DAYS:

• After surgery, patients were not sent home until they could eat, void, and walk. Those days are history. 
• Surgeons took care of their patients post op. Those days are gone.
• Urinary retention was a recognized complication of hernia repair, especially in someone with known BPH. Are those days gone too?
• If you sent someone home after pulling the Foley, you waited till the patent had voided being aware that massive urinary retention has the potential to induce damage to the bladder muscle itself (He had retained over a liter of urine) as well as cause great pain and distress.

I am aware that surgeons are not paid for postop care, but the global fee includes the surgery and the postop care (Follow the money). Hospitals need beds for new patients (Follow the money). [Dont forget that third-party payers wont fund any extra time in hospital.]

Are surgeons no longer trained in post op care? Are surgeons not exposed to the concept of surgical complications? Isnt it interesting how things change for the worse and nobody notices?

I wondered if the friend had really needed the herniorrhaphy. The writer replied:

I looked up that question and found that only 1% of hernias need surgery by becoming symptomatic. I mentioned this to my friend, but he had been "seduced" by the authority of the surgeon who acted as though not operating was inconceivable.

I once had an echocardiogram for occasional PVCs (probably not indicated). The tech discovered gallstones. Within an hour, a surgeon stopped me in the hall and wanted to remove my GB. (So much for privacy!) As luck would have it, I had had the experience of caring for patients who had had GB surgery and had terrible results involving damage to the hepatic duct resulting in liver failure and jaundice. I looked it up and found that asymptomatic gallstones may not need surgery. I have done fine for 30 years. (Knock on wood.)

I think no postop care by the surgeon is "THE NEW NORM."

As a hospitalist, I was assigned to care for surgeons postop patients—one reason I finally retired. This was challenging at times. For example, one day a lady had a tummy tuck by a plastic surgeon. I was "consulted" to follow her and noticed her Hct had dropped. After investigating, I concluded that she must be bleeding into her wound. The surgeon never saw the patient post op. A nurse practitioner saw her but was clueless. I called the surgeon but no response came. When her Hct got down to 25, I gave her some blood and she stabilized and went home. A month later the surgeon stopped me in the hall and said when he had taken out her stitches, a huge amount of black gook plopped out. "She had a wound hematoma," he said. "Thanks for taking care of it." He was not embarrassed at all. I guess my caring for this was the new norm.

Stuff like this happened too often. If I called another surgeon for help they always refused. There was nowhere to turn.

In my fairly extensive experience, postop care by the surgeon is now seen as optional. Hospital employed surgeons are expected to operate, and NPs and/or hospitalists [Dont forget the PAs.] are assigned to do the postop care. This permits more surgeries (revenue).

On a more philosophical note, I am fascinated how "standards" change right before our eyes, but the process goes on unnoticed, slowly, almost invisibly. Then a few people speak up. They notice things. But it doesnt pay to agree with those people. Eventually, the process becomes obvious, and everyone says, "You know what? Health care in America really sucks. When did this happen?"

Are surgical residents being trained in postop care? Do surgeons no longer take care of their patients? I think this is true in orthopedics and plastics. Has it spread to general surgery too?

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