Giving hospitalists a larger clinical footprint

“We are playing the same sport, but a different game,” the wise, thoughtful emergency medicine attending physician once told me. “I am playing speed chess – I need to make a move quickly, or I lose – no matter what. My moves have to be right, but they don’t always necessarily need to be the optimal one. I am not always thinking five moves ahead. You guys [in internal medicine] are playing master chess. You have more time, but that means you are trying to always think about the whole game and make the best move possible.”

Dr. Christopher Moriates

In recent years, the drive toward “efficiency” has intensified on the wards. I am seeing us playing much more speed chess as hospitalists, and I don’t think that is a good thing.

The pendulum has swung quickly from, “problem #7, chronic anemia: stable but I am not sure it has been worked up before, so I ordered a smear, retic count, and iron panel,” to “problem #1, acute blood loss anemia: now stable after transfusion, seems safe for discharge and GI follow-up.” (NOTE: “Acute blood loss anemia” is a phrase I learned from our “clinical documentation integrity specialist” – I think it gets me “50 CDI points” or something.)

Our job is not merely to work shifts and stabilize patients – there already is a specialty for that, and it is not the one we chose.

Clearly the correct balance is somewhere between the two extremes of “working up everything” and “deferring (nearly) everything to the outpatient setting.”

There are many forces that are contributing to current hospitalist work styles. As the work continues to become more exhaustingly intense and the average number of patients seen by a hospitalist grows impossibly upward, the duration of on-service stints has shortened.

In most settings, long gone are the days of the month-long teaching attending rotation. By day 12, I feel worn and ragged. For “nonteaching” services, hospitalists seem to increasingly treat each day as a separate shift to be covered, oftentimes handing the service back-and-forth every few days, or a week at most. With this structure, who can possibly think about the “whole patient”? Whose patient is this anyways?

Read the full post at hospitalleader.org.