I always loved the game Hot Potato. A more stationary version of musical chairs, it involves the passing of the spud as the music plays or the clock ticks, then the last-minute handoff; the excitement of that game trained me for a life of brinkmanship.
The earliest version of the game involved passing a lit candle, with the loser holding the extinguished taper. I always enjoyed my cold war version, a wind-up fake bomb passed around the circle. Hot Potato was the name of a terrible Jim Kelly martial arts movie in 1976, and an even worse short-lived NBC game show in 1984. It is even a poorly rated video game. The newest “Hot Potato” is a computer routing system.
In the game Hot Potato, you never want to be the one with the spud when the music stops. Unfortunately, sometimes patients become that hot potato.
When I was a first-year medical student, I wanted my own patients. I shared the clinical experience with others grudgingly. Someone else would always ask the question I wanted to; they routinely heard the murmur first. Every patient was a new mystery to be solved, a reminder of how little I knew (and still don’t know). By my senior year of school, I still wanted my own patients, but I wanted the most exotic and difficult cases I could find, as a matter of principle.
By internship that glory had faded. I was harassed, sleep deprived, overworked, and underpaid, but otherwise I was OK. If I could avoid another admission, I was happy. New terminology entered my vocabulary. Expressions like “He’s a sieve” or “She’s a wall” described my coworkers in the emergency department (ED). Why would they admit that patient, were they crazy? Your chief resident was strong or weak based on turfing prowess. What could be sweeter than a bounce back to the other service?
As a resident, I perfected what Samuel Shem (a.k.a., Stephen Bergman, MD) described in the classic The House of God as the “buff and turf.” Transfer to surgery, no problem. Patient wants to leave AMA, just have him sign the paperwork. This negative attitude was pervasive. A team was judged by the strength of the resident, and measured by the relative size of the census. Of course, residents today would never feel this way, given work hour limits. That was in the old days.
As a newly minted private practice internist, I wanted all the patients I could see. I took every ED admit, opened all my slots. I was building my practice. I was on a productivity formula and wanted to surpass my targets. I was incentivized. It seemed odd to be working so hard to get patients when I had done the opposite just one year earlier. My colleagues looked on in amazement as I said yes to everything. The best advice I was ever given was to say no, but I did not heed it.
After a few years in practice, I was well stocked with patients. I still accepted all Medicare patients; at the time, I was the only one in private practice who would do so secondary to the lower pay rate. I didn’t mind because of my interest in geriatrics. I enjoyed these old folks, plus they brought in the best homegrown produce. My kids grew sick of okra.
When the HMOs came to town, with their IPAs and IPOs, along with other alphabetic acronyms too fierce to mention, I was once again incentivized to not see patients. It was fine for me to capture their PMPM (per member per month) fee, but I wasn’t encouraged to actually see them, and hospitalization involved a tremendous amount of paperwork and psychological conflict with my IPA handlers. “Do you really need that MRI?” was the question of the day.
I spent a brief and disastrous year in the world of practice management groups, where patients were subsidiary to stock value and practice acquisition. I emerged bent but not broken. Well, maybe slightly broken. Yes, money is the root of all evil.
Next, I began to work for a community-based university practice, on a straight salary. My financial incentives were eliminated, I saw as many as I comfortably could, and I forgot about the money. Life was good. I had a few medical students and an intern. We saw a large but comfortable volume of patients, mostly geriatric. I always tried to see the people who needed to be seen, but not so many that a visit was too brief.
The dark side reared its head again when I got a new boss who wanted the community university practice to go on productivity. Once again I was back to the bean counting rat race: see more patients and squeeze in an extra three this afternoon. “What do you mean you want a day off?”
But then I became a hospitalist and all was right with the world again. It was an excellent consultative practice with ample opportunities for teaching and research. Unfortunately, when the resident hours rules began, we found ourselves staffing services formerly run by teaching teams. We also found ourselves in rotation with the remaining teams.
This was the moment of truth. Would I return to my long abandoned roots? Would I begin once again to order the “surf and turf” platter? Happily, the answer has been “No.” The fullness of time has helped me to realize that patients are not hot potatoes. There are days when I find myself watching the admit board intently or wondering why one service or another is not taking their bounce backs. I have found, however, that the mental energy that is wasted in playing Hot Potato is needed to care for the patients who seek our help. Would I want my mother sitting in an ED while three services did their best to not have her on their lists? OK, in my mom’s case, I could understand. (Just joking, Arlene.)
So, the next time you get the call from the ED and find yourself wondering what that patient is doing on your service, think about the game of Hot Potato. Perhaps when the music stops, you are the right one to have the spud in hand. TH
Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.