Medicolegal Issues

# The Newtonian Hospitalist

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.