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Wednesday, February 1, 2012

Adventures in Hospital Medicine

I just started my first out of town doctoring job. I flew out for an orientation on Thursday and then drove back here for the week of work on Sunday. After Thursday's hospital visit my reaction was "what was I thinking when I said I would do this?" People go through a lot of trouble to end up in jobs where they are comfortable, well known and respected. This job, at least from the vantage point of last Thursday, was a very different thing. I would be responsible for somewhere between 12 and 20 patients who I knew nothing about in a hospital which has over 200 patient beds, 5 floors, 3 adjoining buildings, using two entirely new computer systems.

So what happened? I did sleep well the night before I started, which was great. They gave me 12 patients to start, and my beeper was mercifully quiet for the first 4 hours of my 12 hour shift. The patients were just people, like they are anywhere, which was reassuring, and they were grateful to have someone talk to them and listen to them and try to solve their problems. The computer systems were user friendly compared to lots of computer systems I've seen in medicine. The staff was harried but supportive. I  brought my lunch. I got two admissions and discharged 3 patients and as far as I know I didn't make any heinous errors. The second day was a little harder but I was more comfortable, and today was ridiculous, with people needing to be seen at the same time in multiple areas of the hospital, some of them with logistical issues that were time sensitive, like discharges and procedures, and some of them with actual acute and life threatening illnesses needing intervention. Again, no obvious heinous errors, and everyone was quite understanding.

I'm starting to develop a routine that coordinates gathering all of the nearly infinite pieces of data that go into modern medical care (vital signs, lab tests, imaging results, nurse's observations, consultants and primary care docs' input, physical exams and patients' stories) and then seeing patients, admitting and discharging them and writing notes. Today was a little too free floating, I think, or maybe my patients were just really sick, but I ended up not getting out of there until an hour and a half after my shift was over. I shall make some subtle adjustments tomorrow and see how it goes.

I think this hospital, which is larger than the one I normally work in, has adjusted to the fact that the hospital docs, like me, are stretched thin, and even the patients are a bit more patient than I would be in their position. There are routine errors related to discontinuity of care, such as misdiagnoses and redundant tests and procedures. In general these have not seemed to have dire consequences, but they definitely could. There are systems in place to reduce this risk, but the frequent hand-offs of patients are difficult to do without information loss, Impossible, even. In my home hospital we do 24 hour shifts, going home at night, but always available within 20 minutes or less to come in if necessary. We usually do several days in a row, and know the patients pretty well by the time they are discharged. Our signouts are face to face, whereas the routine with my present job involves only a one or two paragraph computerized communication. With 12 hour shifts and a night and swing person covering all of the patients, face to face hand offs are not logistically possible.

I'm staying in a rather seedy hotel, but in a large room with a kitchen. I have very little time here, so the seediness doesn't much matter. I bought food at a grocery store and have been having comfort food meals like fresh raspberies, croissants with brie and nutella, ramen and hard boiled eggs and greasy chicken thighs. It's hard to improve on that! The locums company I work for will pay for my meals and lodgings so I could be eating out every night, but I shudder to think what a restaurant would charge for the fresh raspberries.

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