I was in my office perusing patient records when I got the call. I’d been selected to be the new Physician Editor of The Hospitalist. I felt surprised—and excited. Then, harsh reality set in: My first deadline was only three weeks away. I checked my pulse—117 and irregularly irregular, good. I brewed some foxglove tea, chewed on some willow bark, and prepared to work.
I found myself experiencing an unusual sensation. What was the emotion I was feeling? A fine mixture of dread and excitement, with an overlay of angst. I’d had this sensation before, but when?
I looked at the May issue of The Hospitalist. How was I going to continue to produce a quality publication—and improve upon it? The people who had supported my selection as editor were counting on me; my mom was counting on me. Heck, even I was even counting on me.
I drew a blank. Where would I go with this? That’s when it hit me: the sense of being in a situation that I wanted, only to discover I wasn’t ready. The tidal forces of time and pressure descended upon me.
In a flash I knew what was happening. I was suffering from delayed post-traumatic residency syndrome. It was 1985, and I was back in Houston’s old Ben Taub Hospital. (Reminiscing is a sure sign of early senescence.) I was the intern coming on service, a very busy general medicine service. Among my new patients, I had to pick up an elderly gentleman who had been ill for years and who had been in the hospital for more than a month. His chart was missing, he was unresponsive, and his family was AWOL.
My beeper kept going off. There was a code on the other side of the hospital, and the ED was calling. Should I give the patient heparin? How do I dose it? Should I give antibiotics and, if so, which ones? Should I draw blood cultures? My circuits totally overloaded.
My resident came to my rescue, with a cup of coffee and good advice: Settle down, find the old records, obtain a history, and perform a physical exam before I even thought about therapeutic intervention.
This was exactly what I needed to do as physician editor. I turned to my current resident-equivalent, in this case Lisa Dionne from John Wiley & Sons—the editorial Yang to my Yin. She gave me the same advice my resident had decades before: Get the back issues of The Hospitalist from SHM, see where it was going, where it had been, learn the terminology, and get organized. Luckily the SHM staff is a lot more responsive then the medical records department at Ben Taub was.
Then, as with any patient, I had to ask some basic questions. What initial symptoms caused the development of The Hospitalist? How long had the publication been present? What made it better, and what made it worse? Was it progressing or was it unchanged? Was I having chest pain? What was SHM, and why did it exist? What did a hospitalist want to read? What was a hospitalist, and why would anyone want to be one?
Why I’m a Hospitalist
That final question seemed the heart of my issue. I pondered what forces drove me to become a hospitalist and why I enjoyed it so much.
When I finished my residency I went into private practice. Like most residents of the time I was totally unprepared for ambulatory care. I could run a code, knew all the latest diagnostic tests, and could even quote a few articles.
But the first time I saw a young man with chronic back pain who wanted to go on disability, or an elderly lady with osteoporosis and breast cancer who wondered if she could take quinine for leg cramps, I was lost. It only took a decade or two for me to feel vaguely competent. Meantime I did some hard time in the hospital, but my focus shifted tectonically toward the outpatient. When my running partner Mitchell Wilson decided to start one of the early hospitalist programs (at the University of Texas) my hospital time ever more rapidly receded.
At the same time, the forces of capitalism were at work: IPAs and IPOs, practice management groups, university expansions and contractions, hospital closings. This was the new shifting sand (or shifting dullness) of medical practice. I was ready for a change, but could I give up my comfortably cluttered office, my established, fairly well-tuned patients, my six-year-old National Geographic magazines in the waiting room? Would going back to the hospital feel like being a resident again? There was only one way to find out.
I said goodbye to the beach and the fire ants, loaded my truck like Jed Clampett, and moved to Rochester—Minn., that is—frozen tundra, lots of geese. Under the auspices of Jeanne Huddleston and the Mayo Clinic Inpatient Internal Medicine Team, I joined the world of hospitalists.
My first impression of life as a hospitalist was that I was cold. Frigid really. Of course it was winter in Minnesota, so I guess I should have expected that. I rapidly discovered that it was a lot nicer being a member of the consulting staff than a member of the house staff. In some ways I felt like an intern again. It was difficult to believe, but hospital medicine had changed over the last decade or two; however, the patients hadn’t.
I was armed with acceptable history taking and exam skills. I had a superb support system in the nurse practitioners and physician assistants who carried my load the first few weeks. My colleagues were supportive. I muddled through and, after several years, felt like I was back to my baseline level of moderate competence.
Though my story is immensely fascinating (to me) from an autobiographical standpoint, does it answer the question of why I enjoy being a hospitalist? Usually people ask me, “What is a hospitalist?” I usually explain that I’m an internist—not an intern—though some days I feel like the latter. The taxonomy of hospitalists is fairly diverse. Some of us come straight from residency, for others it’s the resolution of a mid-career crisis.
One of my favorite things about being a hospitalist is the control I have over my schedule. As an outpatient doctor I had a timetable to keep based on the waiting patient. If I got behind, waxed conversational, or got involved with a family, my day was ruined. Patients got mad at me; my nurses were aggravated.
In the hospital, I have a body of work I must do each day. It’s predictably unpredictable at the beginning of the shift. I have a certain number of patients to see, discharge, and admit. I risk acute medical emergencies, unexpected families who want an update on their mother’s condition, and similar hospitalist activities of daily life (aka HADLs). The volume of work is variable: Some days are difficult, some aren’t. The complexity of cases is stimulating and makes continued learning a necessity. Instead of being isolated in an office I interact with other physicians and staff. The most stimulating aspect I experience is the sensation that hospital medicine is an evolving field and there are hundreds of dedicated colleagues out there trying to make it better.
My goal as physician editor is to work with SHM members to continue to produce a great source of hospitalist information. The Hospitalist readers include internists, family practitioners, pediatricians, nurse practitioners, and physician assistants. They also comprise administrators, businesspeople, and legislators. I perceive important topics to involve medical management, education, communication, economics, government regulation, ethics, and palliative care, as well as the activities of our society, chapters, and members.
With the team from John Wiley & Sons and the support of SHM administration and the members, I hope to accomplish this task. My patient all those years ago survived and left the hospital. I only can hope that The Hospitalist will thrive as well. TH
Jamie Newman, MD, FACP, is senior associate consultant, Hospital Internal Medicine, associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.