The Hospitalist Shift From Hell, and How to Fix It

I came home from my last 12 hour hospitalist shift exhausted.  My eyes were bleary eyed from staring at the EMR , and I was in the state of beatendownness where you have been totally crushed by admissions, cross cover, your coworkers, staff and patients.  Owning a coffee shop was looking better and better, and hey, I love coffee.  However, looking back at the shift from hell is helpful.

Here is a list of what went wrong,and how I will fix it:

  1. I didn’t have a check list in front of me.  I was rushed and frazzled, and didn’t go through my usual mental check list.
  2. I didn’t take a break.  I should have handed the shock box, I mean pager, to one of my co-workers and walked outside for a moment of peace.
  3. I ate too much crap.  Yes, crap. In my frustration I just put my face in to the fridge in the physician lounge and went for it.  Sigh.  I should have brought something from home.
  4. I doubted myself.  I spent a lot of time justifying my thinking to myself.  (I had just finished reading How Doctors Think, and was trying to double check my thinking.)  Doubt slowed me down to the point where I began to question everything.  Solution: hmm, brain transplant?
  5. I wasn’t wearing my scrubs.  I was trying to look more doctor like, so I had on a nice sweater, pressed pants, and the white coat.  (You men wouldn’t understand…)  Next time, forget fashion, I’m wearing scrubs.
  6. I let my colleagues get to me.  We were all crabby from the heavy workload.  Next time I will take a deep breath and remember we are all getting crushed, and put on the lens of perspective.
  7. I was quick to anger.  I got mad when a patient didn’t have a call button close to him, and I found it on top of the sharps box.  He had just had a total knee replacement, for pity’s sake!  I asked the nurse if the staff had a check list they followed when they cleaned the room, so this wouldn’t happen.  She indicated that “they’re pretty good at putting the call light where it should go.  I don’t think they need a check list…”  Ha I say!  How many times am I trying to find the blankety-blank call light for the patient?!  Time for another big breath!  (BTW, check out If Disney Ran Your Hospital.  Good ol’  Walt would see it my way!)
  8. I was exhausted from the get go.  My own mom was in the hospital recently and I spent a lot of time with her, which was good but tiring.  It was eye opening to be on the other side of the bed.  I tried to do too much, and should have gotten help from friends and family, AND NOT FELT GUILTY FOR ASKING!  (Yes, this is a woman thing,doctor thing,  mother thing, brought up Catholic thing.  I’m working on it.)
  9. I wasn’t wearing the no complaining bracelet.  I have a bracelet that I wear to remind me not to complain.  If I do complain, I move it to the other wrist as a reminder to stop carping.  I will wear it today.
  10. I worried too much.  I was worried about patients, my daughter, my dog being in a cold dog house, the dinner in the oven that would be waiting for me when I got home at 9:00 p.m.  And yes, I forgot to set the oven.   By focusing on worry, it was harder to place the focus where it belonged: on the patients.  The daughter and dog were fine, my husband turned on the oven, and the patients were okay.  Today I will leave my home worries at the door of the hospital when I go in.  They will be there waiting for me when I walk out late tonight.

By the way, the ED docs I worked with were great!  They knew we were getting crushed, and were kind and gracious in the face of the united hospitalist of grump coalition they faced.  Today will be better, I’m sure!

And lastly, I’m only human.

Disclaimer: I have no association with the authors mentioned above, and recieve no financial gain in mentioning their books.

How Doctors Think Outside of the Medical Box

It was a tough week in Pookieville.  I worked all week at one of my favorite hospitals.  I like working there because the specialists I work with are hypercompetent and always willing to help.  Furthermore, they like to chat. Well, they like to chat about interesting cases.

I was particularly challenged this week because I had to think out of the box.  I will not share the details of the case, as I don’t intend this blog to be about medical cases per se.

When I picked up  my service, I  assumed care of a very complicated patient, with a disease process that was appropriately handled.   Unfortunately, there was an outcome that was unexpected and completely unpredictable .  It was also quite serious.  What I want to share is how hard it was to think out of the box, which was what was required.  Medical statistics and medical science can not predict all outcomes, which is when the “art” of medicine comes in to play.

I walked in to the room to discuss the latest bump in the road, and the various treatment options to remedy the latest bump.  Now, before I went in the room to talk to the patient, I had done my home work.  I had reviewed the latest bump in the road with the surgeons, specialists,  the sub-specialists and several of my co-hospitalists.  There was no clear consensus as to what should be done about this problem, just a general agreement that this problem was indeed, a big problem.  Most of my colleagues were glad they were not me, because it felt as if all options were fraught with danger to the patient.  “Glad I’m not the one that has to write those orders,” was the general feeling.

Great.

I explained to the family what the issues were, and that we were now in rock and hard place territory.  I explained that there were no randomized, double blinded placebo controlled studies for where we were at.  I explained the options, risks, benefits and side effects of each option.  I explained that  I had done my home work.

“Do you just fling sh– at the wall and see what sticks?”  One incredulous family member asked.

