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Wednesday, August 1, 2012

Mentoring, collegiality, bedside procedures and the luxury of time

Hospitalists, the doctors who provide care to patients admitted to a hospital, sometimes see in excess of 20 patients in a day. I have seen that many a few times and it is awful. An average number of patient contacts for a hospitalist is 16, which just about breaks even financially for the hospitals who hire us, with quite a bit of variation based on how well those patients or their insurance companies pay. 16 is possible but busy. We theoretically have 12 hours to see these patients, make appropriate contacts with their doctors on the outside, their consultants on the inside, write a complete note, order appropriate tests and treatments, handle medical and social crises and occasionally eat a little food and go to the bathroom. We are also answering beepers and phones that go off at random and distressing times and cursing at computers.

In addition to getting the job done, ideally we are also doing it right, with knowledge, humor and compassion, and learning things along the way.

I have noticed that in a hospital or on a day in which I see more like 12 patients, I actually talk to my colleagues about things. Sometimes we talk about patients. We sit near each other at computers and look at results on labs and imaging and say things like, "Wow. That shouldn't have happened." or "Why would her ammonia be that high?" or "That is NOT a lot of platelets." When we have the luxury of time we ask each other about these patients, what do they have, how did they present, what did you do, and wish each other luck. When we don't, we feign deafness and get on with our work.

I also notice this with the consulting specialists. In large hospitals we have lots of specialists, kidney docs, heart docs, infectious diseases, surgeons, pulmonary and GI specialists. When they are not busy and we are not busy we sometimes have long discussions and they learn what is really going on with the patient, including what the home situation is, what is the problem that really needs to be solved in the context of the whole person. We learn how the specialist thinks, what they think and what they can do to help us. We also become friends that way and develop mutual respect.

When we have a little bit of extra time we also make sure to find the nurse for each patient and talk to him or her about what has been happening, not just in the time we are standing at the bedside, but through all the hours of the day, hearing which of our orders actually got carried out and which ones were impractical because of factors we just couldn't anticipate. We explain to the nurse what we really think is going on with the patient, what the physiology is, even look at labs and imaging together. And, of course, we also become friends and develop mutual respect.

When we aren't just wickedly busy, we also can do bedside procedures. We can inject joints that hurt with cortisone. We can remove fluid from chests or abdomens that is suspected of carrying infection or is causing discomfort. We can put in more complex intravenous lines than the nurses can do themselves. (We can do ultrasounds, of course, but that is another story.) A recent article in the journal The Hospitalist (linked here: talks about the demise of competence in bedside procedures among hospitalists. We get too busy to do them and then we don't know how anymore. Often the patients still get the procedures, but they are done by other specialties, radiology, surgical subspecialties, and they are delayed and expensive. When I do a procedure on the patient it is an opportunity to observe that person for a  longer time than normal and to listen to what comes from them when they are not pressured by questions. Also I know exactly what was done, whether I really got the spot I was trying to get, whether there was a hint of a complication and I learn more details of the patient's anatomy.

At the hospital where I just finished working, I had developed a routine that I really liked. It was so good that I keep thinking, "It should always be like this." After I finished my work I would go to the intensive care unit and watch the doctor there do procedures. I would sometimes do the procedures with supervision and critique, even things I know how to do, and learn new ways or better ways to do them. I would bring my most interesting or puzzling problems or the ones I had figured out and we would talk about them, and I would hear about the sickest patients and look at their labs and radiological studies. I would strut my clinical acumen and plumb the depths of my ignorance. How cool is that?

The reason I could do this was not that this hospital was a low volume easy hospital, actually it was the opposite. The luxury of time in this case came from the fact that I was away from home and had no particular reason to return to my seedy motel room. I also decided that getting enough sleep was not strictly necessary since I would be able to catch up when I got back home. Medicine, when done this way, is actually more fun than sleep. Up to a point.

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