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Hip Fractures to Head Bleeds


In the mid-1970s I worked as a hospital orderly. I enjoyed getting an up-close view of the hospital culture and learning a little bit about sick people. And though I didn’t realize it at the time, I was watching the early maturation of a relatively new specialty in that hospital: emergency medicine.

One day I happened to be in the emergency room (I know they call it the emergency department now) when a panic stricken dad carried in his toddler who was having an impressive tonsillar hemorrhage as a complication of a tonsillectomy done a few days earlier. The ER staff took one look at this bloody child and told the dad to carry him way across the campus to the office tower where the ENT surgeon had his office practice. I was drafted to escort the dad, still carrying the child in his arms, and left father and child in the ENT’s office thinking everything would be fine.

I don’t think we can dig our heels in and resist any change in our scope of practice. We will still need an orthopedist to operate on the hip and a neurosurgeon to see patients with “head bleeds,” but maybe the system really needs hospitalists having an increased role in caring for these patients.

I’ve thought about this incident periodically since then and come to two conclusions. The first is that I was totally unaware of how seriously ill this child was until talking later with some of the doctors and nurses at the hospital. Of course I’m now a lot better at recognizing which patients are really sick, but I’ve still had situations in which I failed to appreciate the seriousness of the patient’s condition until thinking about it after the fact. My second conclusion is that this child needed emergent intervention by the ER physician, and shouldn’t have been sent across the campus to an outpatient office.

I suspect the ER doctor thought that management of this acute surgical complication was beyond the scope of his training. So he decided that the risk of delaying intervention so the child could get to the ENT’s office was less than keeping him in the ER to get IV access and start volume replacement, and so on.

Though it would sound ridiculous now, you might imagine the ER doctor defending his decision by saying “I’m not trained in the acute management of surgical complications like that.” After all, like most ER doctors of the time, his training probably consisted of a one-year rotating internship or something similar. There were no (or very few) ER residencies at the time.

But if that doctor is still practicing in an ER somewhere, I’m pretty confident he has developed the expertise required to provide the initial management of patients like this one. Like all ER doctors, and the field of emergency medicine as a whole, he needed to adjust the scope of his practice to meet the needs of the institution and healthcare system where he worked. So even if it were reasonable for him to say initial intervention for acute tonsillar hemorrhage was out of the scope of his training and expertise in the 1970s, he can’t say it anymore. Like all ER doctors, he had to seek out ways to gain training and expertise in these kinds of problems in order to respond to the needs of the institution.

I tell this story because I think we as hospitalists—and the field of hospital medicine as a whole—sometimes find ourselves in situations similar to that of the 1970s ER doctor. We are sometimes asked to provide care that might not have been part of the usual scope of practice for someone with our training. I am trained as an internist, but am sometimes asked to admit patients with problems like hip fracture or hypertensive intracerebral hemorrhage when my first impulse is that an orthopedist or a neurosurgeon should admit that patient. Or I might be asked to admit a 17-year-old and wonder if it would be better for a pediatrician to take care of that patient.

On the one hand I want to say these aren’t really internal medicine problems, so I shouldn’t be the attending for these patients (but could serve as consultant). And while that might be a reasonable position to take today, I’m convinced that I can’t dig my heels in and insist that I never become the primary admitter for these patients. I think there is too big a need for a hospitalist to care for these kinds of patients at my hospital, and it’s unreasonable for me to take a hard line and insist I will never change.

While your list of diagnoses might be different than mine, I think there is a good chance that you’re often asked to care for patients that might be a little outside the traditional scope of the specialty you trained in. Do you think that the field of hospital medicine can—or should—avoid caring for these patients long term? I don’t. I think we need to gradually take on some of the new roles that our hospitals and physician colleagues request of us. Just like the ER doctors of the 1970s, I think we are in a period of significant evolution as our field “grows up.” And rather than resisting this change, I think we should thoughtfully decide where “the system” needs our services the most and work to develop the expertise to meet that need.

Some hospitalists are really uncomfortable with the idea of expanding the scope of their practice and raise a number of objections. They sometimes say “That’s fine if Nelson wants to care for patients with head bleeds, but there is no way I’m going to do it since it’s a sure path to a law suit.” Or “I’m happy to consult and manage the blood pressure, but there’s no way I’m willing to be attending.”

But don’t doctors in most specialties adjust their scope of practice regularly? Think about surgeons who have had to learn laparoscopic techniques after their residency training. And office-based internists who had little outpatient training during residency but have had to learn to be expert at it once they started practice. They are adapting the scope of their practice to the needs of the healthcare system, and they’ve found ways to gain competence and expertise in these areas.

I’m not suggesting we admit any type of patient someone might want us to. Nor am I confident that the two important areas for hospital medicine to become more involved in are hip fracture and hypertensive intracerebral hemorrhage (though they do seem to come up regularly). My point is that I don’t think we can dig our heels in and resist any change in our scope of practice. In our own local practices, and as a specialty, we need to decide the most valuable ways to adjust our practice scope and work diligently to become competent at them. We will still need an orthopedist to operate on the hip and a neurosurgeon to see patients with “head bleeds,” but maybe the system really needs, and could benefit from, hospitalists who have an increased role in caring for these patients. As our field evolves, training programs and CME courses will adapt to meet our need for more training in these areas that may feel new or unfamiliar to many of us.

Some days after the child with tonsillar hemorrhage presented, I learned that he had done OK and had gone home looking good. But the surgeon was furious that we had “dumped” this patient at his door without any warning and had sent the patient into his waiting room where other waiting patients were apparently horrified. The ER doctor could have responded that the surgeon should quit complaining and get used to this kind of thing because “it comes with the turf” of ENT practice. Or he could have told the ENT doctor he’d like for the two of them to work together to develop a way for the ER to play a much bigger role in the early emergent intervention.

I hope that when we find ourselves in a similar situation we try the latter response. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

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