It must appear that way, when we can’t quote studies, and cite statistics and supply comfort from numbers.  We must appear like idiots when we have to use our experience, and our colleagues’ experience to make a decision when there is no clear cut decision, and when the road is paved with ill feelings and anger at an outcome only God could have predicted. 

But none the less, a choice on treatment had to be made. 

Here is how I made my decision on how to treat the problem:

  1. Identified the problem.
  2. Said “@#%*!”
  3. Asked everyone involved in the case their opinion, including the PharmD, and the head of the department of medicine.
  4. Came up with three options, and picked the one I felt was the safest with the best outcome.
  5. Reviewed options with the patient and family.
  6. Realized that there may be MORE options, once I talked to the family.  (Interestingly, the family was the most creative in looking at solutions.)
  7. Walked out of the room, made more phone calls, and finally came upon the solution that we ended up going with.
  8. Called a renowned specialist at the local University and got the specialist’s opinion, who was in concurrence with the ultimate solution I had crafted.
  9. Went back in the room (a bit demoralized, as I had said there were no other options, but now had come up with one.)
  10. Heard the family’s  intense relief at the more moderate, middle of the road option that we ultimately agreed to implement.
  11. Went for it.

So why I am writing about this?  Because it took me TWO hours to do all of this.   It took two hours for me to think and explore every option, and to finally come up with an option that seemed workable, and the least dangerous.  I took the time because I wanted to do what was best.   It was the family that was most able to think outside of the medical box, and who encouraged me to explore further.

Now, was this the right choice?  Only time will tell, and yes, sometimes as physicians we just have to throw sh– against the wall, and then throw some more, and then consult our colleagues, and then think again to find the answer when there is no right answer.

I just hope that in the future, I have enough time to think out side of the medical box.

How do you think out side of the box?

Play Nice in the ED: Why Hospitalists and ED Docs Should Be Friends

I do a lot of work as a hospitalist, and have noted a fair amount of antagonism amongst my colleagues towards the ED.  There seems to be a lot of bickering between ED docs and hospitalists as to WHO should take responsibility for patient care. More specifically, if a patient has been admitted to a hospitalist, but remains in the Emergency Department, which physician is now responsible for that patient’s care?

A few rules:

Patient care comes first.

We are all busy, and we are all good, caring physicians.

If a patient is still in the ED, and a crises occurs, the ED MD needs to be responsible.  If I have seen a patient in the ED, then I should be called. However, if a patient is in crises, shouldn’t the nurse notify the ED physician AND the hospitalist?  Of course!  To notify me a patient is getting “worse” when I haven’t had time to assess the patient is nuts.  But it happens all the time.  Common sense must be employed:  DO WHAT IS BEST FOR THE PATIENT!

Now, what about the patients that are not in crises, but about whomthe nurse has questions?  First, I hate it when nurses call me and ask me if Mr. Prinzmetal should be on telemetry (or ask me to designate a level of admission, say observation or ICU) when I haven’t even seen the patient.  The ED physician should have a good enough sense of the patient to designate where (ICU/floor/telemetry) the patient should go. By all means, if I disagree I will change that designation.  So, please don’t call me with THAT question and waste more of my time (and then wonder why I haven’t seen the admissions that have been called to me.)

Now, as to other questions like potassium replacement, sure, call me.  But, please, please, please do NOT call me with major management questions before I have seen the patient.  I hate it when the ED doc calls me to ask if they should start heparin or nitroglycerin drips on cardiac patients.  You have seen the patient, and made the decision that they have an acute coronary syndrome.  You don’t need my blessing to act accordingly.

When the patient gets to the floor, they are my responsibility. Period.  I am watching over most of the patients in the hospital, as we are consulted on most orthopedic patients, and a fair amount of the general surgery patients.  I just ask that ED docs watch over the patients that are physically in the ED.

ED physicians, if you are busy, it means by extension, I am busy. We need to realize that the ED impacts the entire function of the hospital, and directly effects the work flow of hospitalists.

ED docs: here is my pledge to you:

  • I will say thank you every time you save my butt.  I know how many times you have put in lines and run CORs for me when I am crushingly busy.
  • I realize that for every patient I see, you see three.
  • I know that your job is challenging, and sometimes thankless.  I appreciate it everytime you are able to divert the bottom feeders.
  • I will be thankful for the work ups you do.
  • I will bring you candy my next shift.

This post is in response to “Lost in Transition” regarding handoffs at the Moving Meat Blog.  Thank you, Shadowfax and Whitecoat for the dialogue!  See:  http://allbleedingstops.blogspot.com/2008/11/lost-in-transition.html  and http://whitecoatrants.wordpress.com/

Handoffs or Fumbles: Transferring Care Amongst Physicians

There are many patient hand offs during EVERY physician’s day.  Primary care physicians hand their patients off to ED docs, who in turn hand them off to hospitalists or specialists, who in turn (eventually) hand them back to their out patient physician.  Additionally, there are hospitalist to hospitalist hand offs and specialist to specialist hand offs.  Yikes! 

Here’s my advice on preventing fumbles:

From PCP to ED/Hospitalist: please call the ED or admitting hospitalist if you are direct admitting.  DO NOT HAVE YOUR NURSE CALL BECAUSE YOU ARE TOO BUSY!  Make sure your patient has the following paper work attached to his body:

  • today’s note that clearly states WHY the patient needs an ED eval or admit, and what you did for him in the clinic.
  • legible medication list.
  • legible problem list that includes surgeries and hospitalizations  (Yeah, remember that from med school?  You may have all that in your head, but we are seeing this patient for the first time).
  • contact information on how to get back to you.
  • the concerning EKG that caused you to send Mr. Prinzmetal to the ED in the first place.

From ED MD to hospitalist/specialist:

  • Why the patient needs to be admitted.  Please, please, please don’t say “He just needs to come in.”  Have labs, EKGs, and xrays on hand when you call, and please don’t mind if I ask you a fair amount of questions.  I do NOT expect ED physicians to think of every contingency (that’s my anal retentive job), but I do expect a working diagnosis.
  • What you have done for the patient in the ED, and how he responded.
  • Which specialists you have called, and what their plan is.

From hospitalist to specialist:

  • Why you are calling.  Be VERY clear: “I want you to manage Mr. Prinzmetal’s acute MI.  I think he needs to go to the cath lab.”
  • In what time frame the specialist needs to see the patient.  My favorite specialists will tell me when they will come by, but I try to ask so I can tell the patient.  For pity’s sake, if you need them to see the patient NOW say it!  They aren’t mind readers.
  • What you have done for the patient and how the patient has responded.
  • Have your data handy. I expect the ED to do this for me, and we need to do it for the specialists/consultants.

From specialist to hospitalist/primary care:

  • Communicate the treatment plan.  I love a phone call, but the minimum is a readable note.
  • When you will follow up with the patient.  Expecting a PCP or hospitalist to call you to inquire about follow up plans reduces us to minions and is poor patient care.  Besides, you should be telling this to the patient when you hand them your business card.

From hospitalist to PCP:

  • Call the PCP at discharge(or email the THOROUGH discharge report if you are set up that way).  Most hospitals send dictated summaries, but they frequently arrive after the patient has been seen by the PCP.
  • Make sure the PCP ( and the patient!) has a complete medication list.  Be VERY clear about what medications are new, what has been stopped and what medications remain.
  • Make sure you review pertinent tests and results.
  • Review which specialists saw the patient and what the follow up plans are.
  • Let the PCP know when they need to the newly discharged patient.

There is an interesting post from the Wall Street Journal on surgical resident’s hand offs, but I didn’t find it the most helpful for the PCP-ED-Hospitalist-Specialist circuit.  However, some of the comments are pretty entertaining. Here’s the link if you are interested: http://blogs.wsj.com/health/2008/10/20/how-doctors-can-avoid-perilous-patient-hand-offs/

 FYI: the Washington Redskins had the most fumbles in 2007, reflecting the fumbling going on in the nation’s capitol.

Love to hear your hand off tips! 

How To Listen So Patients Will Talk

I wish that in medical school and residency we had spent more time learning how to communicate.  We finish training stuffed with knowledge (think a brat on a grill!) but are horrible at distilling that knowledge to help people.  As a hospitalist I have tried to hone my interviewing skills, but feel that I could use some improvement.   Here’s my own two cents on how to interview a patient  (of course, I’m a doctor, I’ve got an opinion!):

1) Read the chart before you go in.  I have gone back and forth on this, wanting the patient to tell me what was wrong in their own words, but finally have settled on, “Hello, Mr. Hurting, I understand you have had chest pain (or warts, or whatever) for the past two days (weeks, months, decades…).  Could you tell me more about it?”  I have started doing it this way, because, when I used to say, “Hello, Mr. Hurting, what brings you to the ED today?”  inevitably I would get a wisecrack like, “My wife.”  or “The ambulance.”  I’m hoping my chart reading before hand makes me look smarter!  (I have a personal theory that if I had a British accent, I would appear smarter, but that’s a whole different blog.)

2) Please slow down, and don’t interrupt the patient.  Let them get their spiel out, before you jump in with the questions.   Try not to turn the interview into an interrogation.

3) Review the medication list (the med rec, which I think is your best friend!) every time, using trade and generic names.  Many patients will know one or the other, but not both.  Hopefully you will not encounter the dreaded, “I take the little peach pill” scenario.

4) Try to answer the following questions:
–what is my diagnosis –(why am I sick?)

–what will happen next?  (What tests, treatments, other specialists?)

–when will I be informed of the test results?

–will it hurt?

–when will I get out of here (the hospital)?

–and of course, when can I eat?

5) For pity’s sake, introduce yourself and shake hands!  (I know, this post is slanted towards hospitalists today.)  Give the patient and family a card.  I occasionally give my pager number to so called “needy” families.  I find that they take comfort knowing they can get hold of me, and seldom abuse this.  I must note that some of my colleagues frown on this.  (“We don’t do that,” one of them said frostily.)

6) Always ask, “Do you have any other questions or concerns you want to share with me?” before concluding the interview.  I also tell patients and families how they can get hold of me.  (“Ask your nurse to page me.  We have someone here 24/7.”)

Please feel free to share your suggestions.  My communication skills are a work in progress, and I bet yours are too!